Midterm Material Flashcards
Broadly describe what is meant by ‘malnutrition’.
An all inclusive term that represents all manifestations of poor nutrition. It can mean any or all forms of undernutrition, overweight, and obesity (Webb et al., 2018)
Discuss factors that contribute to over- and under-nutrition.
Economic inequality is a primary cause of both over- and under-nutrition.
Undernutrition → food insecurity
Overnutrition → obesogenic culture
Clearly define food security and give specific examples of what can cause food insecurity.
Food security means that all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food that meets their food preferences and dietary needs for an active and healthy life.
Examples of causes of insecurity:
- Poverty, unemployment, or low income
- Lack of affordable housing
- Chronic health conditions or lack of access to healthcare
- Poor sanitation and high prevalence of infectious disease → disease can impair absorption of nutrients and reduce appetite
- Systemic racism
- Lack of access to arable land
- Conflict, violence, and wars
- Unfair trade
- Biofuels → decrease available crops for food as they are diverted to biofuel production
- Natural disasters
- Climate change
- Food waste
Identify examples of consequences of undernutrition at individual and population levels and justify why issues associated with malnutrition need to be addressed.
-
Maternal underweight → BMI <18.5; represents chronic energy deficiency; associated with LBW children which can lead to stunting; loss in linear growth during the first 1000 days of life is not recovered
- Low birthweight → associated with increased morbidity and mortality; in South Asia, ~28% of infants are born with LBW.
- Child stunting → height for age < -2 SD of median; sign of chronic distress; captures early chronic exposure to undernutrition; 4x higher risk of death
- Child wasting → weight for height < -2 SD of median; major cause of child mortality in famine; sign of acute hunger; 9x higher risk of death
- Underweight → inadequate weight for age; a composite indicator that includes elements of stunting and wasting.
- Undernutrition can also cause various diseases such as blindness due to vitamin A deficiency and neural tube defects due to maternal folic acid deficiency.
- At the population level, undernutrition negatively impacts social and economic development as well as human capital formation. For instance,
- Iron deficiency reduces school performance in children and physical capacity for work in adults.
- Stunting is associated with poor school achievement/performance.
- Reduced school attendance and educational outcomes leads to diminished income capacity in adulthood
- Improvements in nutrition after the age of 2 do not lead to recovery of lost potential; undernourishment in this critical period causes irreversible intellectual impairment.
- Impact of stunting on rapid and disproportionate weight gain later in life increases risk of: CVD, stroke, hypertension, and T2D.
- Undernourished children are at a higher risk of death to common infections.
Differentiate between hunger and malnutrition; clearly indicate what the terms refer to and the ways in which they are similar and/or different.
-
Hunger—is characterised in many ways. It encompasses individual sensations and household behavioural responses, food scarcity (actual or feared) and national food balance sheets that focus on supply of energy (kilocalories) in any country in relation to a minimum threshold of need. The food balance sheet approach is the only standard of measurement used globally. It is based on data collated by the Food and Agriculture Organization of the United Nations. This organisation has replaced its previous use of the word “hunger” in describing this metric with the phrase “chronic undernourishment”.
- This today is defined as “a person’s inability to acquire enough food to meet daily minimum dietary energy requirements during 1 year”
- Malnutrition—An all inclusive term that represents all manifestations of poor nutrition. It can mean any or all forms of undernutrition, overweight, and obesity.
> Thus; we can see that chronic hunger is associated with malnourishment, but it is possible to be malnourished and not hungry.
Describe patterns of hunger and undernutrition throughout the world (e.g., regions most affected, trends over time) and provide examples of how particular regions have achieved nutrition-related improvements.
- Of 800 million undernourished, 780 million are in low income countries, especially in sub-Saharan Africa and South Asia
- Somalia, Yemen, South Sudan, and Nigeria → struggling to cope with famine as of 2017, due to instability induced by conflict, terrorism, drought, and decades of failed governance
- China, Brazil, Ethiopia, and Bangladesh have been successful at reducing hunger.
- South America was particularly successful, reducing undernourishment by over 50% in 25 years.
- Made possible by various strategies, including (Webb et al., 2018):
- (1) Rapid reduction of poverty
- (2) Rising levels of literacy
- (3) Health improvements that reduced preventable child mortality
- (4) Education for women
- (5) Declining fertility
- (6) Improved stability of governance
- (7) Large scale investments in social reform and safety net programmes (supported narrowing of income gap through equitable poverty reduction)
- (8) Improved sanitation
- (9) Food supplementation targeted at mothers and children
- (10) Cash transfers targeted at the poorest groups
- (11) Expanded access to maternal and child health services
> Firstly, they tend to be politically stable countries that have pursued relatively equitable growth policies (not only increasing wealth for some but reducing poverty overall). Secondly, they employ targeted safety nets for the poor and invest in accessible services (education, clean water, healthcare). Thirdly, they assume responsibility for responding to shocks (economic, environmental, or due to conflict) in timely ways that mitigate human suffering. (Webb et al., 2018)
Explain why it is important to promote sustainable food systems and enable all people to access nutritionally adequate diets.
We need food systems that are economically viable and that enhance food security, prevent all forms of malnutrition and minimize further environmental degradation. Achieving healthy diets from sustainable food systems is a global public health goal.
Describe ‘energy’ within a nutritional context and be able to identify and describe 3 energy-requiring processes of the human body.
Energy → ability to do work
Forms → heat, kinetic, mechanical, light, electrical, chemical etc.
- Basal metabolism → Energy required to maintain normal body functions at rest; largest need (60-75% of total kcal needs)
- Physical activity → Energy needed for muscular work; most variable component between people
- Dietary thermogenesis → Energy used to ingest and digest food (e.g., peristalsis: wavelike muscular contractions/relaxation of the intestine that propels contents forward)
Explain the difference between ‘digestion’ and ‘absorption’ of nutrients.
Digestion → The (1) chemical (e.g., enzymes; HCl) and (2) mechanical (e.g., chewing; stomach churning) processes that breakdown food into (3) absorbable units.
Absorption → The uptake of nutrients into the body; the process by which nutrients and other substances are transferred from the digestive system into body fluids for transport throughout the body; most CHO, PRO, & FAT is absorbed within 30 minutes of the chyme reaching the small intestine
Define and describe carbohydrates and the nutritional significance of their consumption.
- CHO (CH2O)n family includes three types of chemical substances:
-
(1) Simple sugars → require little or no digestion
- E.g., glucose, fructose, galactose
- Monosaccharides: can be absorbed ‘as is’; do not need to be broken down by digestive enzymes
- Disaccharides: must be digested into monosaccharides prior to absorption by the GI tract
-
(2) Complex CHO (e.g., starch)
- Starches → glucose molecules linked together
- Glycogen → storage form of glucose in liver and muscle (i.e., ‘animal starch’)
-
(3) Fibre → does not provide energy
- Dietary fibre → polysaccharides that can’t be digested: humans lack the digestive enzymes that could break them down → helps with gastric motility, reduces risk of cardiovascular disease
-
(1) Simple sugars → require little or no digestion
- Significance → ENERGY!
- 40-80% of total food intake, depending on locale, economic status, cultural considerations
- The body can only use one simple sugar for energy → glucose
- Adequate intake prevents protein breakdown for energy → protein sparing effect
- Provides taste, sweetness
Define ‘famine foods’ and their strengths and limitations.
- Famine foods → foods that would otherwise be considered inedible but are eaten during times of extreme food scarcity
- Why → helpful to still have mealtimes; helps to ease hunger pangs
- However → they can make people feel unwell; do not provide notable nutrition-related benefits
-
Examples:
- Corn husks
- Leaves
- Moss
- Dirt
- In the Dutch famine → paper from books, tulip bulbs
Define and describe protein.
- Protein is an essential structural component of all living matter → a sequence of a chain of amino acids
- It is involved in almost every biological process in the body
- 20 different amino acids used to make proteins → 9 of which are ‘essential’ (i.e., must consume in diet)
Identify four functions of protein.
- Brain, liver, kidneys, muscle → more metabolically active than adipose (accounts for ~80% of BMR)
- Structural material in muscles, connective tissue, organs, hemoglobin (e.g., RBCs and fibrin (a type of protein) in clotting blood)
- Basic component of enzymes, hormones, transporters, immune system (e.g., lactase: an enzyme that breaks down lactose into glucose and galactose)
- Maintains and repairs protein-containing tissues (e.g., muscle)
- Energy source → least important role of protein
Summarize protein requirements and comment on the likelihood of a plant-based diet providing sufficient protein (quality and quantity).
- It is possible to provide sufficient protein via a plant-based diet via complimentary proteins (e.g., legumes and cereals) or by consuming complete plant proteins (e.g., soybeans and quinoa)
Identify some consequences of inadequate (or excessive) protein intake.
Inadequate → nutrient deficiencies are usually multiple (e.g., vitamin B12, zinc, niacin, iron)
Excessive → adults can consume up to 35% of kcal from protein without ill effects; higher intake can lead to nausea, weakness, diarrhea, and eventually death
Define fat.
- Body fat → less metabolically active than other tissues (accounts for <20% of BMR)
- Lipids → fats, oils, cholesterol, triglycerides
- Common property → not water soluble (i.e., will not dissolve in water)
- 1 gram of fat provides 9 kcal of energy
What is the kcal/g content of FAT, CHO, and PRO?
FAT → 9 kcal/g
CHO → 4 kcal/g
PRO → 4 kcal/g
What provides ~60% of the world’s food energy?
Carbohydrates, specifically:
(1) Maize, (2) Rice, (3) Wheat
- These are examples of ‘staple foods’:
- Staple foods are eaten regularly, in relatively large amounts - as a result, they supply a large amount of dietary energy and nutrients
- They cannot supply all the nutrients needed → dietary diversity is needed
Where do Canadians get ~21% of the kcal from?
Sugar!
In contexts of food scarcity, why might mothers be advised to add sweeteners to a young child’s food?
“Sugar and honey are ways to increase the energy content, and they can be added to porridge and other foods. This will help your children grow!”
- Sugars provide energy → 4kcal/g
- Sugars provide taste & sweetness → boost the palatability and consumption of an otherwise bland (albeit more nutritious) food
Where can protein be found in the body?
- A lean man weighing 154lbs contains ~24lbs of protein (~16%)
- ~half in muscle
- Remainder in skin, collagen, blood, enzymes, immunoproteins, organs, etc.
- All protein is continually being turned over (i.e., broken down and re-built)
Describe protein quantity.
- How much protein do people need?
- Protein requirements are increased in certain circumstances.
- (1) Infections, burns, fever, surgery (i.e., clinical conditions)
- (2) Pregnancy (second half only)
- (3) Breastfeeding
- (4) Infants and young children
Describe protein quality. [4]
- Complete protein → contain all of the essential amino acids in amounts needed to support the body’s protein requirements; derived from meat, dairy, eggs, soybean, quinoa
- Incomplete protein → are ‘deficient’ in one or more essential amino acids; derived from grains, legumes, nuts, seeds, vegetables
- Limiting amino acid → the amino acid in an incomplete protein that is present in the least amount relative to the requirement for that amino acid (e.g., lysine is the limiting amino acid in cereal grains)
-
Complimentary proteins → a protein that is ‘incomplete’ on its own, but becomes ‘complete’ when combined with another protein source with a complimentary amino acid content
- E.g., legumes and cereals
Answer → 5-month-old infant (protein is required for healthy growth and development; insufficient quality of protein will adversely affect this in a permanent fashion since this is still within the critical first 1000 days of life)
Give examples of complete plant proteins.
Soybean; quinoa → contains all the essential amino acids in sufficient quantity to support human needs
Identify the functions of fat. [5]
- Concentrated energy source → 9kcal/g
- Carrier for essential fatty acids and fat soluble vitamins (A, D, E, K)
- Adds flavour and palatability to food
- Contributes to feeling of satiety
- Components of cell membranes, vitamins, sex hormones, cholesterol
Differentiate between triglycerides, saturated, unsaturated fat, and cholesterol.
- Triglycerides → 98% of dietary fat and most of body’s fat stores; used by cells for energy and tissue maintenance; glycerol backbone + 3 fatty acids (which may be saturated or unsaturated)
- Saturated fat (contains saturated fatty acids); carbon atoms are attached to as many hydrogen atoms as possible; no ‘kinks’; no double bonds; solid at room temperature; mostly found in animal products (e.g., lard, palm oil, coconut oil)
-
Unsaturated fat (contains unsaturated fatty acids); contain fewer than the maximum hydrogens; at least one double bond; ‘kinks’ present; liquid at room temperature; best sources are plant foods (e.g., avocado, flaxseeds, sunflower seeds, canola oil)
- Monounsaturated → one double bond
-
Polyunsaturated → more than one double bond; includes omega-3 and omega-6 FA → ESSENTIAL
- EPA
- DHA
- Trans
- Cholesterol
What is the AMDR for fat?
Know the AMDR for adults and children age 1-3.
What is the AMDR for protein?
Know the AMDR for adults and children age 1-3.
What is the AMDR for CHO?
Know the AMDR for adults and children age 1-3.
What is the risk for mortality associated with higher fat vs higher carbohydrate intakes?
Higher fat intakes associated with lower risk of overall mortality
Higher carbohydrate intakes associated with higher risk of overall mortality
Describe the intergenerational undernourishment cycle.
Undernourished girls have a greater likelihood of becoming undernourished mothers who in turn have a greater chance of giving birth to low birthweight babies, perpetuating an intergenerational cycle. This may be compounded further by adolescent girls who become pregnant before attaining adequate growth and development. Short intervals between pregnancies and having several children may accumulate or exacerbate nutrition deficits, passing these deficiencies on to the children.
Describe the outcomes of good nutrition for women and children.
Improved survival, health, physical growth, cognitive development, school readiness and school performance in children and adolescents; improved survival, health, productivity and wages in women and adults; and improved prosperity and cohesion in societies.
Describe the three categories of enabling determinants used in the UNICEF Conceptual Framework on the Determinants of Maternal and Child Nutrition.
- Governance → Good governance refers to the political, financial, social and public and private sector actions needed to enable children’s and women’s right to nutrition
- Resources → Sufficient resources refer to the environmental, financial, social and human resources needed to enable children’s and women’s right to nutrition.
- Norms → Positive norms refer to the gender, cultural and social actions to enable children’s and women’s right to nutrition.
Describe the three categories of underlying determinants used in the UNICEF Conceptual Framework on the Determinants of Maternal and Child Nutrition.
- Food → comprises age-appropriate, nutrient-rich foods – including breastmilk and complementary foods for children in the first two years of life – with safe drinking water and household food security for all children and women.
- Feeding → comprises age-appropriate dietary practices – including breastfeeding, responsive feeding and stimulation in early childhood – with adequate food preparation, food consumption and hygiene practices for all children and women.
- Environments → comprise healthy food environments, adequate nutrition, health and sanitation services, and healthy living environments that prevent disease and promote good diets and physical activity for all children and women.
Describe the two categories of immediate determinants used in the UNICEF Conceptual Framework on the Determinants of Maternal and Child Nutrition.
- Diets → Good diets are driven by adequate food and feeding to support good nutrition for children and women.
- Care → Good care is driven by adequate services and practices to support good nutrition for children and women.
> The co-occurrence of good diets and good care leads to adequate nutrition for children and women across the life course.
Describe the situation in Venezuela.
- Since ~2013 has seen economic, political, and social collapse.
- ~94% life in poverty (lack economic access to sufficient food)
- Government initiated food distribution program was meant to be delivered twice a month but people only received them once every ~3 months.
- Hyperinflation has led to soaring food prices - third highest in the world
- Involuntary weightless is common
- Food production and imports have fallen (lack physical access to sufficient food)
- Dietary quality has shifted from meat & dairy to cheap vegetables (e.g., cassava)
- ~20% of the population fled the country
- Now they live as refugees in neighbouring countries in slums
- Inadequate access to food, water, and sanitation; rely on one meal a day (flour, rice)
- Experience xenophobia and discrimination
- Now they live as refugees in neighbouring countries in slums
Define and describe vitamins.
- Vitamins are chemical substances that perform specific functions in the body
- Organic compounds (i.e., contain carbon)
- They are essential nutrients in the diet (must be consumed in small amounts.
- Body cannot produce them, or produce them in sufficient amounts
- 13 vitamins → 4 fat-soluble; 9 water-soluble
- Inadequate intakes of vitamins leads to deficiency diseases
Define minerals and describe their functional properties.
- Minerals are elements - specific single atoms that perform particular functions int he body
- Human body contains 40 or more minerals, but only 15 are essential in the diet (obtain others through air we breathe, etc.)
- Single atom of a mineral typically carries a charge, so minerals are quite reactive.
Define bioavailability and give an example of how bioavailability of a nutrient has implications for nutritional status.
- Proportion of intake that is capable of being absorbed through/by small intestine and made available for metabolic use or storage.
- e.g., tannic acid in tea that can bind elemental iron and prevent its absorption
- e.g., zinc bound to phytate in grain is unavailable for absorption but zinc found in meat is easily accessed since the body easily digests protein to release the zinc
Of all the kcal consumed throughout the world, ~60% are from maize, rice, and wheat.
Does this raise any concerns?
What might be some potential issues?
- Micronutrient deficiencies → poor dietary diversity
- If something goes wrong with those crops → corn is not very resilient for example → people suffer
- Agricultural implications
What are two issues to consider when assessing the adequacy of protein intake?
Quality & quantity of protein in diet
Describe water-soluble vitamins.
- Vitamin C & the B vitamins (thiamin, riboflavin, niacin, folate, etc.)
- Only small amounts stored in the body
- Intake beyond body’s needs excreted in urine
- Deficiencies can develop rather quickly if intake is insufficient (within a few weeks or months)
- Exception → Vitamin B12 (recirculation of a small amount that can be effective for years; thus, signs of deficiency take a long time to develop)
Describe fat-soluble vitamins.
- Vitamins A, D, E, K
- Stored in body, primarily in adipose and the liver
- Because extra is stored in the body, symptoms of deficiency take a long time to develop if dietary intake is poor
- If dietary intake was too high for a period of time → toxicity may develop
Describe the consequences of the fact that minerals are charged.
- (1) They can combine with minerals with the opposite charge, and form stable compounds that become parts of tissue (e.g., bone)
- (2) Their electric charge can stimulate muscles to contract and nerves to fire.
- (3) They may combine with other substances in food to form stable compounds that are not easily absorbed. Examples:
- Zinc → bound to ‘phytate’ in whole grains and so it is very poorly absorbed - but zinc in meat is bound to protein, so it is easily absorbed
- Iron → If tea/coffee is consumed with an iron-rich meal, the tannic acid in tea will bind to iron in the small intestine → decreases iron absorption by up to 50%
Define and describe nutrition assessment.
-
Nutrition assessment → how we measure nutritional status; the science of determining nutritional status by analyzing individual’s:
- A → Anthropometric measurements
- B → Biochemical tests
- C → Clinical signs
-
D → Dietary assessment
- Both in terms of history and current data
-
Why conduct them?
- To determine who is malnourished (baseline) and to evaluate the impact of any program or other change (follow-up) → need to measure nutritional status
- Optimal nutritional status is a balance
- To determine who is malnourished (baseline) and to evaluate the impact of any program or other change (follow-up) → need to measure nutritional status
Describe specific examples of anthropometric measurements and their strengths and limitations.
- Anthropometry → measurement of (1) physical dimensions and (2) gross composition of the body
-
Key measurements → height; weight; mid upper arm circumference (MUAC)
- Results compared to standard values in order to interpret them
Clearly define, describe, and evaluate: Wasting.
-
Wasting → reflects acute malnutrition; generally result of weight loss due to recent period of starvation or severe disease
- Severe Acute Malnutrition → weight-for-height is -3 SD or more below WHO standard
- Moderate Acute Malnutrition → between -2 and -3 SD below WHO standard
Briefly describe how biochemical measurements can be used in nutrition assessments.
- Measure a nutrient or its metabolite in blood, urine, faces… or measure other components related to nutritional status.
Differentiate between clinical signs and symptoms.
- Clinical methods → use medical history and physical examination to detect and interpret the signs (can be observed by a trained examiner; affected person usually unaware of them) and symptoms (subjective; reported by affected person → e.g., feeling tired, dizzy, nauseous) of malnutrition
Identify and explain some useful clinical signs of malnutrition. [5]
- Hair → depigmentation of hair suggests protein deficiency; ‘flag sign’ = transfer depigmentation of hair (reflects period of undernutrition and then improvement); dull, discolouration
- Eyes → xerophthalmia = night blindness, photophobia, Bitot’s spots (distinct white-grey foamy plaques lateral to cornea), corneal ulceration or scarring → suggests deficiency in vitamin A
- Skin → pallor (paleness) of skin and conjunctiva → consider iron deficiency anemia
- Nails → transverse ridging (consider protein deficiency); Koilonychia (spoon-shaped nails) → consider iron deficiency anemia
- Bilateral pitting oedema (= swelling due to excess fluid accumulation) → sign of severe acute malnutrition → how to test (see photo)
Summarize the limitations of a physical examination in the assessment of nutritional status.
- Signs and symptoms can be hard to interpret
- (1) Physical signs are often not specific (especially if deficiency is mild or moderate)
- Same sign could be caused by different deficiencies; signs may be caused by non-nutrition factors
- (2) Examiner inconsistencies
- (3) Inter-individual variability
Identify and describe various types of dietary assessment.
- Dietary assessment → measurements of foods and beverages consumed by a person in one day, several days, or longer time period (months - years) → difficult to accurately assess!
-
24 hour recalls
- (1) Participant asked for a quick list of foods/beverages consumed in the past 24 hours
- (2) Starting with the first item on the list, the interviewer probes for details (type, amounts, additions or condiments, preparation method)
- (3) Review details and amounts and correct any inaccuracies.
-
Food records → ‘multiple-pass’ method
- Person records type and amount of food/beverage consumed for a period of time
- Typically lasts 1 - 7 days
- Foods/beverages are written down right after they are eaten
-
Food frequency questionnaires
- Can determine how often person consumes a limited number of foods
- Usually 150 or fewer items.
Determine which method of dietary assessment would be most appropriate in various settings.
- Goal? Resources? Respondents? Setting?
- Depends on goal of assessment (e.g., assess vitamin A status; optimize athletic performance)
- Depends on resources available (remote location? funding? people power?)
- Depends on the individual/population of interest (are they literate? is memory potentially a problem? can they access an online tool?)
Describe MUAC.
- Measures muscle content; correlates with total muscle mass → a way to detect wasting and acute malnutrition
- Reflects protein status
- Common for field assessment (measurement is quick, easy, and informative)
- MAM = <12.5 cm
- SAM = <11.5 cm
- Major determinants → arm muscle; subcutaneous fat
- More sensitive measure of malnutrition than low body weight
- Strong predictor of risk for death
- Easy measurement to perform
- Primarily used for children aged 6-59 months of age
- Some studies have shown low MUAC is correlated with poor outcomes among adults and adolescents.
- No international cut-offs exist
- Additional research is needed
- Example → MUAC < 23.5cm in pregnant women associated with higher risk of having baby born with LBW in Guatemala
Clearly define, describe, and evaluate: Stunting
- Low height-for-age → shows a physiological restriction of growth (brain growth & cognition as well)
- Failure to reach linear growth potential
- Reflects chronic malnutrition (sustained and cumulative episodes of undernutrition)
- Child considered ‘stunted’ if height-for-age is -2 SD below WHO standard
- Recumbent length → measured if child cannot stand erect without assistance
Describe two benefits and two limitations of MUAC.
Strengths:
(1) Cheap: Cost of a MUAC arm band is not prohibitively expensive, so even the most vulnerable/impoverished people can gain access to this important anthropometric monitoring tool.
(2) Simple & effective: Anyone (service providers; community members) can easily learn how to use a MUAC arm band and simply understand and interpret the results.
Limitations:
(1) Excludes older children, adolescents & adults: In children over 3 years old there are no standards cut-offs correlating with risk for mortality. This means that MUAC cannot currently be used to monitor the nutritional status of older children.
(2) Not always informative: Only very low MUAC scores provide information on nutritional status; however, normal or high MUAC scores may result in overlooked nutritional concerns. Furthermore, MUAC only confers information about wasting, but does not correlate with stunting.
Stunting and wasting can occur together or independently.
True or False?
True.
Stunting and wasting cannot occur together or independently.
True or False?
False.
What is the difference between ‘failing to grow’ and ‘having failed to grow’?
Clearly define, describe, and evaluate: underweight and BMI.
- Low weight for age in children
- Influenced by both height-for-age and weight-for-height, so interpretation can be difficult
- Indicator of poor nutritional status
- Reflects chronic and/or acute malnutrition
What are the strengths [5] and limitations [4] of 24 hour diet recalls?
Strengths
- Quick
- Inexpensive
- Easy for person to complete
- Can be used in a variety of settings
- Does not alter diet
Limitations
- Under/over-reporting of certain foods
- Relies on memory
- Labour-intensive data entry
- One recall does not represent individual’s typical intake
What are the strengths [4] and limitations [5] of food records?
Strengths
- Does not rely on memory
- Can provide great detail
- Can give insight into eating habits/patterns
- Multiple days more representative of individual’s usual intake
Limitations
- Takes time and effort to complete accurate record
- Requires literacy
- Recording diet alters diet
- Labour-intensive data entry and analysis
- May not represent usual intake
What are the strengths [4] and limitations [4] of food frequency questionnaires?
Strengths
- Can be self-administered
- Machine-readable
- Inexpensive
- May be more representative of usual intake
Limitations
- May not include foods usually consumed by participants
- May not include information on portion size
- Typically requires literacy
- If self-administered, cannot ask clarifying questions
Critically evaluate the causes of high prevalence undernutrition in Nepal.
- Early marriage
- Low eduation
- poverty
- Natural disasters
- Climate change
- Lack of health care
- No clean water
- Poor sanitation
- Son preference/daughter aversion
Comment on whether it is appropriate to use international standards (e.g., cut-offs for wasting and stunting) to evaluate a child’s growth.
- Race/ethnicity has a small impact on preschool growth, compared to environmental effects
Describe the UNICEF conceptual framework of the determinants of child undernutrition and use it to analyze the causes of malnutrition in complex situations.
Demonstrate the correct use of the terms contained in the framework (e.g., basic, underlying, immediate; household food insecurity; inadequate care; etc.)
- Immediate causes: acts on the individual
- Underlying causes: acts on the household/community
- Basic causes: acts on the whole society (affect some groups more than others)
Describe how son preference/daughter aversion may contribute to malnourishment.
- Common in many regions of the world
- Can affect family size and treatment of girls (who eats what and when; who is in charge of household tasks; who gets an education; etc.), for example:
- Photo: woman in India pictured with her 5 children; after first giving birth to two girls, family now satisfied that number of sons > number of daughters
- Study in India → girls in families with stronger son preference do more hours of household labour each week
- Study in Bangladesh → Children’s nutritional status adversely affected by family size, but girls more negatively affected than boys
Answer → B
What factors put children at risk for malnourishment? [4]
- Low weight (BMI) of mother
- Child’s age → younger children are more at risk
- Higher birth order (1st child in a family is 1st birth order; 5th or 6th child may have less resources)
- Lower standard of living
What factors are protective of malnourishment for children? [2]
- Mother’s education (minimum of 5 years of education)
- Participation in vitamin A or nutrition program
For many years, the proportion of people experiencing hunger and food insecurity was declining throughout the world. However, in recent years it has stayed the same.
True or False?
False.
For many years, the proportion of people experiencing hunger and food insecurity was declining throughout the world. However, in recent years it has started to increase.
For many years, the proportion of people experiencing hunger and food insecurity was declining throughout the world. However, in recent years it has started to increase.
True or False?
True.
For many years, the proportion of people experiencing hunger and food insecurity was declining throughout the world. However, in recent years it has decreased even more dramatically.
True or False?
False.
For many years, the proportion of people experiencing hunger and food insecurity was declining throughout the world. However, in recent years it has started to increase.
To eliminate hunger in the world, we need to focus on increasing global food production – especially production of staple foods such as rice, wheat, maize, and cassava.
True or False?
False.
More than half of the risk factors that contribute to the global burden of disease are related to poor quality dietary intake.
True or False?
True.
Less than half of the risk factors that contribute to the global burden of disease are related to poor quality dietary intake.
True or False?
False.
More than half of the risk factors that contribute to the global burden of disease are related to poor quality dietary intake.
Explain, with specific examples, what is meant by: nutrition transition
- Nutrition transition is the shift in dietary consumption and energy expenditure that coincides with economic, demographic, and epidemiological changes.
- The “nutrition transition” is a model used to describe the shifts in diets, physical activity and causes of disease that accompany changes in economic development, lifestyle, urbanisation, and demography. It most commonly is used to refer to the change from traditional diets towards “Western” diets rich in fats, sugars, meat and highly processed foods and low in fibre, and accompanied by a rise in sedentary lifestyles.
Answer: C
A: Immediate cause
B: Underlying cause
C: Basic cause
Briefly define malnutrition.
Poor nutritional status due to dietary intake either above or below optimal level.
Describe marasmus.
- = wasting
- Body tries to conserve energy (reduced activity of liver, kidneys, heart, etc.)
- Mainly due to energy deficiency; but some diversity present, just not enough!
- Use proteins from muscle and other tissues to help meet body’s protein requirements.
- Note: loss of >30% of body protein results in:
- Less strength for breathing
- Susceptibility to infections
- Abnormal organ function
- Death
Describe Kwashiorkor.
- Bilateral pitting edema starts in feet, progresses to legs, arms, hands, face.
- More serious!
- Associated with metabolic abnormalities.
- Kwashiorkor is more difficult to treat and has lower survival rates than marasmus
Describe marasmic-kwashiorkor.
- Both wasting and bilateral pitting edema
- A form of severe acute malnutrition
- Features of both are present simultaneously.
- Edema can hide growth failure
What are the immediate, underlying, and basic causes of Alemitu’s malnutrition?
- Immediate: inadequate dietary intake
- Underlying: inadequate feeding care/practices (e.g., lack of exclusive breastfeeding)
- Basic: inadequate access to land; inadequate employment & income
How many people living with type 2 diabetes live in low and middle-income countries?
- Type 2 diabetes is a growing worldwide concern
- 79% of people living with T2D live in low and middle-income countries
Describe how dietary intake changes in the nutrition transition paradigm.
Diets rich in complex carbs and lean protein are traded for diets rich in simple carbs, added sugars, saturated fats, and processed food.
Describe how physical activity changes in the nutrition transition paradigm.
‘ Active transportation’, physical occupations and physical labour during daily tasks are traded for cars, buses, trains, etc, sedentary occupations, and automation.
How much iron do we need?
- Vegetarian recommendation = 1.8x higher = males 14mg and females 32 mg
Who is at risk or affected by iron deficiency?
- Iron-deficiency affects more than 2 billion people worldwide
- Severe iron deficiency results in death of 50,000 women per year in pregnancy and childbirth
- Iron deficiency lowers productivity of workforces: estimated losses of 2% or more of GDP in worst-affected countries
How can nutritional assessment detect iron deficiency?
- Two components of nutrition assessment are important
- Biochemical → blood test measuring hemoglobin (indicates anemia is present) and serum ferritin (indicates anemia is iron-deficiency related)
- Clinical → pale conjunctiva indicates low circulating levels of RBCs
Identify, describe, and evaluate strategies that could reduce iron deficiency and improve iron status.
- Change diet to increase iron intake and absorption → dietary diversity; increase enhancers, and reduce inhibitors
- Fortification → industrial (iron fortification of flour) or household (lucky iron fish)
- Control hookwork (and other infections that can cause anemia) → wear shoes!
Identify and justify WHO recommendations for zinc supplementation during acute diarrheal episodes in children.
Evaluate one approach to increase adherence to this recommendation in rural Zambia.
- Deficiency contributes to growth failure and weakened immunity in children
- Contributes to 800k child deaths per year (resulting from diarrhea, pneumonia, malaria)
- ColaLife operational trial of ‘Kit Yamoyo’; 10 packages fit in a crate of Coke
- Proportion of children with diarrhea treated with oral rehydration salts and zinc at baseline <1%; after 1 year of trial: 45%
- Other findings:
- 93% mixed salts correctly
- only 4% of kits were actually transported in Coke crates
- Success resulted from creating effective value chain → every step adds value and generates profit for organization or individual
- Design
- Manufacture
- Assembly
- Storage
- Distribution
- Purchase by mother
Describe and evaluate the impact of fortification as a strategy to reduce the global prevalence of iodine deficiency.
- 75% of the world population has access to iodized salt
- However, fortification programs are not always mandatory; levels of fortification vary
What is a key factor affecting iron absorption?
- The type of iron consumed
- 2 types of iron in foods: heme and non-heme
- Heme → part of hemoglobin and myoglobin → more absorbable
- Non-heme → not part of hemoglobin and myoglobin; found in BOTH animal and plant foods
Describe vitamin A deficiency.
- VAD is one of the most widespread and serious nutritional issues for young children (affects ~⅓ of children aged 6-59 months)
- Leading cause of preventable blindness
- Deficiency compromises immune system activity: increases risk for infections, disease, and death (150 million children at increased risk of dying from infectious disease due to VAD
- A public health problem in >50% of countries
What is xerophthalmia? What are the signs and symptoms?
- A consequence of vitamin A deficiency; progresses as follows:
- Night blindness = earliest sign; specific; sensitive; responds very rapidly to vitamin A therapy (within 1-2 days can be reversed)
- Conjunctival xerosis
- Bitot’s spots; potentially still reversible
- Corneal xerosis; irreversible
- Ulceration; irreversible
- Necrosis/keratomalacia = permanent damage; irreversible
Why has vitamin A deficiency been described as ‘nutritionally acquired immunodeficiency disorder’?
- Compromised immunity with VAD
- Mucous barriers that line gastrointestinal, respiratory, and genitourinary tracts are not as effective
- Immune system response impaired
- VAD predisposes individuals to severe infection, including:
- Respiratory infection (coughing)
- Infectious diarrhea
- Dysentery
- Measles (if a child with VAD gets measles they have a 50% chance of dying)
- HIV, malaria
- VAD responsible for 35% of child deaths in Mozambique!
- Community based improvement in vitamin A status of deficiency children reduces their overall risk of dying by 20-30%.
Answer: A (immediate)
Describe the cycle of malnutrition in women, and list some socio-economic factors.
What percent of infants worldwide are exclusively breastfed for the first 6 months?
42%
Why is ‘breast best’?
- Reduced infant mortality
- Non-breastfed infants in developing countries 6-10x more likely to die in first months of life
- Diarrhea and pneumonia are more severe in non-breastfed infants
2. Reduced risk of postpartum hemorrhage if mother can breastfeed shortly after delivery
3. Increased birth spacing
- An interval of at least 24 months between a live birth and the next conception reduces risk of negative outcomes for mother and infant
Describe the composition of breastmilk.
- Vitamins → sufficient amounts, except vitamin D (and vitamin K)
- Minerals → low in iron (but bioavailability high, and infant stores will last ~6 months)
- Anti-infective factors → Immunoglobulins, white blood cells, lysozyme, lactoferrin, etc.
- Other bioactive factors → Lipase, growth factors (e.g., promote growth and development of intestinal tract), laxative factors
What is colostrum?
- Concentrated, very nutritious, mild laxative, contains growth factors and antibodies
- Infant will consume only ~1 tsp of colostrum in a feeding!
Which of the statements is TRUE?
D → all of the above are true
Should HIV+ women breastfeed their infants?
Children of HIV-Infected mothers are more likely to be stunted, wasted, or underweight.
- If a safe alternative is available → use that safe alternative (e.g., commercial infant formula (if safe water, sanitation, reliable preparation, sufficient supply); safe donor breast milk)
- If no safe alternative is available → breastfeed and antiretroviral therapy (exclusive for 6 months; continue for at least 12 months with addition of complementary foods)
How many pregnant women in low-and middle-income countries have anemia?
Up to 50%!
What is ‘Lip Yaleh’?
- Ethiopia’s National Health Care Quality Strategy 2016-2020 aims to reduce maternal mortality to 199 per 100,000 live births
- In October 2019, a song ‘Lib Yaleh’ was released emphasizing ‘care at the clinic saves lives’ as part of efforts to reduce maternal mortality.
