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Basic concepts related to unternutrition, causes and effects

Body does not have enough/right kind of food to meet his needs: energy, macronutrients, micronutrients. Most vulnerable groups: children, pregnant woman and elderly

Indicators of Child Undernutrition: underweight for one's age, log height for age (stunted: chronic malnutrition), low weght for height (wasted, only seasonal malnutrition), measure mid-uüüer arm circumgence as a proxy for weight, and head circumfence as a proxy for height, blood samples (vitamins and minerals)

Hidden hunger: problem of dietary quality/dietary diversity, chronic undersupply of micronutrients

70% of stunting takes place before the second birthday. Prevalence mostly in south africa and southern asia => dependant on social economical status

Prevalence of wasting high in africa, southeastern asia and southern asia.

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Effect of Malnutrition in a child

Malnutrition has an effect on the intellectual development not only because it get enough calories, but also because there is less movement so less motor skills trained and less exploring; aswell less schooling (teacher don't expect much of a "small" child): stunting between 12 and 36 months of age predicted poorer cognitive performance and/or lower school grades attained in middle childhood

Circle: if the mother is malnutritioned => the child is born underweight and starts already with deficiency => not good brain developement as an adult => poor => and it starts again from the beginning "hunger carusel". Problem: stunting is mostly not detected (when a lot of children are suffering of stunting, then you can't see, that your child is smaller than it should be => and if it is not detected, it can't be treated)!

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Most impotant actors of "hidden hunger" and their effects on development and health

The main actors are Vitamin A, zinc, iron and iodine => severe deficiencies cause typical clinical symptom, but they are often unnoticed but have serious consequences. Almost 1/3 of people are deficient

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Food Aid

  • Not always given for free
  • Project food aid (for a specific project, sometimes it is bought in the country itself or it is brought from abroad)
  • Relief food aid (i.e. during wars, food can be bought from local farmers and sold less expensive)
  • 50% of the food aid is provided by the World Food Programme
  • Depends on world markt prices and stocks. I.e. if there are too much food on the market, they provide it to poor country. If there is not enough, there is less food aid
  • For emergency it is okay, but in gerneral, it is a difficult topic because it can damage local production! (decline in food prices and so local producers are hurted)
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School meals

  • May be effective, when well designed (school meals and snacks)
  • In low- and middle-income countries designed to address malnutrition and hunger
  • Improve schoolchildren's food consumption and dietary diversity
  • Might help physical growth in terms of height and weight, but only limited effects (animal-products are lacking)
  • Inflluence learning and educational performance and classroom attendance
  • Ensure that girls are well prepared to become mothers
  • May support rural livelihoods when produced locally
  • Are more effective when integrated with school-based health and nutrition education
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Supplementation

  • Specific supplement
  • The deficiency should be detected and the target group defined.
  • Specifically for vitamin A, zinc and iron => should be longterm
  • Malnourished children receiving supplementation of protein and micronutrients imrpove their physical and mental developent and their productivity
  • May lead to reduction of child mortality (20-40% in children < 4)
  • Relative low cost (vitamin A)
  • Most widely practiced
  • Home fortification with multiple micronutrient powders tackles widespread micronutrient deficiencies

=> not longterm, there should be more than one micronutrient supplemented

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Ready-to-use therapeutic food

  • Energydense, micronutrient enhanced pastes (with peanuts, oil, sugar, milk powder and vitamin and mineral supplements
  • Targeted at children suffering from uncomplicated severe acute malnutrition and who retain an appetite (not treated in hospital)
  • Good shelf life, does not spoil easily even after opening
  • Not water based, risk of bacterial growth is very limited
  • Safe and easy to use without close medical supervision
  • May be used in combination with breastfeeding and other best practices for infant and young child feeding (not inhibit it)
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Fortification of Commercial Foods

  • Mostly basic foods are being fortified with micronutrients
  • Should be eaten at a daily basis by the targeted population
  • Taste and appearance should not change and the price should not change
  • Most common case: fortification of salt with iodine
  • Industrilized countries: dairy products with vitamin D, flour with folic acid
  • Developing countries: vitamin A
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Biofortification

  • Goal: enhance micronutrient denssity through breeding in agricultural products
  • E.g. rice varieties with a high iron or zinc content and high biovailability
  • Target population: poor rural population
  • Crops must be adopted by farmers (their productionsystem should be taken in account) and consumed by the target population
  • Narrow genetic variation, a long-development time, and the dependence on the phytoavailability of the mineral nutrients in the soil are limitations
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Biotechnology - "golden rice"

  • Rice variety which  accumulated carotenoids, source of vitamin A
  • Beta-carotene derived from golden rice is effectively vitamin A in humans
  • Contains actually two genes from maize - GMO-crop (genetically modified organism)
  • No charge for the nutritional trait within the seed to smallholder farmers who sell locally
  • No individual or organization involved with the development of golden rice will benefit financially from ist adoption
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Dietary diversification and modification

  • Changes in food production (farmers) and food selection patterns
  • Goal: enhance availability of and access to foods with high content and bioavailability of micronutrients throughout the year. But do they really eat it?
  • Higher dietary diversity enhances food intake and micronutrient intake
  • Mostly focus on fruit and vegetables, some additionally on grains and legumes
  • Some improvement in absorption from zinc is likely with the reduction of phytate (soaking, wild-type maize)
  • Increasing intake of absorption enhancers (flesh foods enhance the absorption of non-heam iron from plant-based foods), ascorbis acid enhances non-heam iron from single meals
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Agriculture diversification

  • Rural population is more suffering under undernutrition and poverty
  • More calories available in urban than rural (big difference between the riches and the poorest)
  • Coverage of the basic need by the different farmes: only medium and big size farmes earn enough money to cover their basic needs. Landless and small one can cover only 1/4 or 1/2 of it. As bigger they are, as more possibilities for diversity they have => Access to land has a direct link to diversity; same accounts for animals
  • Assets (land, animals, tools) allow for: crop diversification, access to credits and loans and resilience after shocks (disasters, severe illnesses, price shocks)
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Cash Transfer Programs

  • Direct cash to poor and vulnerable households
  • To imrpove food security, health and nutritional and educational status
  • Studies show that such programs may work
  • If you give people cash, there should be more money available and they should be more food secure
  • More resources for improvements to sanitation dacilities
  • More money for emergency if there is an illness
  • Care practices and behaviour (e.g. breastfeeding)
  • Resource control for main caregiver (usually mother) => may better advocate for her preferences
  • Study shows: always good for child nutritonal status, food security, health care and caregiver empowerment
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Role of Nutrition Education

  • Target group should be included in developing a program
  • The food should be aavailable and affordable for them
  • Not enough, together with other meassures (i.e. it needs changes of the law)
  • How do you reach the most vulnerable groups?
  • Focus on longterm interventions
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Why is a nourished mother the most effective way for public health intervention for babies?

The vitamin content of human milk correlates with the nutrition status of the mother. The effect of maternal suppl. In malnouriseh is effective, in well-nourished it is only limited effective.

=> Nourished mothers is the most effective way for public health for babies. You need to supplement the mother, so the baby will be well nourished. The macronutrient quantity is not influenced by the mother. But the quantity of the milk is, it will be less.=> nourished the mother and she will produce more milk.

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Define Public Health Nutrition:

"the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society".

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Assessment - Defining the problem

by doing research. What are all the factors, who have an influence? Can you modify this determinants (i.e. you cannot change the gens) What are the needs of the stakeholders (i.e. food industry). Define your population group => Research. We try to find out what should it be then we found out what it is like and so we can implement an intervention.

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Policy development, planing a strategy / a program

Give examples

Strategies, action  plans, interventions, projects on a local / regional / national or international level i.e. by taxes, front labeling, food tracing, changing the recipes in terms of sugar/salt/transfats (food industry). The interventions can be planned on a government base (like introducing a law) going down to an only monitoring base. 

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Implementing and Monitoring: 

should start already during implementing the intervention. Continuing function that provides the management and main stakeholders with early indications of progress => management function. You need something to monitor, before you start monitoring

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Evaluation

a selective exercise that attempts to systematically and objectively assess progress towards and the achievement of an outcome => often led by an independent party. Evidencec for decision-making (do we continue to fund the program, do we expand the program, do we shut it down?), evidence to infrom science

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Recognize current and emerging global and country-specific concerns in public health nutrition:

Malnutrition, Obesity, NCDs, Breastfeeding, reduced physical activity, Anemia

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Recognize the value of strategies / action plans (international / national) for PHN intervention:

Health problems are a big issue, i.e. the double / triple burden of diseases: On one side there is malnutrition present but also obese and nutrition defincies (anemia, stunting, wasting). It is important, that something is done about it. Aswell the economic burden (disease are costing a lot of money).

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Explain the social ecological model as an general basis for PHN interventions:

Socio-ecological models were developed to further the understanding of the dynamic interrelations among various personal and environmental factors.

It describes, which factors influence behaviour. I.e. Intrapersonal: attitudes, knowledge, self-efficacy, developmental history…

Interpersonal: social networks, social support (family, parents, co-workers, peers)

Organisational: social institutions with rules, regulations, policies and ethos that may promote health

Community: shared identities, relationships among organization, institutions and informational networks within defined boundaries

Environment/policy: Policies, advocacy, environments and structures that impact on health 

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Define goals and objectives for public health interventions:

Goal i.e.: reduce exposure to second-hand tobacco smoke in children

Short-term objective i.e.: at the end of the first year of the program, 50% of the adults in xxx will be aware of messages about the hazards of secondhand tobacco smoke

Long-term objective i.e.: By the end of 2020, reduce by 25% the prevalence of adult smokers in the home. Criteria: SMART

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Recognize the complexity of nutritional epidemiology

Diet as a complex expsoure (we all have to eat..), Confounding in nutritional epidemiology, measurement error in nutritional epidemiology, exerimental studies often not feasible (also time-intensive, costly, problems with compliance, blinding difficult), preliminary or unconfirmed findings come to the attention of the media and the general public => no single study can provide a definitive answer and no study design is without limitations".

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mortality

Mortality: the number of death in a population during a given time or place

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Prevalence:

current cases (new and preexisting cases)

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Incidence:

 number of new events/cases in a defined population in a specific period of time

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Relative Risks

baseline risk for the outcome => Absolut Risk intervention group is divided by the absolute Risk of the control group, is this subtractet from 100% = Relative Risk Reduction

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Absolut Risk

percentage of people with the outcome in a group. Is calculated for the intervention and control group and then compared = Absolute Risk Reduction. This defines the effectivness of an intervention.