Autonomic Nervous System Eunice Lee Debora Jeong Joshua Iannotti Period 4.
deficiencies in resource-poor populationsdbbs.wustl.edu/curstudents/Documents/Markey/Iannotti Markey...
Transcript of deficiencies in resource-poor populationsdbbs.wustl.edu/curstudents/Documents/Markey/Iannotti Markey...
Hidden hunger: micronutrient deficiencies in resource-poor populations
Lora Iannotti, PhD Translating Global Health; Lucille P. Markey Special Emphasis
Pathway in Human Pathobiology September 16, 2014
Pathways to Global Public Health and Wash U
• Degrees of freedom – political science & French, foreign affairs
• 1990 – First trip to Haiti
• Professional experiences beyond academia
– US Congressional Select Committee on Hunger – NGOs, UN/FAO, World Bank, IDB
• Nonparametric paths back to Haiti – Haiti, Ghana, Benin, Haiti, Kenya, Tanzania, Zambia, Zimbabwe,
Sudan, Egypt, Kenya, Tanzania, Haiti, Peru, Haiti
• PhD International Nutrition
– Bloomberg/JHSPH, infectious disease, epi, and public health
Why undernutrition?
45% child deaths due to undernutrition
• Undernutrition (IUGR, sub-optimal BF, stunting, wasting, vit A and zinc deficiencies) cause 3.1 million or 45% of all childhood deaths (Black et al. Lancet 2013)
• More than 10% of total global burden of disease is attributable to maternal and child undernutrition (Black et al. Lancet 2008)
• OR 3.0 (1.0-8.9) dying from malaria if a child is wasted (WHZ<-2) (Black et al. 2008)
WHO 2011
Essential Nutrients • Constituents in the diet required for growth,
health, and survival - not endogenously produced in sufficient levels
– Macronutrients – protein/amino acids, carbohydrates,
lipids/fatty acids, fiber
– Micronutrients • Vitamins (organic) – A (β-carotene, retinol), B (thiamin), riboflavin, niacin,
pyridoxine, cobalamin, pantothenic acid, folate), C (ascorbic acid), D (calciferol), E (α-tocopherol), K, choline
• Minerals/elements/trace minerals (inorganic) – calcium, iron, zinc, iodine,
selenium, copper, fluoride, phosphorus, magnesium, manganese
– Water & electrolytes – sodium, chloride, potassium, inorganic sulfate
It’s all in the packaging
Deconstruct & reconstruct
http://www.countingblocks.com/building-blocks/
Vitamin A
• Physiology – Vision: retinal opsin → rhodopsin – Immunity: epithelial tissue, adaptive immunity – Gene expression: reproductive health, cellular
differentiation, embryogenesis, etc.
• Deficiency – Leading cause of preventable blindness globally – 250 million preschool age children have VAD
• Dietary sources – Preformed retinol – liver, meats, fish, eggs, and milk – Proformed retinoids - dark green, yellow, and orange
fruits and vegetables – 1 RE = 1μg retinol = 12 μg β-carotene =24 μg carotenoid
Vitamin B12 (cobalamin)
• Physiology – Synthesized by anaerobic bacteria in ileal, after deuodenum – Cobalamin needed to synthesize succinyl CoA and methionine
• Deficiency – megalobastic anemia – neurological disease (demyelination and peripheral
neuropathy); impaired brain development
• Dietary sources – No plants except algae – Meat, poultry, fish, eggs, milk, and fortified foods
Choline
• Physiology – Cell membrane structure and signaling – Source of methyl groups – Neurotransmission, precursor for acetylcholine
• Deficiency – De novo synthesis, but dietary intakes required (1998)
– Brain development (cognition & memory), fetal development, fatty liver, and hepatocarcinomas
• Dietary sources – Eggs, human and animal milk, wheat germ (betaine),
beef liver, spinach (betaine)
– Most abundant in animal source foods
Iron
• Physiology – Oxidation-reduction reactions – Oxygen transport, enzyme activity in cellular respiration, division, neurotransmission, immunity, and growth
• Deficiency
– 115,000 maternal deaths; 18% of children < 5 yrs – 3.4 million DALYs attributable to IDA
• Dietary sources – Heme iron (20-50% absorbed): meat, poultry; Non-heme
(0.1-35% absorbed): fruits, vegetables, grain – Enhancers: meat, vitamin C; Inhibitors: phytates and
polyphenols
Zinc
• Physiology – Zn > 300 enzymes structural & regulatory roles
– Protein and nucleic acid synthesis
– Growth & immune functioning
• Deficiency – 30% of children < 5yrs stunted
– 17.3% of world’s population inadequate zinc intake
• Dietary sources – Fish, shellfish meats, whole grains, nuts, and legumes
– Enhancers: protein-rich foods/meat; Inhibitors: phytates in maize, legumes, oxylates
Key concepts: Brown School MPH Program
• CELLS TO SOCIETY
• TRANSDISCIPLINARITY
Agriculture and Food Systems
• Food production and processing
•Availability of micronutrient-rich foods
• Food safety and quality
Inadequate practices • Infrequent feeding • Inadequate feeding
during and after illness • Thin food consistency • Non-responsive feeding
Health and Healthcare • Access to healthcare • Qualified healthcare
providers • Availability of supplies
•Infrastructure •Health care systems and
policies
Education • Access to quality
education • Qualified teachers
• Qualified health educators • Infrastructure (schools and
training institutions)
Food and water safety • Contaminated food
and water • Poor hygiene
practices • Unsafe storage and preparation of foods
Concurrent problems & short-term consequences Long-term consequences
Poor quality foods • Poor micronutrient
quality • Low dietary diversity and intake of animal-
source foods • Anti-nutrient content • Low energy content of
complementary foods
Water, Sanitation and Environment
• Water and sanitation infrastructure and
services • Population density •Climate change •Urbanization
Political economy • Food prices and trade
policy •Poverty, income and wealth
• Financial services
• Employment and livelihoods
Community and societal factors
Inadequate Complementary Feeding
Stunted Growth and Development
Health ↑Mortality
↑Morbidities
Developmental ↓Cognitive, motor,
and language development
Economic ↑Health
expenditures ↑Opportunity costs for care of sick child
Economic ↓ Work capacity
↓ Work productivity
Developmental ↓School
performance ↓ Learning capacity
Unachieved potential
Health ↓Adult stature ↑Obesity and associated co-
morbidities ↓ Reproductive
health
Infection
Clinical and subclinical infection
Enteric infection: Diarrheal disease,
environmental enteropathy, helminths • Respiratory infections
• Malaria • Reduced appetite due
to infection • Inflammation
Household and family factors
Maternal factors • Poor nutrition during
pre-conception, pregnancy and lactation • Short maternal stature
• Infection • Adolescent pregnancy
• Mental health •IUGR and preterm birth • Short birth spacing • Hypertension
Inadequate practices • Delayed initiation • Non-exclusive breastfeeding
• Early cessation of breastfeeding
Context
Causes
Consequences
Society and Culture • Beliefs and norms
• Social support networks • Child caregivers (parental
and non-parental) • Women’s status
Home environment • Inadequate child
stimulation and activity • Poor care practices •Inadequate sanitation
and water supply • Food insecurity
• Inappropriate intra-household food
allocation • Low caregiver education
Breastfeeding
Application:
HAITI, KENYA,
ECUADOR
Rotovirus,
ETEC,
campylobacter,
v. cholera
WASH
Nutributter
Mamba
Eggs
Urban poverty
livelihoods
Research focus
• What are the most effective interventions to promote healthy growth and development among young children living in resource-poor countries?
– Address micronutrient deficiencies related to poverty and infectious diseases in vitamins A, B12, choline, iron, & zinc
Global public health research Brown School
(St. Louis) *PI *Office of Research, Business, IT, Service, Communications, etc. *RAs
Nutributter RCT (Cap Haitien)
* Study Coordinator * 3 enumerators * 2 data managers * Wash U students
Eggs for young child nutrition (Ecuador)
* 2 Study Coordinators *5 enumerators *Wash U student
Mamba School Study (Cap Haitien)
* Study Coordinators * 6 enumerators * 2 data managers * Wash U students
Partners: MSPP, PNCS/MENFP, Meds & Food for Kids, Konbit Sante, NSRL, Edesia
Funders: World Bank, USDA, Alive & Thrive, Inter-American Development Bank, World Food Program
Partners: University of San Francisco in Quito, PAHO, UC-Davis Funders: Mathile Institute
• Infrastructure & logistics: research site, banking, vehicles, accommodations
• Human resources: university partnerships, training, communication
• IRB: 2 committees, 3 languages, culture • Environment: drought, political volatility
RESTORING THE PEARL OF THE CARIBBEAN
Haiti
Haiti: context • History
– Occupation, dependencies→ weakened
healthcare system
– Major earthquake Jan 2010
– Cholera & widespread diarrhea
• Rapid urbanization and poverty
– >50% population live urban areas; 3.9 % per year
– 80% in poverty (less than $2); 54% in abject poverty (<$1)
• Nutrition (DHS/EMMUS 2012)
– 20.9% stunted, 11.4% underweight, 5.1% wasted
– Hidden hunger: 65% of infants 6-59 mo were anemic; and 16.9% of children 6-59 mo live in HH with iodized salt
Study Site – Cap Haitien Cap Haitien
Partners & Funders
Funders:
Bill & Melinda Gates Foundation to FHI 360, through the Alive & Thrive Small Grants Program managed
by UC Davis; World Bank; World Food Program; Inter-American Development Bank
Objectives
To test the efficacy of a small-quantity lipid-based supplement (LNS), Nutributter® (NB), delivered within an integrated package of services (IP) on promoting linear growth, over time
• improve complementary feeding practices in poor urban context
• examine effects of NB on infant and young child feeding (IYCF) practices
Fortified peanut butter paste
• Prevention, not treatment! – Intervene early to prevent stunting
– Micronutrient nutrition in school age children
• Poverty intervention – high quality food + education
– Local peanut farmers &
economic development
A. Boshara photo 2012
MFK 2013
Intervention: Nutributter ®
Ingredients: peanut
paste, sugar, vegetable
fat, dry skimmed milk
powder, maltodextrines,
whey, vitamin and
mineral pre-mix,
emulsifier
Interventions MOH Integrated Package
• Integrated Management of Childhood Illness (IMCI) – Health education: community
health agents provide information at clinic & rally posts
– Vaccinations
– Vitamin A supplementation
– Growth monitoring & promotion
– Reproductive health
Study Design – mixed methods • RCT & impact evaluation
• Control, 3-mo NB, 6-mo NB
• Followed monthly for anthropometry, morbidity, and development outcomes
• Sustained growth effect→ 6 mo post-intervention
• Qualitative research & process evaluation
– In-depth interviews, matrix scoring, focus groups, observations, etc.
• Geospatial analyses
– Handheld Global Positioning System (GPS) units to map (n=150) of households, water sources, sanitation, markets, health service providers, churches
Trial profile
Group 1
Control
group
(n=191)
Group 2
Nutributter
3 mo
(n=196)
Group 3
Nutributter
6 mo
(n=202)
Monthly follow-up visits: → 6 months
GIS analyses
RCT
*Recruited and screened (n=709)
* Enrolled and randomized (n=589)
Qualitative
research &
process
evaluation
POST-
Intervention (6 mo)
Intervention Period
(6 mo)
Control (n=144)
NB 3 mo (n=126)
NB 6 mo
(n=150)
48 losses to
follow-up
70 losses to
follow-up
52 losses to
follow-up
Nadege: qualitative research
Growth effects – longitudinal regression
3-mo NB
vs. control
6-mo NB
vs. control
Unadj β
(SE) P
Adj β
(SE)2 P
Unadj β
(SE) P
Adj β
(SE)2 P
At 6 mo
LAZ -0.10
(0.05) 0.06
-0.12
(0.05) 0.03 0.08 (0.05) 0.16
0.13
(0.05) 0.02
WAZ 0.02
(0.05) 0.65
0.01
(0.05) 0.86 0.08 (0.05) 0.09
0.12
(0.05) 0.02
At 12 mo
LAZ -0.09
(0.05) 0.06
-0.11
(0.05) 0.03 0.06 (0.05) 0.20
0.10
(0.05) 0.04
WAZ 0.03
(0.05) 0.54
0.02
(0.05) 0.73 0.08 (0.04) 0.09
0.11
(0.04) 0.02
Iannotti et al AJCN 2014
Public health: entire distribution shifted
0
.02
.04
.06
.08
.1
Den
sity
65 70 75 80 85 90 95 100child height (cm)
Group 1: Control
Group 2: NB for 3 mo
Group 3: NB for 6 mo
kernel = epanechnikov, bandwidth = 1.4094
Kernel density estimate
Do no harm: looking for unintended consequences
• Increased dietary diversity 0.23 ±0.07 SE (P<0.001)
• ↓ BF frequency 1.17 ±0.25 SE (P<0.001)
• ↑ water (84%) & sugar drinks (51%)
• Vitamin A supplementation – VAS in last 6 mo (99.3%)
– 3-4 doses
– 80% in NB groups >upper level
Upper level VA
Mamba School Feeding Project
• McGovern-Dole International Food for Education and Child Nutrition – Micronutrient-fortified food aid products pilot
• Partners: Meds & Food for Kids (MFK), Washington University, Edesia, National Soybean Research Laboratory, Ministry of Education/Haiti
• Why does it matter? – School age children in Haiti – BIA, anemia, & anthropometry – First time RUSF tested in this age group – Global, bilateral, and national policies and food aid program
Design & Methods
• Cluster-randomized controlled trial (quasi-experimental design)
– Formative research/school profiles used to collect SES and nutrition to help match schools
• Sample & comparison groups (6 schools):
– 1,200 school aged children 3-13 years
– 1) control; 2) Tablet Sereyal (unfortified biscuit); 3) Mamba Lespri
• Impact & Process Evaluation
– Impact outcomes – anemia, BIA, anthropometry, school attendance
– Process outcomes – food acceptability, functionality, feasibility
Egg nutrition – Pastocalle, Ecuador
Egg study – Pastocalle, Ecuador
• RCT to test effects of daily egg consumption among children 6-12 mo (n=180)
• Eggs purchased from local producers
• Outcomes: anthropometry, biomarkers of choline, vitamin B12, lipids and amino acids
To conclude • Travel abroad & across campus
– Learn language, build relationships, make a commitment
– Understand larger context and population
– Attend public health and global health speaker series
• Think and work holistically – Integrated systems of actors
– Multitude of health determinants, and apply transdisciplinary approaches
Thank you!