TF In the poor nations almost everyone is hungry; in the - PowerPoint Presentation

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

Which THREE of the following are True?

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

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

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

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Page 5Page 5Nutrition in global health - OverviewInequities in food distribution  global hunger & starvationOne billion are too hungry to live productive lives - an equal number are adversely affected by overweight!6 major deficiencies impact health through the life cycle: water, protein, iron, vitamin A, iodine, folic acid

Childbearing women & their children are hardest hit

Meanwhile

, overnutrition & inactivity



risk of heart disease, osteoporosis, cancer, diabetes, strokes, etc

.

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Global Nutrition We have a roadmap to a world without hungerWhere are we headed?The uglyWe know what worksIt wasn’t an accident

How did we get here?

Where are we now?

Can anything

help? Yes

Stuffed & starved

The bad

We keep doing what

we know

doesn’t work?

The good

Most of you will see hunger in museums!

We are part of the problem

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

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

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3 Critical periods: nutrition in the life-cycle4 slides: Perinatal nutrition: 0-6 mo: Breast vs. formula 1st 5 y Weaning & infancy –intellectual developSchool years; ability to learn Work performance Elderly Page 9

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

A click on the note button takes viewer to the note

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Nutrition through the life-cyclePage 11

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

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Factors in perinatal nutrition (see also Module on Acute malnutrition)Delaying clamping the umbilical cord until it stops pulsing iron stores see: www.naturalchildbirth.org/natural/resources/labor/labor04.htm http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/jccom/en/index.htmlIdeally, babies should receive vitamins E & K injections at birthA baby who’s healthy at birth may experience "failure to thrive" (or "growth faltering") in the first year of life. So …..Good infant feeding behaviors must start early. Most importantly, breast-feeding should be initiated within an hour of birth & maintained exclusively for 6 months. Breastfeeding could prevent 1.3 million deaths each year http://www2.unicef.org/nutrition/index_22657.html Page 13

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Perinatal nutrition requires attention1Malnutrition in pregnancy  birth defects & low birth-weightFailure to thrive is an early danger sign, requiring investigation Nutrition in infancy to early life impacts physical & cognitive development. It determines immediate & future risks of blindness, thyroid function, bone development, & moreUnder-nutrition or deficiencies of many micronutrients can cause failure to thrive“ Iron, vitamins K and E are of particular importance. Refer to:1http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.htmlPage 14

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

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Parenthetically – a personal perspectiveHow easily we see the moral failings of the past. Slavery, the holocausts & genocides, conquests motivated by greedWhen future generations look amazed at the moral blindness of this generation, what will stand out? Clearly child hungerWhere life expectancy is short, toddlers are orphans. In war or famine a region may lack necessities. You can’t blame a child Yet in rich countries, yes, the US & Canada, we turn our empty eyes and hands away from those outside our bordersA napalmed child turned a nation’s mind to peace. What will it take to open our eyes to children dying of hunger? Page 16

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Nutrition through the life cycle - adolescenceAdolescence carries risks for both poor & affluentAdolescent & adult patterns of food consumption & activity massively impact immediate & future health risksAdolescents are notoriously careless about health. Their eating patterns can lead quickly to obesity or anorexia. Page 17

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Nutrition through the life cycle - adolescenceAdolescence carries risks for both poor & affluentDieting can lead to deficiencies of vit. C, protein, folic acid in a sedentary person. Even if a good mix of foods is consumed, total food intake may be insufficient.A pattern of healthy eating in adolescence sets a pattern that can promote lifelong healthA foundation for healthy bones is set by exercise, calcium, & vitamin D. After early adult life, bones go slowly downhillPage 18

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Nutrition through the life cycle – adult lifeNutrition & acute & infectious diseasesMalnutrition depletes immunity leading to increased risk & severity of infections & parasites: AIDS, malaria, etc.Flagrant deficiencies of specific micronutrients can put at risk the life & health of the mother in pregnancy & lactationNutritional anaemias, pellagra, blindness, skin disordersberiberi, scurvy, etc, can range in severity from mild to fatalPage 19

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Adult life - degenerative diseasesIn late life, risk of breast, prostatic, & most other cancers are predicted by diet, obesity, inactivity or smoking in adult life Also heart disease, strokes, osteoporosis, diabetesCancers and diabetes are now leading causes of death & disability in low- and middle-income countries (see Lancet August 13, 2009) Nearly two-thirds of the world’s 7.6 million cancer-related deaths now occur in developing nations.Page 20

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

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Differential nutritional vulnerability of femalesWomen suffer 80% of hip fractures; lifetime risk 30 - 40% compared with 13% for men.Osteoporosis prevention (exercise, calcium, & vitamin D) must start well before age 30 when bones still respond. Negative calcium balance in later life is not very responsive to nutritional measures.Page 22

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Under- & over-nutrition occur in all culturesDisparities in income, nutrition & health care are increasing between countries & within groups in the same country In addition, in low and middle income countries diseases of overnutrition are increasingly commonObesity related disorders, including diabetes, are now as important in some lower to middle income countries as in North America and the European UnionPage 23

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Also, under-nutrition occurs in many rich nationsIn rich nations, enormous wealth for some has left others ravaged by health costs, unemployment, foreclosuresDeveloped countries have marginalized cultural groups. Hunger is common in N & S America, China & E EuropeFor example, ~49% of US children (and over 80% of black children) require food-aid at some time during childhoodScandinavia & few western European countries are almost the only exceptionsPage 24

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Overnutrition is no longer limited to rich countriesObesity is a growing problem worldwide, particularly among those who lack resources for a wide range of food choices. All too often, the cheapest foods are high calorie, poor in nutrients, rich in sugar, salt, fat, & trans-fats The predominant cause of obesity is under-exercising rather than overeating. On average, overweight people eat slightly fewer calories than lean people, but are much less active Obesity increases risk of many disorders, most notably cardiovascular disease, cancer, adult-onset diabetes. “Prevention is much better than cure”. Page 25

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Overnutrition is no longer limited to rich countriesPreviously, the poorest were almost immune to diabetes, hypertension, gout, & atherosclerosis & heart diseaseNo longer. These are growing problems, impacting health worldwide. In the next few slides we’ll consider prevention.Diabetes has reached epidemic proportions threatening, vision, kidney function, mobility, heart-health & life itself. A cluster of symptoms, hypertension, hyperlipidemia, and hyperglycemia is sometimes called “metabolic syndrome”Each of them increases risk of heart disease, and together the risk is greatly amplified. Read on…..Page 26

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Prevention of heart attacks and strokesRisk factors : hypertension, hyperlipidemias (LDL / “bad” cholesterol), inactivity & diabetes. All correlated with obesitySmoking is the most life-shortening risk factor of allThese risks can be changed earlier or later, by modification of diet & other life-style changes or medication In the past 5 years research has established that exercise & a lean body are the most powerful predictors of a long healthy life, and also of clear thinking into old agePage 27

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Prevention of heart attacks and strokesThere is no easy solution to obesity. In a typical study: <10% of people dieting, <10% of those exercising, and <15% of those exercising & dieting, lost weight.However, over 80% of those who underwent stomach stapling or banding lost weight! Not very encouraging, for lifestyle treatment. Many argue that surgery to control weight should be done more oftenPage 28

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Measures to diminish cardiovascular risksLifestyle measures: have greatest impact in older people! Increasing consumption of fruit & vegetables by one to two servings can cut cardiovascular risk by 30%Reduction of blood pressure by 6 mm Hg reduces stroke risk by 40% & heart attack by 15%. Hydrochlorthiazides (diuretics) are inexpensive and effectiveMoreover, a 10% reduction in LDL cholesterol reduces the risk of coronary heart disease by 30%Page 29

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Measures to diminish cardiovascular risksModest cutbacks in saturated fat & salt improve blood pressure & lipids; & diminish risk of cardiovascular diseaseLifestyle measures are, optimally, combined with pharmaceutical intervention Best practices in the area of diabetes & cardiovascular disease are a moving target. Anyone teaching or practicing in this area needs skills in finding evidence-based information in an ocean of misinformation.Page 30

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Nutrition in later life and old ageWorldwide, the proportion of people over 60 is increasing. By 2025, the world will have more than 1.2 billion older persons – two-thirds of them in low income countriesThe foundation laid in earlier life determines risk ofdiabetes, heart disease, hypertension, strokes, osteoporosis, cancer, etc. All these bring special nutritional concerns. Many of the diseases of late life are diagnosed too late for effective treatment. Prevention at an early age is the goalPage 31

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Nutrition in later life and old ageOld age can be cut short by many kinds of malnutritionDeficiencies of calcium, iron, water, vit. B12 can severely compromise old ageLoss of taste and smell can render the elderly at risk for food poisoning from spoiled foodLoss of thirst sensitivity in this age group makes dehydration (inadequate water intake) a common cause of confusion, headache, & occasionally kidney stonesPrevention is better than cure, & symptomatic treatments that are effective ,are often unavailable to the aged in LMICsPage 32

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Dietary patterns across cultures2. Peasant agriculturalists – successful small scale farmers (currently the largest group)Benefits: close to food sources; if no punitive taxes or rents;usually well adapted to their traditional dietsRisks: single crop emphasis  malnutrition, plagues (locusts, rodents), exploitation, warfare and plunderPrevalent problems: vitamin deficiency, starvation, alcoholismPage 33

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Dietary patterns across cultures3. Indigent, landless crop plantersBenefits: Community, share with family, neighbors, income is typically less than a dollar a dayRisks: Crop failure, drought or famine, erosion, soil-exhaustion, pestilence, economic exploitation (by landlords, seed providers, loan-sharks), displacement, forced migration, civil unrest or foreign invasionProblems: 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 healthPage 34

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Dietary patterns across cultures4. Urban slum dwellers – fastest growing group Benefits: hope for jobs, escape from drought or crop failure Risks: overcrowding, poverty, poor hygiene, limited food choice, social disruption  loss of traditional diets, crime Prevalent problems: deficiencies of essential nutrients, alcoholism, obesity, kwashiorkor, epidemicsPage 35

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Dietary patterns across cultures5. Affluent urbanites – most recent category Benefits: many food choices (appropriate and inappropriate) Risks: inactivity along with high fat, sugar, alcohol intakes Prevalent problems: overnutrition, obese babies and adultsdiabetes (carbohydrates), cholesterol, atheroma (lipid), strokes, heart disease diabetes, gout (uric acid - meat sources)Page 36Note J

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5 Nutrition & disease cause vs effect4 slides: Acute and chronic malnutrition; Socio-cultural determinants of malnutrition Undernutrition as contributor to much childhood mortality / morbidity Micronutrient deficiencies: Iron, Vitamin A, iodine, calcium, etc. Nutrition &major diseases: CV, strokes, diabetesOver-nutrition, obesity Page 37

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

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Top 6 global manifestations of malnutritionWater is a food (“food” is the material we eat & drink”)In hot climates, we can die in a few hours from a lack of it2) Protein-energy malnutritionThe machinery of life, sculpted from 20 different amino acidsDeficiency is most serious in children (time of fastest growth):  "failure to thrive", stunted growthPage 39We begin with a perspective, then we take each of the 6 in turnThe material in this section is well reviewed at: http://www.pitt.edu/~super1/lecture/lec0141/index.htmIron, vitamin A, iodine – check the latest information at: http://www.micronutrient.org/English/view.asp?x=1

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Top 6 global manifestations of malnutrition (cont.)3) Iron deficiency - prevalent in Africa and AsiaWomen & children are the most seriously affectedIn parts of Africa 60% of children have  blood ironAbout a quarter of these have symptoms of anaemiaPage 404) Vitamin A deficiencyOver 100 million children under 5 suffer vitamin A deficiencyIn high deficiency areas vit. A tabs  child mortality by 23 % &  child blindness by 80%. Night-blindness is an early sign

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5) Don’t underestimate iodine deficiency disordersWHO 2003: “1.6 billion people don’t get enough iodine”. This is the major cause of preventable brain damage.Thanks to MDG programmes the problem is shrinking! http://www.who.int/vmnis/iodine/status/en/index.html In addition nutrition determines chronic disease risk Heart disease, osteoporosis, cancer, diabetes, strokes, etc.We’ll go through these one at a time in the following slidesPage 41Top 6 global manifestations of malnutrition (cont.)For categories of at risk people across countries, see Note K

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6) Folic Acid is required for healthy babiesA deficiency causes spina-bifida – a common birth defectSupplements are recommended before start of pregnancy50% of pregnancies are unintentional!Women who might become pregnant, need adviceMore details on these nutrients in the ensuing slidesPage 42Top 6 global manifestations of malnutrition (cont.)

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Water: one of our most important foodsAdequate safe water is most important dietary component9 million worldwide have water-borne diseasesIn India, contaminated water kills 300,000 children annually Problems relating to water supply & safety have simple, relatively inexpensive solutionsWater “ownership” is, however, contentious & usually follows military power (e.g. in Middle East)In hot humid conditions workers may need over 5 l / day & also need to replace the NaCl lost along with water in sweatPage 43http://www.who.int/water_sanitation_health/mdg1/en/index.html

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The special importance of proteinsPage 44Proteins are the machinery of life. We have no storage form. If we must use our protein “stores”, our tissues lose functionPlasma, liver and kidney lose function first. Their proteins are the most “labile”. Then, digestive tract, muscle & heartProteins are made up of 20 amino acids. 12 are non-essential – they can be made from other dietary components8 amino acids are “essential”. If even one is missing, no protein can be synthesized. A protein lacking any one essential amino acid has zero “biological value

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Dietary deficiency of proteins is deadlyPage 45When any essential amino acid is missing, all the rest are burned & no protein synthesis can occur – zero!All essential aa’s must be there at the same time. Meeting an amino acid need 1 day later is uselessA 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 soProtein complementarity, de-emphasized in nutrition courses, can be vital where protein intake is compromised

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

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Protein & energy nutrition are inseparablePage 47When the diet lacks carbohydrates, it uses some amino acids to make glucose for brain, muscle, etc.When a diet lacks total calories, proteins are co-opted, first dietary, then plasma, liver, kidney, etc.For these reasons, a diet previously adequate in essential amino acids becomes inadequate if carbohydrate or calories are removed. Google “protein-sparing effects of carbohydrates” if you want to understand this further

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Protein-energy malnutrition - in adultsPage 48Tissues are raided, with the following consequences:Loss of plasma proteins  oedema*Loss of liver & kidney function  diminished inactivation & excretion of carcinogens and toxinsLoss of immune function  gastro-intestinal infectionsLoss of digestive tract / liver function  amino acids can’t be utilized for proteins. No treatment can prevent deathLoss of muscle and heart tissue  weakness, heart failure

*Oedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities

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Hungry kids – difficulties in diagnosisPage 49Marasmic babies may not seem undernourished until a check for “pitting oedema” reveals that what appear to be strong arms and legs, are in reality oedematousAnother diagnostic complication is that most deficiencies are combined, as in protein energy malnutrition “PEM” with multiple vitamin deficienciesThe distinctions are crucial both in determining treatment, and in determining if the underlying problem in the community is scarcity of food, a protein, or many nutrients

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Page 50In uncomplicated kwashiorkor, only protein is lacking - “Malnourished, not undernourished” The risk of death or permanently retarded development is great, and the risk is increased because its easier to miss the diagnosisKwashiorkor babies may have more than adequate calories in their diets. They may be chubby, with substantial subcutaneous fat Kwashiorkor may go unnoticed even when urgent hospitalization is needed, or when death is imminentProtein malnutrition is different

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

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Tracking protein-energy malnutrition in kidsFailure to thrive may be an early warning of flagrant PEM in an individual child or a community. Always investigate the causeGrowth charts give weight for stature / length across age. They provide criteria to estimate severity. Proper use requires training!Change in position on a chart shows effectiveness of treatment & probability of survivalIf many children in a community show up at risk on growth charts, authorities must be alerted to endemic problemsPage 52

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Early measures required on PEM diagnosisTreatment is urgent - hospitalization is preferred if availableDelayed physical growth is often restored in catch-up growth when a good diet is providedCognitive disabilities may be irreversible if prolongedReady-to use foods (RTUF) for PEM have saved many livesOral rehydration salt (ORS) therapy is also life-saving when there is accompanying diarrhoea (which is usually the case) Page 53Note L

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Early measures required on PEM diagnosisBoth RTUF and ORS can be given at home in a bottle (Wikipedia). World production of ORS is around 500 million sachets / year. Improvisation of ORS is described at http://rehydrate.org/ors/made-at-home.htm#recipesPowdered milk protein in boiled water can be very helpful as an emergency measure Acute fatality rate can be 25% even with prompt treatmentPage 54

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Iron deficiency affects 500 million globallyCauses: insufficient availability of dietary iron, or increased iron requirements to meet reproductive demands, haemmorhage, parasitic infections (often concurrently).The result is an increasingly severe anaemia, reduced work productivity → poverty, diminished learning ability, increased susceptibility to infectionFor more on consequences of iron deficiency, see …Page 55Note Mhttp://www.micronutrient.org/English/view.asp?x=579

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Iron deficiency affects 500 million globally Iron deficiency is best diagnosed in the preclinical stage, by measurement of transferrin saturationFemales > males due to iron loss at menstruation -- 56% of pregnant women are affected – 3 x as many as in developed countries25% of men also are deficient in iron in the developing world Page 56

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Treatment of iron deficiency: rebuilding iron reserves Iron tablets are effective within weeks, but non-compliance is common so compliance must be checkedIncrease iron intake through combining iron-rich foods with agents that  iron absorption (like vitamin C)Encourage availability and consumption of iron-fortified foodsPage 57

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Treatment of iron deficiency: rebuilding iron reserves Weekly / daily supplementation is recommended for vulnerable groups in areas with intractable iron deficiencyTreat causes of diminished iron reserves: haemorrhage, parasites (including malaria), and hemolytic conditions.Be alert! Iron may be lethal in some inherited anaemias (thalassemias, sickle cell, or Hb M) common in Africa & Asia Page 58

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Iron excess - dangerous to somePage 59Those with haemolytic anaemias: (eg thalassaemia – common in people of African or Asian descent). Iron should not be prescribed until the cause of an anaemia is knownWhere iron pots are used for cooking or beer: Siderosis: iron deposition in liver, kidney, heart, pancreas  organ failureChildren: Parents' iron pills are attractive to kids in developed countries. The most common of fatal childhood poisoningsThose with familial haemochromatosis: This common inherited disease has symptoms similar to siderosis (above)The first sign of this disease is often inoperable liver cancerNote N

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Vitamin A deficiency in public healthVit. A deficiency is a public health problem in over 70 countries, especially in Africa, SE Asia & the W Pacific where it affects 250 million mostly aged 0-4 years Night blindness may predict vitamin A deficiency, with risk of permanent total blindness if it progresses.There is also increased risk of severe illness and death from infections such as diarrhoeal disease and measlesVitamin A supplements can be beneficial when given as seldom as once a year. Check the latest information at:http://www.micronutrient.org/english/View.asp?x=577Page 60

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Vitamin A deficiency & perinatal healthVit. A is crucial for maternal & child survival, supplements in high-risk areas can dramatically decrease maternal mortality*In pregnant women Vit. A deficiency is seen in the last trimester when demands by unborn child & mother are highestPartnerships for progress in vitamin A nutritionIn 1998 WHO, UNICEF, CIDA, USAID (ia) launched a global initiative in 40 countries that has to date averted 1.25 million deaths, by giving vitamin A to kids at clinicsPage 61*This issue is under active investigation. For the status at time of writing see Lancet, Volume 376, Issue 9744, p 873 - 874, 11 September 2010

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Vitamin A deficiency & perinatal healthNight blindness in pregnant women - an early danger signIn children, the cost-effective prevention is breast-feedingGenetically engineered high Vit. A rice crops could help Caution: Vit. A supplements as retinol are controversial. It can be toxic & teratogenic ( birth defects). However, given as carotene, vitamin A supplements are safe, leading only to an orange tinge in skin colour.Page 62

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Iodine deficiency disorders The world’s major cause of preventable brain damageIn 1990: 1.6 billion people were at risk in over 100 countries, mainly in parts of Africa and Asia where soil is iodine-deficient 38 Million children have mental impairment from lack of iodineAs a result of the micronutrient initiative, this number is fallingPage 63For latest data, see: http://www.micronutrient.org/english/View.asp?x=578

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Iodine deficiency disorders Consequences start before birth and continue afterward In utero, spontaneous abortion, congenital abnormalities & retarded foetal developmentIn early childhood and progress toward adolescence iodine deficiency causes cretinism, an irreversible retardation. Impacts home, school, & workToday we are on the verge of eliminating iron deficiency --- a major public health triumph like getting rid of smallpox & polioPage 64

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Toward iodine sufficiency – iodized saltA cost-effective low-tech therapy, iodized salt costs just $0.05 per person per yearUNICEF, ICCIDD (International Council for Control of IDD), & the salt industry have set up iodization programmes.Globally, 66% of households have access to iodized salt.As of 2009 the number of at risk countries has been halved!However, progress has slowed and we are a decade behind promises of the international community. 54 countries are still affected – efforts must continuePage 65