Malnutrition

Malnutrition

Nutrition is part of a balance:

• Undernutrition: immunosuppression and susceptibility to infection
• Optimal nutrition: normal immune function
• Overnutrition: immune-activation and susceptibility to inflammatory diseases

There is malnutrition in case of undernutrition and overnutrition.

Undernutrition and overnutrition

Undernutrition is an insufficient intake of macro- or micronutrients to meet nutritional needs. Macronutrients are proteins and fat, micronutrients are vitamins and minerals. There are 2 types of undernutrition:

• Growth failure
• Micronutrient malnutrition

Overnutrition is an excess amount of energy leading to overweight and possibly chronic disease.

Nutritional transition

Besides a demographic and epidemiologic transition, there also is a nutrition transition. There is interaction between these 3 transitions. Nutrition transition is the pattern from scarcity to over-consumption → a change from an active lifestyle and whole grain foods to a sedentary lifestyle and ready-made convenience foods. A nutritional transition has different stages:

1. Paleolithic man/hunter-gatherers
2. Settlements begin → famine emerges → high prevalence of undernutrition
3. Industrialization → receding famine → slow mortality decline
4. Nutrition related noncommunicable diseases predominate
5. Desired societal/behavioral change → focus on medical intervention, policy initiatives and behavioral changes

Macronutrient deficiencies

There are different types of macronutrient undernutrition:

• Normal: normal weight and height
• Wasted: thinner than normal
• Stunted: shorter than normal
• Wasted and stunted: thinner and shorter than normal

Wasting is indicative of acute undernutrition, such as in famine or emergencies requiring humanitarian assistance. Stunting is indicative of chronic undernutrition and is common in low income populations in non-emergency cases.

Child undernutrition

• Wasting: extreme thinness → weight for height below -2 SD
• Stunting: extreme shortness → height for age below -2 SD
• Underweight: composite measure of undernutrition capturing thinness and/or shortness → weight for age below -2 SD

Protein energy malnutrition

Protein energy malnutrition, also known as Marasmos, is an extreme protein and energy deficiency. It results in an appearance of skin and bones with little or no subcutaneous fat and a pronounced loss of muscle mass. It can lead to limited brain growth and development. It is a very serious condition of undernutrition.

Protein and vitamin deficiency

Protein and vitamin deficiency, is also known as Kwashiorkor. It can lead to oedema, retention of some subcutaneous fat, red coloring of the hair, apathy and growth retardation. It is a very serious condition of undernutrition.

Micronutrient deficiencies

The 4 most prevalent micronutrient deficiencies are:

• Vitamin A: xerophthalmia/blindness
  • Important to mucous membranes → dryness causes temporary night blindness of permanent damage leading to blindness
  • Important to immune function: supplementation has resulted in reduced risk of measles and diarrhea
  • Dietary sources: liver, yellow/red vegetables
• Iodine: cretnism, goiter
  • Needed for thyroid hormones
    • Regulates the basal metabolic rate
    • Important to early development of the fetus
  • Insufficient iodine → overactive pituitary gland → TSH production → thyroid gland produces more TH → increase in activity and size of the thyroid gland
  • Dietary sources: sea foods, iodized salt
• Iron: anemia
  • Necessary component of hemoglobin
  • Deficiencies related to dietary insufficiency or blood loss
  • Heme iron comes from animal sources, non-heme iron comes from plants and is harder to absorb
  • Non-heme iron absorption is influenced by:
    • Enhancers: vitamin C (present in tomatoes), sugars
    • Inhibitors: phytates, tannins
  • Dietary sources: heme iron (meat, fish, liver), non-heme iron (plant sources)
• Zinc: diminished immune function and growth
  • Crucial in numerous enzymes and metabolic processes
  • Synthesis of RNA, DNA and protein
  • Important to rapidly growing immune cells
  • Currently added to ORS as a therapy for diarrhea and dehydration
  • Dietary sources: meat, fish, shellfish, fowl, eggs, diary, sometimes wheat and seeds

Some micronutrients interact with each other → zinc-copper competition may lead to anemia.

Food fortification

Food fortification is the process of adding micronutrients to food. This isn’t always a good idea.

Global burden of undernutrition

Undernutrition affects nearly half of all deaths of children under 5 years:

• Increased risk of mortality from common infections
• Increased frequency and severity of these infections
• Delay in recovery of these infections

Causes of undernutrition

The causes of undernutrition are complicated:

• Basic causes
  • Poor resources
  • Poor control
• Underlying causes
  • Inadequate access to food
  • Inadequate care for children and women
  • Insufficient health services and unhealthy environment
• Immediate causes
  • Disease
  • Inadequate dietary intake

The main direct causes of child undernutrition differ per age group:

• <6 months: not breastfed
• 6-12 months: infectious disease and complementary feeding practices
• 1-3 years: inadequate care and poverty
• >3 years: HIV/AIDS and TB

Undernutrition is intergenerational → if a child has been malnourished before birth, it has an increased risk of being malnourished at a later age. Stunting is carried over to the next generation → stunted women will have a higher risk of undernourished children during pregnancies. Malnutrition in early life gives an increased risk of developing coronary heart diseases.

Noncommunicable diseases

Nutrition transitions result in new nutritional risk patterns. Overweight and chronic disease are also problems of LMIC experiencing economic growth. Many LMIC have to address both child undernutrition and adult chronic disease risks at the same time → consequences of nutrition transition show a double burden of malnutrition.

In the chronic disease phase of nutrition transition, the diet is rich in animal fat and ready-made foods and low in fiber. The economy is more reliant on sedentary labor, people having a higher income and there are growing disparities between rich and poor:

• A higher income results in a new lifestyle with labor saving devices and mechanized transport
• Energy dense foods become more affordable for lower income populations
• There is an increase in obesity, heart disease and other related chronic diseases

Thus, LMIC now go from famine patterns to chronic disease situations in a short period of time. There is a faster transition of obesity risk shifting from the rich to the poor. For example, low socio-economic status women experience higher obesity risks than men do. This linkage was initially found in Brazil, but also in South Africa and it’s emerging in Guatemala.

Several factors contribute to this chronic disease onset:

• Diet of affluence
• Low physical activity

Fetal programming hypothesis

The fetal programming hypothesis focused on the physiology/biology, but could be amplified by behavioral responses to previous famine. In several groups, there is an association with cardiovascular disease and diabetes:

• Dutch Hunger Winter
• UK birth records data

Low birthweight is related to undernutrition in early childhood. It also is related to the mother’s nutritional and environmental exposures:

• Low body weight
• Anemia
• Smoking
• Infectious diseases

In human studies there only is indirect evidence for this, but in animal studies there is direct evidence. It takes several cycles of good nutrition to ameliorate negative effects.

Body Mass Index

The BMI can be calculated as follows: weight/height². BMI initially only was designed for adults and was seen as a simple way to control for height. Initially there were different cutoffs for men and women, but this is not the case anymore. Now there is a separate call for Asian populations.

Children

BMI was never meant for use in children:

• Children have normal fat mass changes
• BMI changes in a non-linear pattern from birth until 20 years old
• BMI in children cannot be compared to the BMI values of adults

Because BMI couldn’t be used, there are percentile references in children:

• 5^th percentile as underweight, 85^th percentile as risk for obesity
• The reference point assumes 3x more overweight and obesity than underweight

Percentile reference in children have nothing to do with the values used for adults. There are revised BMI cut-offs for children. Child BMI may be distorted by differences in:

• Height
• Age at puberty
• Body composition
• Nutrition status (related to height)

Advantage and disadvantages

Advantages of BMI are:

• Easier to calculate by age and sex
• Just one cutoff value by age and sex
• Weight for height Z-scores

Disadvantages of BMI are:

• Require a separate reference value for every height by sex
• Doesn’t distinguish by age
• Inappropriate for very tall or short populations

Waist circumference

Often the waist circumference is measured together with the BMI:

• In women >80 is associated with increased risk and >88 cm with a substantially increased risk
• In men >94 cm is associated with increased risk and >102 with a substantially increased risk

International Diabetes Federation cut-off points:

• In all women >80 cm
• In Europoid men >94 cm
• In South Asians, Chinese and Japanese men >90 cm

Measures of central adiposity are found to be affected by stress and physical activity. There are no reference values for children to adolescents. In adults, waist abdominal adiposity is related to chronic disease outcome.

Global Surgery

Definition

Global surgery is the term adopted to describe a rapidly developing multidisciplinary field aiming to provide improved and equitable surgical care across international health systems.

The global surgical package includes all the necessary services normally furnished by a surgeon before, during and after a procedure. Anesthesia is essential for a surgical package.

Epidemiology

17 million people per year die of surgery-related events. 4 million people die within 30 days after an operation → in many places, surgery isn’t safe. As a solution, 2,2 million more surgeons and anesthesiologists need to be trained.

Parachute missions

In the 20^th century, parachute missions commonly found place. In these cases, a team of western surgeons travelled to remote areas in LMIC to treat patients.

Steps

When deciding where to start an operation, the following should be taken into account:

1. Local problem holder
2. Sustainable knowledge transfer
3. Research
4. New technologies
   • Videos that show how to do surgery
5. Collaboration

Leapfrogging is the notion that areas which have poorly-developed technology or economic bases can move themselves forward rapidly through the adoption of modern systems without going through intermediary steps.

Library of global surgery

There is a library of global surgery, which contains books with 15 of the most essential surgical conditions that attribute to 80% of the surgical volume in LMIC. This helps and informs doctors about which conditions to treat.

RC Medical technology and Global Health

Deadly animals

The mosquito is the most deadly animal in the world.

Frugal thermometer

For many people in Africa, a thermometer is a luxury they just can’t afford. Even the healthcare workers usually diagnose fever by touching a person’s forehead with the back of their hand, a practice that leads to both over- and underdiagnosis. People are often advised to go to the hospital and take pills when they don’t need to, or they don’t get the urgent medical attention they need.

Frugal innovation means taking a complicated thing and making it simple and affordable. It could, for example, be an object that already exists but then stripped of the additional bits and pieces that make it expensive. The technology that’s left can then be used as the basis of a simpler and cheaper version that can be produced locally. You can charge up a frugal thermometer by winding a handle for a few seconds, and the display not only shows the temperature in numbers and degrees, but also a green smiley-face if a person’s temperature is normal, or a red unhappy smiley if they’re sick.

Reactions

The frugal thermometer led to the following reactions:

• Fever is just an indication of being sick → more diagnostics are needed
• Fever is an elevation, not a fixed temperature threshold
• It depends on the condition of the person as well
• What is the price, what is the business model?
• Who is authorized to diagnose?
• Even with a negative diagnosis, people will take medicine → there is no trust
• Complex algorithms for diagnosis, but low skilled staff
• Is it part of the public or private healthcare system, is it rural or urban?
• Etc.

The development of this product led to more questions than answers, but it facilitated and provoked dialogue.

Diagnostic challenges

Diagnostic challenges in LMIC can be:

• No access to diagnostics → misdiagnosis
• 60% of outpatient malaria diagnostics → overload work

These challenges are complex and interrelated.

Microscope

The current challenges with the microscope are:

• Maintenance
• Expertise
• Expensive
• High flexibility
• Needs electricity
• Intensive work → human errors
• Information gets lost
• Information is not recorded
• Mostly unavailable
• Etc.

Substitutes may be the excelscope or the reversed smartphone lens. These are cheap and easy to repair.

Is technology the solution?

Currently, many smart devices are under development. However, very few end up in the hand of end-users. This means that there are poorly defined market, user and product specifications.

Design thinking can facilitate that bridging role between technology and healthcare use:

• Multidisciplinary team
• Co-creation and inclusiveness
• Frequent iteration and experimentation
• Validation in the lab and field
• Integrated solutions
• Make societal and scientific impact

Community effectiveness is determined by:

• Efficacy
• Diagnostics accuracy
• Medical professional compliance
• Patient compliance
• Coverage

Schistoscope

A schistoscope is a low-cost digital microscope:

• Field deployable
• Integrated sample preparation and diagnosis
• Support of a smart algorithm
• Fits the capacity of community trained personnel
• Can be produced and maintained in Africa
• Enables E-Health and digital data

Diagnostics versus treatment

A diagnostic test often is very cheap, while treatment is very expensive → if thousands of people suddenly are diagnosed, there often isn’t enough money for treatment. This leads to an ethical dilemma.

RC NCDs

NCDs in LMIC

Cardiovascular diseases take much more deaths than malaria, HIV/AIDS and TB together → NCDs form a major threat. A raised blood pressure is the most important risk factor for CVDs and is increasing over time in Sub-Saharan Africa.

In 1980, diabetes was almost absent in Sub-Saharan Africa and Asia. Presently, the main burden of diabetes is in these exact same regions. It is leading to more and more morbidity and mortality.

Causes

Causes of NCDs can be divided into 3 categories:

• Metabolic and physiological risk factors
• Behavioral risk factors
• Underlying drivers

The 4 key NCDs (CVD, diabetes, cancer, chronic lung disease) are largely preventable by effective interventions that tackle 4 shared modifiable risk factors:

• Tobacco use
• Unhealthy diets
• Physical inactivity
• Harmful use of alcohol

Evidence-based interventions

There are many other evidence-based interventions to reduce the burden of NCDs:

• Strong evidence and cost effective
  • Nicotine dependence treatment
  • Promoting adequate breastfeeding and complementary feeding
  • Enforcing drink-driving laws
  • Restrictions on marketing of foods/drinks high in salt/fats/sugar
  • Food taxes and subsidies to promote healthy diets
• Strong evidence but expensive
  • Healthy nutrition environments in school
  • Nutrition information and counseling in health care
  • National physical activity guidelines
  • School-based physical activity programs for children
  • Workplace programs for physical activity and healthy diets
  • Community programs for physical activity and healthy diets
  • Designing the built environment to promote physical activity

Conclusion

Shortly, there is an unprecedented NCD epidemic worldwide. We know what to do and we know what the most cost-effective interventions are. However, not much is happening:

• The politics about regulations → people want to be free to choose
• Changing lifestyle is difficult
  • Social determinants of health are estimated to explain 80% of an individual health status
• Care for people with NCDs is difficult with low resources and poor infrastructure

Thus, the global NCD epidemic requires drastic changes in care delivery and prevention efforts. Healthy living as a prevention and medicine is essential → human behavior should be taken into account. Also, costs and resources are important.

RC FAIR data management and COVID

Data representativity and quality

Africa shows very low numbers of COVID cases and deaths. This may not really be the case → cases may not be recorded in data management systems.

Most health solutions in global health are now artificial intelligence driven:

• Data representativity
• Data quality

Data representativity

Data representativity is a big issue globally. Genetic studies of human disease are predominantly based on populations of European ancestry. Data from Africa are extremely biased to cities and people with a sufficiently wealthy background who can afford health care → averages from high end city services data do not represent the entire population. This influences the effectiveness of diagnosis and treatment, as well as prevention.

Low data ownership

Data is produced in health facilities or in digital apps and moved to clouds on other continents where data is used, but the use of the data is not returned to the place where the data is produced. This has an ethical nature which also has consequences for the quality of the data. In case of low data ownership, the data is not owned by the place where it is produced.

Data regulations

In Europe, data is regulated by GDPR. Data is owned by a data subject and the responsibilities of data ownership and maintaining data quality should be tasked to data processors and data controllers.

In Africa, health facilities and patients have no control over the data they generate. The information is just taken away from them and used on other continents, where it is valuable.

General overview of health facilities in African countries:

• In some clinics data are collected manually with pen and paper

• Not all health facilities have tools to analyze data at the point of care
• Data ownership within health facilities where data is produced is not retained → there is no benefit of increasing quality of data at the point of care
• Health professionals cannot gain insights into critical health data needed for research and analytics within or across healthcare facilities

Summary

Summarized, data is unavailable in vulnerable in remote settings. There is a need for data localization and ownership. Production of data must be relevant to local practices, but this is often not the case. There are unresolved digital data challenges such as lack of interoperability → data is not connected to each other. There is a lack of capacity and training of data stewards and curriculum development for data science.

FAIR Data Science

FAIR date science may offer solutions to the current situation.

Principles

FAIR data principles are:

• Findable: others can discover your data
• Accessible: your data can be made available for others under defined conditions
• Interoperable: your data can be integrated with other data or can be easily used by machines
• Reusable: your data can be re-used by others

Benefits

Benefits of making data in a FAIR format globally are:

• Gain maximum potential from data assets
• Greater discoverability and enhanced visibility
• Improving the reproducibility and reliability of research
• Provide data analytics from different data sources through data visiting

Development

Development of a FAIR-based architecture:

• Data is curated, stored and used within the health facilities where it is produced
• Data security is arranged by the health facility where data is produced
• Efficiencies of data production, processing and reuse is increased by one editing entry into a machine-readable editor
• Data is findable, interoperable and reusable
• Data access permission is arranged within the context of each facility and recognizing national and other relevant regulatory frameworks

VODAN

The Virus Outbreak Data Network (VODAN) Africa and Asia was formed in April 2020. Deficiencies of current healthcare information systems are spotted leading to the discussion of a feasible alternative to tackle the damage caused by the COVID-19 pandemic, especially in developing geographies such as Africa.

An example is the loss of the data on Ebola collected from Liberia. To address this, VODAN Africa developed an architecture to record clinical health care and research data collected on the incidence of COVID-19, producing these as human- and machine-readable data objects in a distributed architecture of locally governed, linked, human- and machine-readable data.

Now, VODAN operates in 84 health facilities in 8 countries. Data is entered, stored in local deposits and then sent to DHS instead of being sent to DHS directly. There are 2 dashboards:

• Dashboard for analytics within the clinic/hospital only → shows data on a local level
• VODAN Africa dashboard for general statistics → shows data on a global level

This also is the case for research data.

Data collection

Data is collected as followed:

1. Personal data
   1. Medical measurements
   2. Patient data records
   3. Pseudo-anonymous data
2. Data
   1. Anonymous data
   2. Processed data
   3. Aggregated data

The more personal the data, the higher the sensitivity and specificity. The more anonymous the data, the higher the accessibility.

Aims and goals

Aims and goals of FAIR are:

• Data interoperability: data in a format that can be automatically read and processed by a computer
• Personal health train: trains can visit multiple local FAIR data points to get their questions answered
• Data security: the more data is de-identified through computation, the more it can be used as aggregated data for research or policy, including for algorithmic decisions

RC Culture/medical anthropology

Medical anthropology

Rudolph Virchow: medicine is a social science, and politics is nothing more than medicine on a large scale.

Medical anthropology is a subfield of anthropology. It studies:

• Health and wellbeing
• The experience and distribution of illness
• The prevention and treatment of sickness
• Healing processes
• Social relations of therapy management
• Cultural importance and utilization of pluralistic medical systems

Disease, illness and sickness:

• Disease: the doctor’s perspective on ill-health
  • Without context or cultural meaning
• Illness: the patient’s perspective on ill-health
  • With cultural, social and emotional context
• Sickness: the society’s perspective on ill-health
  • Sick individuals have a different social role than healthy individuals
  • The language of distress differs in cultures → sickness is culturally defined

Mother and child health

Mother and child health are intertwined:

• Biologically and physiologically
• Socio-culturally

The Millennium Development Goals

The MDGs were designed between 2005 and 2015. Goal 3 is to promote gender equality and to empower women, goal 5 is to improve maternal health.

Happiness

Women seem to be happier without children then with, although in some parts of the world, women are unhappy without children.

Culture

Culture the whole of norms, beliefs, values and practices in a society. It is the full range of learned human behavior patterns. Culture is a whole of different cultures and subcultures. Cultures are in contact with each other and constantly changing.

Culture has an important influence on all aspects of life of all people:

• Behavior, perceptions, emotions and religion
• Experience of pain, stress and illness

Culture can be studies with the qualitative research method.

Qualitative research

Why you should do qualitative research:

• When the field of study is unknown, it is more open and more involved than rigid and standardized research
• From the point of view of the concerned
• After a quantitative research for precise and substantial descriptions

There are different methods and techniques for qualitative research:

• Audio: registration of sounds
• Visual: photography or film
• Internet: digital data sources, email or Whatsapp
• Interviewing
• Participant observation: what people say they do is often different from what they often do

Approaches

Different approaches towards health, illness and disease:

• Biomedical approach of health, illness and disease: scientifically explained
• Pluralistic approach: looks beside the physiological cause → may have a social, spiritual cause
• Complementary and alternative medicine

Rituals

Characteristics of a ritual:

• Action
• Performed in a fixed order
• Always has a significance
  • Tooth brushing isn’t a ritual because it doesn’t have a symbolic meaning

A ritual expresses key values, renews values and demonstrates these values in a dramatic form.

Types of rituals:

• Cosmic cycle or calendrical rituals
• Rituals of social transitions
• Rituals of misfortune

Functions of rituals:

• Psychological
• Social
• Protective