nutrition in global health context
DESCRIPTION
Nutrition in Global Health Context. Allan Davison (Simon Fraser University ) and @@ helpers April , 2011 Prepared as part of an education project of the Global Health Education Consortium and collaborating partners. Module overview (Delete this slide when no longer necessary). - PowerPoint PPT PresentationTRANSCRIPT
Nutrition in Global Health Context
Allan Davison (Simon Fraser University) and helpers
April 2011
Prepared as part of an education project of the Global Health Education Consortium
and collaborating partners
Module overview (Delete this slide when no longer necessary)bull 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 ndash Title pagendash Module goalsndash List of module sectionsndash Learning objectivesndash Section contentndash Case studyndash Supplementary notendash Thought or discussion questionsndash Special features (voiceovers video clips etc)ndash Quiz (including several quiz options)ndash Section or Module summaryndash Further readings and other resourcesndash Acknowledgementsndash Credits
Page 2
Module overview (Delete this slide when no longer necessary)bull 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
bull 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 andor 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 3
Module overview (Delete this slide when no longer necessary)bull Module submission Send draft module to Tom Hall (
thallepiucsfedu) and to Glenn Nordehn (gnordehngmailcom) 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
bull 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 GHECrsquos website
Page 4
Module features (Delete this slide when no longer necessary)bull Your module can accommodate these features
ndash PowerPoint-like slides with text graphics and buttons that will take viewers to supplementary notes amp resources
ndash Ability to highlight by arrows circles colors or other means selected features of any slide
ndash 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
ndash Video and YouTube clips We can provide you with help in how to add these features
ndash Pop quizzes and end-of-module quizzes that provide answers feedback and tabulation of correct answers
ndash Links to any URLs on the internetPage 5
Page 6
Module goals (Replace illustrative text with your own text)
Note to authors This slide describes the overall goal for the module It is more general than the learning objectives that follow for individual sections
List of module sections (Replace template text)
bull Section 1 bull Section 2 bull Section 3 bull Section 4 bull Section 5
Page 7
Page 8
Learning objectives Section 1
On completing this section you will be able to1 List the principal causes and risk factors affecting 2 Describe how the major risk factors affect these factors3 Etc4 Etc
Note to authors Prefer active verbs (eg list make describe able tohellip) over passive verbs (understand know appreciatehellip) whenever possible Keep objectives short and specific Be sure that these objectives are fully covered in the section and are addressed in the quiz
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Module overview (Delete this slide when no longer necessary)bull 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 ndash Title pagendash Module goalsndash List of module sectionsndash Learning objectivesndash Section contentndash Case studyndash Supplementary notendash Thought or discussion questionsndash Special features (voiceovers video clips etc)ndash Quiz (including several quiz options)ndash Section or Module summaryndash Further readings and other resourcesndash Acknowledgementsndash Credits
Page 2
Module overview (Delete this slide when no longer necessary)bull 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
bull 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 andor 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 3
Module overview (Delete this slide when no longer necessary)bull Module submission Send draft module to Tom Hall (
thallepiucsfedu) and to Glenn Nordehn (gnordehngmailcom) 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
bull 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 GHECrsquos website
Page 4
Module features (Delete this slide when no longer necessary)bull Your module can accommodate these features
ndash PowerPoint-like slides with text graphics and buttons that will take viewers to supplementary notes amp resources
ndash Ability to highlight by arrows circles colors or other means selected features of any slide
ndash 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
ndash Video and YouTube clips We can provide you with help in how to add these features
ndash Pop quizzes and end-of-module quizzes that provide answers feedback and tabulation of correct answers
ndash Links to any URLs on the internetPage 5
Page 6
Module goals (Replace illustrative text with your own text)
Note to authors This slide describes the overall goal for the module It is more general than the learning objectives that follow for individual sections
List of module sections (Replace template text)
bull Section 1 bull Section 2 bull Section 3 bull Section 4 bull Section 5
Page 7
Page 8
Learning objectives Section 1
On completing this section you will be able to1 List the principal causes and risk factors affecting 2 Describe how the major risk factors affect these factors3 Etc4 Etc
Note to authors Prefer active verbs (eg list make describe able tohellip) over passive verbs (understand know appreciatehellip) whenever possible Keep objectives short and specific Be sure that these objectives are fully covered in the section and are addressed in the quiz
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Module overview (Delete this slide when no longer necessary)bull 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
bull 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 andor 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 3
Module overview (Delete this slide when no longer necessary)bull Module submission Send draft module to Tom Hall (
thallepiucsfedu) and to Glenn Nordehn (gnordehngmailcom) 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
bull 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 GHECrsquos website
Page 4
Module features (Delete this slide when no longer necessary)bull Your module can accommodate these features
ndash PowerPoint-like slides with text graphics and buttons that will take viewers to supplementary notes amp resources
ndash Ability to highlight by arrows circles colors or other means selected features of any slide
ndash 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
ndash Video and YouTube clips We can provide you with help in how to add these features
ndash Pop quizzes and end-of-module quizzes that provide answers feedback and tabulation of correct answers
ndash Links to any URLs on the internetPage 5
Page 6
Module goals (Replace illustrative text with your own text)
Note to authors This slide describes the overall goal for the module It is more general than the learning objectives that follow for individual sections
List of module sections (Replace template text)
bull Section 1 bull Section 2 bull Section 3 bull Section 4 bull Section 5
Page 7
Page 8
Learning objectives Section 1
On completing this section you will be able to1 List the principal causes and risk factors affecting 2 Describe how the major risk factors affect these factors3 Etc4 Etc
Note to authors Prefer active verbs (eg list make describe able tohellip) over passive verbs (understand know appreciatehellip) whenever possible Keep objectives short and specific Be sure that these objectives are fully covered in the section and are addressed in the quiz
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Module overview (Delete this slide when no longer necessary)bull Module submission Send draft module to Tom Hall (
thallepiucsfedu) and to Glenn Nordehn (gnordehngmailcom) 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
bull 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 GHECrsquos website
Page 4
Module features (Delete this slide when no longer necessary)bull Your module can accommodate these features
ndash PowerPoint-like slides with text graphics and buttons that will take viewers to supplementary notes amp resources
ndash Ability to highlight by arrows circles colors or other means selected features of any slide
ndash 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
ndash Video and YouTube clips We can provide you with help in how to add these features
ndash Pop quizzes and end-of-module quizzes that provide answers feedback and tabulation of correct answers
ndash Links to any URLs on the internetPage 5
Page 6
Module goals (Replace illustrative text with your own text)
Note to authors This slide describes the overall goal for the module It is more general than the learning objectives that follow for individual sections
List of module sections (Replace template text)
bull Section 1 bull Section 2 bull Section 3 bull Section 4 bull Section 5
Page 7
Page 8
Learning objectives Section 1
On completing this section you will be able to1 List the principal causes and risk factors affecting 2 Describe how the major risk factors affect these factors3 Etc4 Etc
Note to authors Prefer active verbs (eg list make describe able tohellip) over passive verbs (understand know appreciatehellip) whenever possible Keep objectives short and specific Be sure that these objectives are fully covered in the section and are addressed in the quiz
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Module features (Delete this slide when no longer necessary)bull Your module can accommodate these features
ndash PowerPoint-like slides with text graphics and buttons that will take viewers to supplementary notes amp resources
ndash Ability to highlight by arrows circles colors or other means selected features of any slide
ndash 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
ndash Video and YouTube clips We can provide you with help in how to add these features
ndash Pop quizzes and end-of-module quizzes that provide answers feedback and tabulation of correct answers
ndash Links to any URLs on the internetPage 5
Page 6
Module goals (Replace illustrative text with your own text)
Note to authors This slide describes the overall goal for the module It is more general than the learning objectives that follow for individual sections
List of module sections (Replace template text)
bull Section 1 bull Section 2 bull Section 3 bull Section 4 bull Section 5
Page 7
Page 8
Learning objectives Section 1
On completing this section you will be able to1 List the principal causes and risk factors affecting 2 Describe how the major risk factors affect these factors3 Etc4 Etc
Note to authors Prefer active verbs (eg list make describe able tohellip) over passive verbs (understand know appreciatehellip) whenever possible Keep objectives short and specific Be sure that these objectives are fully covered in the section and are addressed in the quiz
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 6
Module goals (Replace illustrative text with your own text)
Note to authors This slide describes the overall goal for the module It is more general than the learning objectives that follow for individual sections
List of module sections (Replace template text)
bull Section 1 bull Section 2 bull Section 3 bull Section 4 bull Section 5
Page 7
Page 8
Learning objectives Section 1
On completing this section you will be able to1 List the principal causes and risk factors affecting 2 Describe how the major risk factors affect these factors3 Etc4 Etc
Note to authors Prefer active verbs (eg list make describe able tohellip) over passive verbs (understand know appreciatehellip) whenever possible Keep objectives short and specific Be sure that these objectives are fully covered in the section and are addressed in the quiz
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
List of module sections (Replace template text)
bull Section 1 bull Section 2 bull Section 3 bull Section 4 bull Section 5
Page 7
Page 8
Learning objectives Section 1
On completing this section you will be able to1 List the principal causes and risk factors affecting 2 Describe how the major risk factors affect these factors3 Etc4 Etc
Note to authors Prefer active verbs (eg list make describe able tohellip) over passive verbs (understand know appreciatehellip) whenever possible Keep objectives short and specific Be sure that these objectives are fully covered in the section and are addressed in the quiz
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 8
Learning objectives Section 1
On completing this section you will be able to1 List the principal causes and risk factors affecting 2 Describe how the major risk factors affect these factors3 Etc4 Etc
Note to authors Prefer active verbs (eg list make describe able tohellip) over passive verbs (understand know appreciatehellip) whenever possible Keep objectives short and specific Be sure that these objectives are fully covered in the section and are addressed in the quiz
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Section content
bull Note to authors This and additional inserted slides can be used to provide the content for Section 1
Page 9
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 10Page 10
[Add topic title]
bull [Add content for this topic]bull [Present details]bull [Give an example]bull [hellip]
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Nutrition in Global Health
Prepared as part of an education project of the Global Health Education Consortium amp collaborating partners
Allan J Davison PhD Professor BiochemistFaculty of Sciences Simon Fraser University
Department of Biomedical Sciences amp KinesiologyJune 2011
Roadmap to the worldrsquos nutritional healthCauses mechanisms solutions
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 12Page 12
Nutrition in global health - OverviewbullInequities in food distribution global hunger amp starvationbullOne billion are too hungry to live productive lives - an equal
number are adversely affected by overweightbull6 major deficiencies impact health through the life cycle
water protein iron vitamin A iodine folic acidbullChildbearing women amp their children are hardest hit
Meanwhile overnutrition amp inactivity risk of heart disease osteoporosis cancer diabetes strokes etc
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 13Page 13
Fundamentals and emphasis
ndash As we consider cause and effect we must ask How amp why have such inequities come to beWho and what factors impede solutions
What current initiatives will bring the resolution
ndash To help answer these we will emphasizeImmediate causes - scarcity of specific
nutrients Primary and secondary preventionPublic health approaches to solutions
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Other GHEC modules contribute to our understanding of Nutrition in Global Health
Page 14
This module does not stand alone ldquoRoadmap to a world without hungerrdquo will follow (see note)Two other GHEC modules deal with poverty amp hunger
a) Module 48 Acute malnutrition ndash Clinical aspects (deals with treatment)
b) Why is the 3rd world the 3rd world (underlying and diverse causes of poverty amp hunger) httpglobalhealtheduorgresourcesPagesdefaultaspx
To see this module in the context of what will follow see Note A
Note A
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server)
bull As a reality check and to create ldquoteachable momentsrdquo for what follows we now invite you to take a 5-minute pre-quiz
bull You will be offered 10 true-or-false questions to dispel some common misconceptions
bull Some of this misinformation is spread by those who have something to gain from it
bull After completing the pre-quiz we hope you will continue this module with greater interest and renewed clarity
Page 15
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 16Page 16
Learning objectives
1 Describe the extent of malnutrition amp its impact on people of the planet and understand how MDGs depend on nutrition
2 Analyze the factors that determine nutritional health3 Identify nutritional problems among individuals amp populations
identify causes amp appropriate solutions4 Assess risks at various stages of the life cycle amp recommend
strategies for diminishing risk5 Compare competing theories accounting for the inequities6 Predict outcomes by projecting current trends into the future
amp foresee a pathway toward a world without hunger
After completing this module you should be able to
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
To get the most out of this moduleIf you arehellip
bull a nutritionist or student of nutrition
bull a student of one of the health professions
bull planning a project in regions with severe nutritional problems
bull a public health practitioner
bull Pay attention to global amp public health amp policy implications
bull Pay attention to perspectives amp realities in desperate situations
bull Emphasize check-lists to prepare for field work amp gather information to recommendadvocate for intervention
bull Use these slides amp resources in your information teaching sessions
Page 17
You may want to hellip
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Preface Nutrition is crucial to global health
bull Among the immediately modifiable factors that affect individual amp public health hellip nutrition is of prime importance
bull Nutrition at every stage of life lays a foundation for health in the ensuing stage
bull For all nations rich amp poor nutrition determines physical health amp development through the life-cycle includingndash Success in childbearing cognitive function socio-economic
independence education disease resistance amp employabilityndash Health amp economic development are contingent on provision of
adequate food nutritional resources amp support Page 18
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
A vicious cycle economics hunger health
Page 19
Economic marginalization inability to
provide for self or family
Poverty diminished access to agricultural amp
food resources malnutrition
Physical amp cognitive impairment
susceptibility to disease early death
inability to earn an income
nutrition
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
The Millennium Development Goals
Page 20
At a UN Millennium (2002) summit the nations of the world set eight MDGs to be achieved by 2015
bull The worlds main development challenges were identifiedbull Specific actions and targets (the MDGs)bull A commitment to provide the means was made by
189 nations amp signed by 147 heads of stateThe MDGs break down into bull 21 quantifiable targets bull Targets are measured by 60 time-lined indicators
Some nations have kept their trust But some of the richest in the world have announced that they will not meet their commitments
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Nutrition amp Millennium Development Goals
Page 21
Primary goal is to eradicate extreme poverty amp hunger
Nutrition ndash is a direct prerequisite to goals1 3 4 5 amp 6 indirectly to 2 7 amp 8
see next 2 slides1
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 22
1 Eradicate extreme poverty amp hunger Poverty is the main determinant of hunger In turn malnutrition irreversibly compromises physical amp cognitive development amp thus transmits poverty amp hunger to future generations
2 Achieve universal primary education Malnutrition diminishes the chance that a child will go to school stay in school or perform well in school
3 Promote gender equality empower women Womenrsquos malnutrition impairs the whole familyrsquos health amp nutrition
Centrality of nutrition to MDGs 1 2 amp 3
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Centrality of nutrition to MDGs 4 5 amp 6
4 Reduce child mortality Delivery of a live healthy child is dependent above all on a well nourished mother Protein amp folic acid are critical here
5 Improve maternal health Malnutrition accentuates all major risk factors for maternal mortality eg inadequate protein iron iodine vitamin A amp calcium
6 Combat serious infectious diseases Malnutrition aggravates infections immune competence transmission amp mortality in HIV malaria tuberculosisAdapted from Gillespie and Haddad (2003) httpwebworldbankorg
Page 23
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 24
Goal Sub-targets likely to be achieved At risk unless urgent actions are taken 1 Eradicate extreme poverty amp hunger
reduce poverty by frac12 developing countriesrsquo export earnings devoted to servicing external debt fell by ~50
Eradicate hunger frac12 those in sub-Saharan Africa may still live on lt $1d frac14 of all children are underweight Prospects for fairer trade are bleak
2 Universal primary education
Primary school enrolment of at least 90 Promising progress
3 Promote gender equality empower women
The gender parity index in primary education gt 95
Of 113 countries 18 may achieve parity in 2o ed Parity in employment amp politics ndash seems unlikely
4 Reduce child mortality
Measles deaths is declining 89 of children receiving vaccination
Child mortality has dropped by frac12 but still too high
5 Improve maternal health
Some progress but 500000 pregnant women still die of complications
6 infectious disease amp safe water
AIDS declining deaths amp new infections malaria prevention has tripled tuberculosis to decline 16b people have gained access to safe drinking water
Some 25 billion people almost half the developing worldrsquos population live without improved sanitation
7 Global partnership for development
Unprecedented verbal agreement amp generous promises
In reality aid expenditures declined for last 2 years Few meet promised 07 of GNP
Slow progress toward the MDGsAt mid-way most MDGs are partly met
Only goal 2 is fully within reach
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 25
Nutrition in Global HealthCourse overview
1 Overview of nutrition across humankind2 Nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Universal limitations amp health consequences
bull We canrsquot survive without about 15 essential mineral elements so they are needed in our diets most in trace amounts
bull We canrsquot manufacture about 15 vitamins so they must be provided in our diets
And in additionhelliphellip
Page 26
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Universal limitations amp 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 ndash a period of rapid growth we are vulnerable to ldquokwashiorkorrdquo (protein insufficiency) because we canrsquot synthesize 8 ldquoessentialrdquo amino acids missing from our diet
2) In later life we are vulnerable to obesity amp diabetes ndash in part because we can make fat from carbohydrate but we canrsquot easily convert stored fats back to carbohydrates
Page 27
Note B
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Categories of nutritional statusNutritional status is assessed as one of four
categories 1 Good nutritional status All nutrients (right quantities time amp
place) allow optimal growth maintenance amp 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 (amp then body) protein is burned for energy A secondary protein deficiency ensues ndash 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 28
Note C
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Worldwide distribution of malnutritionOver 20 million children suffer from acute malnutrition WHO
Page 29
Scientific American Sept 2007
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Worldwide nutritional inequities follow poverty
(as do health inequities amp life expectancy)
bull Globally there is plenty of food for everyone but hellipthose who have more than they need find reasons not to share
bull The result ndash in the time you spend on this module over 1000 children will have died of hunger
bull Each day 1500 children go forever blind from lack of vitamin A
bull The poorest are 50-200x more likely to die in pregnancy (more than half these deaths are attributable to iron deficiency)
bull About 2 billion people (56 of pregnant women) have iron deficiency Their babies have low birth-weight amp mortality
Page 30
Note D
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
ldquoThe poorest of the poorrdquo - Public health nutritionists identify a subclass of the hungry - those who try to survive on resources worth less than $1 per day
bull We define this subclass as people who dont get enough to meet the ordinary demands of life
bull They lack the resources to earn a living or obtain whatrsquos needed for normal growth maintenance amp reproduction
bull It goes without saying that they are unable to provide the necessities for those who depend on them
Page 31
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
ldquoThe bottom billionrdquo (title of a book by Paul Collier )
bull Their lack of access to resources is such that a significant fraction will be unable to stay alive
bull 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 months planting
Page 32
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Unhelpful misconceptions about aid
Page 33
False ldquoMost aid money goes into the Swiss bank accounts of corrupt African dictatorsrdquo
ldquoAid creates dependence amp impedes self-sufficiencyrdquoldquoDespite all the aid $ the problems are only getting worserdquo
The truth is Overwhelmingly African leaders are not corrupt When they are most bribes come from the West
Well planned aid builds capacity amp self-sufficiency
Overall hunger worldwide is diminishing MDGs go forward because of the countries that honour their pledges
Note E
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Money Useless - no nearby shopsbull Itrsquos hard to imagine a malnourished community and
you may want to experience field conditions in advanceNo commerce Try it at a Medecins sans Frontieres site httpwwwstarvedforattentionorg
bull No shops to spend money in no one to employ anyone no one to sell things to
bull Hungry children are all too visible and those who didnrsquot survive are in tiny unmarked graves
Their needs are much more immediate than money We donrsquot need studies to learn what they need - read onPage 34
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
If they donrsquot need money ndash what do they need
bull Short term they likely need emergency rations safe waterIn conflict zones shelter amp safety to live plant harvest
bull Medium term they need to become self-sufficient withgood seeds fertilizer usable water sanitation low technology agricultural info amp resources health services mosquito nets pharmaceuticals
bull Long term they need the prerequisites of sustainable economic development - tools for development ndash see Part 2
bull Kids need particular attention ndash see note below amp later slides
Page 35
Note F
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
The goal is to see everyone self-sufficient bull People in the poverty trap live from hand to mouth with no opportunity
to put resources aside to build a better futurebull Such communities cannot access the ladder of economic development
without external helpbull The MDG promises of 07 of rich country GDP for aid was chosen to
eliminate extreme poverty amp hunger in 3 decadesbull But there are many nations that failed to meet this goal including both
the US and Canada
bull 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 36
Note G
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Some communities subsist in the ldquopoverty traprdquobull 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
bull 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 amp offer new life to the dispossessed as North America once opened its doors to the poor
Page 37
Note H
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 38
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top Six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Human Nutrition Fundamentals in Global Context
Page 39
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 amp what to you might reasonably ask for amp 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 3rd world health problems
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Dietary patterns across cultures
1 Hunter gatherers ndash the earliest category
Benefits mixed diet well nourished in good times
Risks famine or drought warfare amp plunder resource- depletion through population pressure
Prevalent problems starvation thirst life-expectancy
Page 40
Note I
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Dietary patterns across cultures2 Peasant agriculturalists ndash successful small scale
farmers (currently the largest group)bull Benefits close to food sources if no punitive taxes or rents
usually well adapted to their traditional dietsbull Risks single crop emphasis malnutrition plagues (locusts
rodents) exploitation warfare and plunderbull Prevalent problems vitamin deficiency starvation
alcoholism
Page 41
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
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 42
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Dietary patterns across cultures
4 Urban slum dwellers ndash 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 43
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Dietary patterns across cultures5 Affluent urbanites ndash 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 44
Note J
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 45
Nutrition in Global HealthCauses mechanisms solutions
Nutrition is crucial to global health amp MDGs
1 Overview of nutrition across humankind2 Human nutrition fundamentals in global context3 Top six nutrition problems amp their solutions4 Nutrition across the life cycle in rich amp poor nations5 Cause amp effect in population nutrition6 Overview and where we are now
Bridge to Part 2 Roadmap to a world without hunger
7
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Top 6 global manifestations of malnutrition
1) Water is a food (ldquofoodrdquo is the material we eat amp drinkrdquo)In hot climates we can die in a few hours from a lack of it
2) Protein-energy malnutritionbull The machinery of life sculpted from 20 different
amino acidsbull Deficiency is most serious in children (time of
fastest growth) failure to thrive stunted growthPage 46
We begin with a perspective then we take each of the 6 in turn
The material in this section is well reviewed at httpwwwpittedu~super1lecturelec0141indexhtmIron vitamin A iodine ndash check the latest information at httpwwwmicronutrientorgEnglishviewaspx=1
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Top 6 global manifestations of malnutrition (cont)
3) Iron deficiency - prevalent in Africa and Asiabull Women amp children are the most seriously affectedbull In parts of Africa 60 of children have blood ironbull About a quarter of these have symptoms of anaemia
Page 47
4) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencybull In high deficiency areas vit A tabs child mortality by gt20
amp child blindness by 80 Night-blindness is an early sign
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
5) Donrsquot underestimate iodine deficiency disordersbull WHO 2003 ldquo16 billion people donrsquot get enough iodinerdquo This
is the major cause of preventable brain damagebull Thanks to MDG programmes the problem is shrinking
httpwwwwhointvmnisiodinestatusenindexhtml
In addition nutrition determines chronic disease risk bull Heart disease osteoporosis cancer diabetes strokes etcWersquoll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Page 48
Top 6 global manifestations of malnutrition (cont)
Note K
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
6) Folic Acid is required for healthy babiesbull A deficiency causes spina-bifida ndash a common birth defectbull Supplements are recommended before start of pregnancybull 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
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Water one of our most important foods
bull Adequate safe water is most important dietary component
bull 9 million worldwide have water-borne diseasesbull In India contaminated water kills 300000 children
annually bull Problems relating to water supply amp safety have
simple relatively inexpensive solutionsbull Water ldquoownershiprdquo is however contentious amp
usually follows military power (eg in Middle East)
bull In hot humid conditions workers may need over 5 liters day amp to replace the NaCl lost along with water in sweat
Page 50
httpwwwwhointwater_sanitation_healthmdg1enindexhtml
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
The special importance of proteins
Page 51
bull Proteins are the machinery of life We have no storage form If we must use protein ldquostoresrdquo tissues lose function
bull Plasma liver and kidney lose function first Their proteins are the most ldquolabilerdquo Then digestive tract muscle amp heart
bull Proteins are made up of 20 amino acids 12 are non-essential and can be made from other dietary components
bull 8 amino acids are ldquoessentialrdquo If even one is missing no protein can be synthesized A protein lacking any one essential amino acid has zero ldquobiological value
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Dietary deficiency of proteins is deadly
Page 52
bull When any essential amino acid is missing all the rest are burned amp no protein synthesis can occur ndash zero
bull All essential aarsquos must be there at the same time Meeting an amino acid need one day later is useless
bull 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
bull 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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
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
bull In the African presentation of kwashiorkor a child is exposed to a protein deficient diet (ages 1 to 5) amp adapts successfully
bull Then a 1-week lack of protein (parent loses job baby is fed glucose-water only or a gastro-intestinal infection) kwash
bull Child is treated for kwash sent back to home to same diet amp reaches adolescence usually without recurrence
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Protein amp energy nutrition are inseparable
Page 54
bull When the diet lacks carbohydrates it uses some amino acids to make glucose for brain muscle etc
bull When a diet lacks total calories proteins are co-opted first dietary then plasma liver kidney etc
bull For these reasons a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed
bull Do an internet search on ldquoprotein-sparing effects of carbohydratesrdquo if you want to understand this further
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Protein-energy malnutrition - in adults
Page 55
Tissues are raided with the following consequences
bull Loss of plasma proteins oedema
bull Loss of liver amp kidney function diminished inactivation amp excretion of carcinogens and toxins
bull Loss of immune function gastro-intestinal infections
bull Loss of digestive tract liver function amino acids canrsquot be utilized for proteins No treatment can prevent death
bull Loss of muscle and heart tissue weakness heart failureOedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Hungry kids ndash difficulties in diagnosis
Page 56
bull Marasmic babies may not seem undernourished until a check for ldquopitting oedemardquo reveals that what appear to be strong arms and legs are in reality oedematous
bull Another diagnostic complication is that most deficiencies are combined as in protein energy malnutrition (ldquoPEMrdquo) with multiple vitamin deficiencies
bull 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 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 57
bull In uncomplicated kwashiorkor only protein is lacking - ldquoMalnourished not undernourishedrdquo
bull The risk of death or permanently retarded development is great and the risk is increased because its easier to miss the diagnosis
bull Kwashiorkor babies may have more than adequate calories in their diets They may be chubby with substantial subcutaneous fat
bull 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
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Protein malnutrition diagnosisWhen there are many sick kids in a community but
none look undernourished be sure to look for protein deficiency Why
bull Itrsquos important not to miss the diagnosis Kwashiorkor has a high fatality rate even with hospitalization
bull The 1st symptom to present is often diarrhoea or oedema
bull The child may be treated for a gastrointestinal infection while the underlying cause kwashiorkor goes undiagnosed
bull 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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
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
bull Growth charts give weight for stature length across age They provide criteria to estimate severity Proper use requires training
bull Change in position on a chart shows effectiveness of treatment amp probability of survival
bull 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
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Early measures required on PEM diagnosis
bull Treatment is urgent - hospitalization is preferred if available
bull Delayed physical growth is often restored in catch-up growth when a good diet is provided
bull Cognitive disabilities may be irreversible if prolonged
bull Ready-to use foods (RTUF) for PEM have saved many lives
bull 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
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Early measures required on PEM diagnosis
bull 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 httprehydrateorgorsmade-at-homehtmrecipes
bull Powdered milk protein in boiled water can be very helpful as an emergency measure
bull Acute fatality rate can be 25 even with prompt treatment
Page 61
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Iron deficiency affects 500 million globally
bull Causes insufficient availability of dietary iron or increased iron requirements to meet reproductive demands haemmorhage parasitic infections (often concurrently)
bull The result is an increasingly severe anaemia reduced work productivity rarr poverty diminished learning ability increased susceptibility to infection
For more on consequences of iron deficiency see Note M Page 62
Note M
httpwwwmicronutrientorgEnglishviewaspx=579
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Iron deficiency affects 500 million globally
bull Iron deficiency is best diagnosed in the preclinical stage by measurement of transferrin saturation
bull Females gt males due to iron loss at menstruation -- gt50 of pregnant women are affected in the developing world ndash 3 times as many as in developed countries
bull 25 of men also are deficient in iron in the developing world
Page 63
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Treatment of iron deficiency rebuilding iron reserves
bull Iron tablets are effective within weeks but non-compliance is common so compliance must be checked
bull Increase iron intake through combining iron-rich foods with agents that iron absorption (like vitamin C)
bull Encourage availability and consumption of iron-fortified foods Page 64
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Treatment of iron deficiency rebuilding iron reserves
bull Weekly daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiency
bull Treat causes of diminished iron reserves haemorrhage parasites (including malaria) and hemolytic conditions
bull Be alert Iron may be lethal in some inherited anaemias (thalassemias sickle cell or Hb M) common in Africa amp Asia
Page 65
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Iron excess - dangerous to some
Page 66
bull Those with haemolytic anaemias (eg thalassaemia ndash common in people of African or Asian descent) Iron should not be prescribed until the cause of an anaemia is known
bull Where iron pots are used for cooking or beer Siderosis iron deposition in liver kidney heart pancreas organ failure
bull Children Parents iron pills are attractive to kids in developed countries The most common of fatal childhood poisonings
bull 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 healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Vitamin A deficiency in public healthbull Vit A deficiency is a public health problem in over
70 countries especially in Africa SE Asia amp the W Pacific where it affects 250 million mostly aged 0-4 years
bull Night blindness may predict vitamin A deficiency with risk of permanent total blindness if it progresses
bull There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measles
bull Vitamin A supplements can be beneficial when given as seldom as once a year Check the latest information at
httpwwwmicronutrientorgenglishViewaspx=577
Page 67
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Vitamin A deficiency amp perinatal health
bull Vit A is crucial for maternal amp child survival supplements in high-risk areas can dramatically decrease maternal mortality
bull In pregnant women Vit A deficiency is seen in the last trimester when demands by unborn child amp mother are highest
bull 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 125 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 2010
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Vitamin A deficiency amp perinatal health
bull Night blindness in pregnant women - an early danger signbull In children the cost-effective prevention is breast-feedingbull Genetically engineered high Vit A rice crops could help
Caution Vit A supplements as retinol are controversial It can be toxic amp 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 bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Iodine deficiency disorders bull The worldrsquos major cause of preventable brain
damageIn 1990 16 billion people were at risk in over 100 countries mainly in parts of Africa and Asia where soil is iodine-deficient
bull Close to 40 million children have mental impairment from lack of iodine
bull As a result of the micronutrient initiative this number is falling
Page 70
For latest data see httpwwwmicronutrientorgenglishViewaspx=578
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Iodine deficiency disorders bull Consequences start before birth and continue afterward
ndash In utero spontaneous abortion congenital abnormalities amp retarded foetal development
ndash In early childhood and progress toward adolescence iodine deficiency causes cretinism an irreversible retardation Impacts home school amp work
ndash Today we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox amp polio
Page 71
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Toward iodine sufficiency ndash iodized saltbull A cost-effective low-tech therapy iodized salt costs
just $005 per person per yearbull UNICEF ICCIDD (International Council for Control
of IDD) amp the salt industry have set up iodization programmesGlobally 66 of households have access to iodized salt
bull As of 2009 the number of at risk countries has been halved
bull However progress has slowed and we are a decade behind promises of the international community
bull 54 countries are still affected ndash efforts must continue
Page 72
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 73
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Healthy diet
Optimal health physical amp mental development
reproduction survival
Absence of disease
foodamp water
healthservicesAccess to peri-
natalcare
Good nutritional status
Precursors
FoundationsAgriculturalproductivity
Economicdevelopment
Infrastructurenon-exploitive investment
intellectual property
Geography stability climateabsence of conflict natural resources
access to markets etc
Education NB women
of mouths to be fed
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Case studybull 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 considerationsndash What actually happenedndash What factors should be considered and their relative importance ndash 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 75
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 76
Supplementary noteNote to authors A ldquonoterdquo 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)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Maternal mortality (Demonstration index slide for a note)
bull 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
bull The major direct causes of maternal morbidity and mortality include hemorrhage infection high blood pressure unsafe abortion and obstructed labor
Page 77
Note button
A click on the note button takes viewer
to the note
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 78
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 (httpwww
whointreproductive-healthpublicationsmaternal_mortality_2005indexhtml
accessed 14 August 2008)
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Photo credits
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 79
Supplementary note to the preceding slide
Source httpwwwwhointmaking_pregnancy_safertopicsmaternal_mortalityenindexhtml
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 80
Supplementary note to a preceding slide
Why do mothers dieWomen 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
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 81
Supplementary note to a preceding slide
Semmelweiss 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 patients unique situation case by caseThe 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 Semmelweiss main finding mdash that all instances of puerperal fever could be traced back to only one single cause lack of cleanliness mdash 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 Semmelweiss groundbreaking idea was contrary to all established medical understandingAs 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]
Specifically Semmelweiss 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 othersDuring 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
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
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 82
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 Virchowrsquos great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time[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]
Supplementary note -- Example of extensive text
Author note You can copypaste and reduce font size to put text in a slide It will later be converted by GHEC into a supplementary note
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Thought or discussion questionsbull Note to authors These can be very useful and may be
used at multiple locations Two varietiesndash Thought question This is a ldquostop and thinkrdquo question that invites
the learner before proceeding to the next slide to think about the question and perhaps provide a short answer For example ldquoBefore 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 recipientrdquo
ndash Discussion question This can be a more general question especially suitable for use when the module has been assigned prior to a class
Page 83
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Special featuresbull 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 themndash Voiceoversndash Video and YouTube clipsndash Hotlinks to other resources
bull If you would like to use one or another of such features but need assistance please let us know
Page 84
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Audio voiceoverbull This slide describes and the following slide demonstrates
an audio voiceover Yoursquoll need a microphone (low cost) plugged into your computerndash Click on the loudspeaker and hear brief text
bull Voiceovers allow you to comment or expand on a slide and in the process lsquohumanizersquo your presence to the learner Clicking on the loudspeaker initiates the recording
bull 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 85
Page 86
Box 1 Five common shortcomings ofhealth-care delivery
Inverse care People with the most means ndash whose needs forhealth care are often less ndash consume the most care whereasthose with the least means and greatest health problems consumethe least10 Public spending on health services mostoften benefits the rich more than the poor11 in high- and low incomecountries alike1213Impoverishing care Wherever people lack social protectionand payment for care is largely out-of-pocket at the point ofservice they can be confronted with catastrophic expensesOver 100 million people annually fall into poverty because theyhave to pay for health care14Fragmented and fragmenting care The excessive specializationof health-care providers and the narrow focus of manydisease control programmes discourage a holistic approachto the individuals and the families they deal with and do notappreciate the need for continuity in care15 Health servicesfor poor and marginalized groups are often highly fragmentedand severely under-resourced16 while development aid oftenadds to the fragmentation17Unsafe care Poor system design that is unable to ensure safetyand hygiene standards leads to high rates of hospital-acquiredinfections along with medication errors and other avoidableadverse effects that are an underestimated cause of deathand ill-health18Misdirected care Resource allocation clusters around curativeservices at great cost neglecting the potential of primaryprevention and health promotion to prevent up to 70 of thedisease burden1920 At the same time the health sector lacksthe expertise to mitigate the adverse effects on health fromother 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 canrsquot get good reproduction then either donrsquot use a voiceover or ask your universityrsquos IT staff for help
Page 87
Quiz format options ndash Author noteThe next slides demonstrate six types of question options that you can use as ldquopop upsrdquo 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 studentrsquos response is not correct Do not be concerned with formatting we will handle that at the time of assembling your module
Page 88
Quiz format option 1
How many women die each year due to pregnancy-related conditions
a abc -- incorrect correct answer ishellipb def -- incorrect correct answer ishellipc ghi -- correctd jkl -- incorrect correct answer ishellipe mno -- incorrect correct answer ishellip
Page 89
Quiz format option 2
Which two of the following answers are major risk factors for pregnancy-related morbidity
a abc -- incorrect correct answers arehellipb def -- incorrect correct answers arehellipc ghi -- correctd jkl -- incorrect correct answers arehellipe mno -- correct
Page 90
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 ishellipb def -- incorrect correct answer ishellipc ghi -- incorrect correct answer ishellipd jkl -- incorrect correct answer ishellipe mno -- correct
Quiz format option 4Match each item on the left with the appropriate line on the right
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
bull 123bull 456bull 789bull 987bull 654bull 321
Page 91
Note Be sure to indicate which items are linked
Quiz option 5 ndash ranking Rank the below answers starting from most important to least important
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
Page 92
Note Be sure to show the correct ranking
Quiz option 6 ndash truefalseIndicate whether each answer is true or false (When response is incorrect a brief explanation as to why it is incorrect should be provided)
bull Abc [true]bull Def [false]bull Ghi [false]bull Jkl [true]bull Mno [true]bull Pqr [false]
Page 93
Quizbull Now we invite you to take the module quiz and
test your recent learningbull This module quiz includes
ndash [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]
bull After completing your quiz come back for the summary of this module presentation
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Page 88
Quiz format option 1
How many women die each year due to pregnancy-related conditions
a abc -- incorrect correct answer ishellipb def -- incorrect correct answer ishellipc ghi -- correctd jkl -- incorrect correct answer ishellipe mno -- incorrect correct answer ishellip
Page 89
Quiz format option 2
Which two of the following answers are major risk factors for pregnancy-related morbidity
a abc -- incorrect correct answers arehellipb def -- incorrect correct answers arehellipc ghi -- correctd jkl -- incorrect correct answers arehellipe mno -- correct
Page 90
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 ishellipb def -- incorrect correct answer ishellipc ghi -- incorrect correct answer ishellipd jkl -- incorrect correct answer ishellipe mno -- correct
Quiz format option 4Match each item on the left with the appropriate line on the right
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
bull 123bull 456bull 789bull 987bull 654bull 321
Page 91
Note Be sure to indicate which items are linked
Quiz option 5 ndash ranking Rank the below answers starting from most important to least important
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
Page 92
Note Be sure to show the correct ranking
Quiz option 6 ndash truefalseIndicate whether each answer is true or false (When response is incorrect a brief explanation as to why it is incorrect should be provided)
bull Abc [true]bull Def [false]bull Ghi [false]bull Jkl [true]bull Mno [true]bull Pqr [false]
Page 93
Quizbull Now we invite you to take the module quiz and
test your recent learningbull This module quiz includes
ndash [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]
bull After completing your quiz come back for the summary of this module presentation
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Page 89
Quiz format option 2
Which two of the following answers are major risk factors for pregnancy-related morbidity
a abc -- incorrect correct answers arehellipb def -- incorrect correct answers arehellipc ghi -- correctd jkl -- incorrect correct answers arehellipe mno -- correct
Page 90
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 ishellipb def -- incorrect correct answer ishellipc ghi -- incorrect correct answer ishellipd jkl -- incorrect correct answer ishellipe mno -- correct
Quiz format option 4Match each item on the left with the appropriate line on the right
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
bull 123bull 456bull 789bull 987bull 654bull 321
Page 91
Note Be sure to indicate which items are linked
Quiz option 5 ndash ranking Rank the below answers starting from most important to least important
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
Page 92
Note Be sure to show the correct ranking
Quiz option 6 ndash truefalseIndicate whether each answer is true or false (When response is incorrect a brief explanation as to why it is incorrect should be provided)
bull Abc [true]bull Def [false]bull Ghi [false]bull Jkl [true]bull Mno [true]bull Pqr [false]
Page 93
Quizbull Now we invite you to take the module quiz and
test your recent learningbull This module quiz includes
ndash [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]
bull After completing your quiz come back for the summary of this module presentation
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Page 90
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 ishellipb def -- incorrect correct answer ishellipc ghi -- incorrect correct answer ishellipd jkl -- incorrect correct answer ishellipe mno -- correct
Quiz format option 4Match each item on the left with the appropriate line on the right
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
bull 123bull 456bull 789bull 987bull 654bull 321
Page 91
Note Be sure to indicate which items are linked
Quiz option 5 ndash ranking Rank the below answers starting from most important to least important
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
Page 92
Note Be sure to show the correct ranking
Quiz option 6 ndash truefalseIndicate whether each answer is true or false (When response is incorrect a brief explanation as to why it is incorrect should be provided)
bull Abc [true]bull Def [false]bull Ghi [false]bull Jkl [true]bull Mno [true]bull Pqr [false]
Page 93
Quizbull Now we invite you to take the module quiz and
test your recent learningbull This module quiz includes
ndash [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]
bull After completing your quiz come back for the summary of this module presentation
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Quiz format option 4Match each item on the left with the appropriate line on the right
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
bull 123bull 456bull 789bull 987bull 654bull 321
Page 91
Note Be sure to indicate which items are linked
Quiz option 5 ndash ranking Rank the below answers starting from most important to least important
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
Page 92
Note Be sure to show the correct ranking
Quiz option 6 ndash truefalseIndicate whether each answer is true or false (When response is incorrect a brief explanation as to why it is incorrect should be provided)
bull Abc [true]bull Def [false]bull Ghi [false]bull Jkl [true]bull Mno [true]bull Pqr [false]
Page 93
Quizbull Now we invite you to take the module quiz and
test your recent learningbull This module quiz includes
ndash [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]
bull After completing your quiz come back for the summary of this module presentation
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Quiz option 5 ndash ranking Rank the below answers starting from most important to least important
bull Abcbull Defbull Ghibull Jklbull Mnobull Pqr
Page 92
Note Be sure to show the correct ranking
Quiz option 6 ndash truefalseIndicate whether each answer is true or false (When response is incorrect a brief explanation as to why it is incorrect should be provided)
bull Abc [true]bull Def [false]bull Ghi [false]bull Jkl [true]bull Mno [true]bull Pqr [false]
Page 93
Quizbull Now we invite you to take the module quiz and
test your recent learningbull This module quiz includes
ndash [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]
bull After completing your quiz come back for the summary of this module presentation
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Quiz option 6 ndash truefalseIndicate whether each answer is true or false (When response is incorrect a brief explanation as to why it is incorrect should be provided)
bull Abc [true]bull Def [false]bull Ghi [false]bull Jkl [true]bull Mno [true]bull Pqr [false]
Page 93
Quizbull Now we invite you to take the module quiz and
test your recent learningbull This module quiz includes
ndash [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]
bull After completing your quiz come back for the summary of this module presentation
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Quizbull Now we invite you to take the module quiz and
test your recent learningbull This module quiz includes
ndash [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]
bull After completing your quiz come back for the summary of this module presentation
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Page 95Page 95
Summary
bull [Add content to your summary slide(s) ]bull [State what has been learned and if appropriate ways
to apply the learning ]bull [Make sure you cover the most important points in your
module objectiveshellip]
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Page 96Page 96
Further readings amp other resources
bull Note to authors Provide a listing briefly annotated if useful of additional resources relevant to the modulersquos topic Especially useful are recent journal reviews and good online material
bull Source abcbull Source defbull Source ghibull Source etc
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Page 97Page 97
Acknowledgments
bull 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 ldquoCreditsrdquo slide
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
Credits [for named authors you can include contact information if desired]
bull [Add author 1 information]bull [Add author 2 information]bull [Add hellip ]
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-
End of module
[Reserved for GHEC notes and acknowledgment of donor organizations]
- Nutrition in Global Health Context
- Module overview (Delete this slide when no longer necessary)
- Module overview (Delete this slide when no longer necessary) (2)
- Module overview (Delete this slide when no longer necessary) (3)
- Module features (Delete this slide when no longer necessary)
- Slide 6
- List of module sections (Replace template text)
- Learning objectives Section 1
- Section content
- [Add topic title]
- Nutrition in Global Health
- Nutrition in global health - Overview
- Fundamentals and emphasis
- Other GHEC modules contribute to our understanding of Nutrition
- Pre-quiz (pending completion of ldquoquizrdquo feature in GHECrsquos server
- Learning objectives
- To get the most out of this module
- Preface Nutrition is crucial to global health
- A vicious cycle economics hunger health
- The Millennium Development Goals
- Nutrition amp Millennium Development Goals
- Centrality of nutrition to MDGs 1 2 amp 3
- Centrality of nutrition to MDGs 4 5 amp 6
- Slow progress toward the MDGs
- Nutrition in Global Health Course overview
- Universal limitations amp health consequences
- Universal limitations amp health consequences (2)
- Categories of nutritional status
- Worldwide distribution of malnutrition
- Worldwide nutritional inequities follow poverty (as do health
- ldquoThe bottom billionrdquo (title of a book by Paul Collier )
- ldquoThe bottom billionrdquo (title of a book by Paul Collier ) (2)
- Unhelpful misconceptions about aid
- Money Useless - no nearby shops
- If they donrsquot need money ndash what do they need
- The goal is to see everyone self-sufficient
- Some communities subsist in the ldquopoverty traprdquo
- Nutrition in Global Health Causes mechanisms solutions Nutri
- Human Nutrition Fundamentals in Global Context
- Dietary patterns across cultures
- Dietary patterns across cultures (2)
- Dietary patterns across cultures (3)
- Dietary patterns across cultures (4)
- Dietary patterns across cultures (5)
- Nutrition in Global Health Causes mechanisms solutions Nutri (2)
- Top 6 global manifestations of malnutrition
- Top 6 global manifestations of malnutrition (cont)
- Top 6 global manifestations of malnutrition (cont) (2)
- Top 6 global manifestations of malnutrition (cont) (3)
- Water one of our most important foods
- The special importance of proteins
- Dietary deficiency of proteins is deadly
- Humans adapt to low protein intakes
- Protein amp energy nutrition are inseparable
- Protein-energy malnutrition - in adults
- Hungry kids ndash difficulties in diagnosis
- Protein malnutrition is different
- Protein malnutrition diagnosis
- Tracking protein-energy malnutrition in kids
- Early measures required on PEM diagnosis
- Early measures required on PEM diagnosis (2)
- Iron deficiency affects 500 million globally
- Iron deficiency affects 500 million globally
- Treatment of iron deficiency rebuilding iron reserves
- Treatment of iron deficiency rebuilding iron reserves (2)
- Iron excess - dangerous to some
- Vitamin A deficiency in public health
- Vitamin A deficiency amp perinatal health
- Vitamin A deficiency amp perinatal health (2)
- Iodine deficiency disorders
- Iodine deficiency disorders (2)
- Toward iodine sufficiency ndash iodized salt
- Slide 73
- Slide 74
- Case study
- Slide 76
- Maternal mortality (Demonstration index slide for a note)
- Slide 78
- Slide 79
- Slide 80
- Slide 81
- Slide 82
- Thought or discussion questions
- Special features
- Audio voiceover
- Slide 86
- Slide 87
- Slide 88
- Slide 89
- Slide 90
- Quiz format option 4 Match each item on the left with the appr
- Quiz option 5 ndash ranking Rank the below answers starting from
- Quiz option 6 ndash truefalse Indicate whether each answer is true
- Quiz
- Summary
- Further readings amp other resources
- Acknowledgments
- Credits [for named authors you can include contact information
- End of module
-