nutrition

Kwashiorker

"the disease that the first child gets when the new child comes" in Ghana rapid response to severe protein deficiency, high carbohydrate diet usually accompanied by underlying infections and disease edema, mild to moderate weight loss, growth impairment, fatty liver This is actually more deadly than marasmus, esp in children infected with measles. Was mistaken historically, esp in slave children, as a sign of health. Very dangerous due to edema and associated effects on heart, etc. Dettwyler talked about seeing this in the rural areas of Mali where children had diet high in carbs but very low in protein.

Marasmus

"to waste away" slow development; result of chronic malnurition caused by severe deficiency of protein and energy sources in children who are not breastfed or weaned early extreme weight loss, muscle and fat loss, and growth impairment Common in poor areas where formula is used- sometimes diluted to make it last longer due to expense- and water quality is poor. It's especially bad in infants because of rapid brain growth. Commonly listed as cause of death of infants after 1860. Dettwyler talks about this in Mali during her study.

The Politics of Pellagra

A little more about social and cultural dimensions of pellagra, which has been widely studied. As stated earlier, 10,000 people died from pellagra around 1915. Part of the unwillingness to connect this to diet and poverty was the fact that it undermined the narrative of reconstruction and the "New South". But because of high poverty and a diet mostly consisting of cornmeal, effects were catastrophic

Pellagra and Gender

As discussed in the reading, data from the early 20th c. in the U.S. showed that morbidity from pellagra in women was 20x that seen in men and mortality rates were double (critics of Goldberger thought that men were just more resilient than women). Sex differences, esp niacin inhibiting effects of estrogen, as well as gender differences, esp cultural practices where women eat after men and children, contributed to this.

Pellagra and Ethnicity

Connected to class, which is closely tied to ethnicity. In Ireland, during the potato famine, Prime Minister of Britain Robert Peel ordered corn to be sent there to feed millions of starving people. It was the cheapest grain that he could order, but they didn't inform people about how to treat it. Even though pellagra wasn't a named disease yet, historical records suggest that thousands of people likely suffered from it. The next PM actually stopped those shipments and didn't replace corn with something else. In other places like South Africa, people living in high poverty areas (with black majorities) suffered from pellagra as late as the 1950s without any intervention at all, even though the cause was well-known by that time- it wasn't until the 1980s that the foods supply began to be fortified.

Methods

Dietary recall (24 hr+) Dietary intake: biochemical analysis observed and unobserved weighted food record food diary Ethnographic- participant observation, interviews, etc. Food Balance Sheets (UNFAO)- population-wide data

food security and public health

Food security is not just about having a full stomach- good nutrition is crucial for maintaining good health, including warding off infectious disease. Probably the most important global public health issue- a well-nourished child is more likely to survive infections from contaminated water, etc.

joseph goldberger enrichment of grains cereals

Goldberger was a public health specialist in the early 20th century. He was concerned about high fatality rates of a disease called "pellagra" in the American south and was convinced that there was a dietary cause. Many other public health officials thought that pellagra had an infectious cause. He noted that even though pellagra was common in institutions and prisons, only the prisoners and patients got pellagra, not the staff so that it was unlikely to be infectious. To prove his assertion, he actually ingested scabs of pellagra victims to show that it wasn't infectious (yes, you read that right!). He also recruited prisoners to go on a niacin-free diet (the substance that he thought was missing) to induce pellagra symptoms and then cured them with high-niacin foods like chicken. He not only figured out the cause of pellagra, but advocated for the scientific and social recognition of the connection between poverty and disease (high niacin foods like meat are expensive). Henry Sebrell was his assistant (Goldberger died relatively young) and successor. He later was the director of the National Institute of Health from 1950-1955 and is known for discovering the cause of riboflavin deficiency and promoting nutrition as being as important as preventing infections. During this time, there was concern that the milling process for grains removed all of the nutrition (the germ) and that the U.S. should fortify the food supply with vitamins. Sebrell thought it was crazy to remove the nutrition from foods only to put it back in (but everyone loved their bread smooth and bleached white). Many were concerned with fortification because they didn't know how much of certain vitamins was necessary to put back into the food; they were also concerned that it would be too costly, and would create a black market in white flour. During WWII, War Food Order 1 mandated enriching foods (B1, B2, B3 and folate) given to soldiers and after the war became mandated for the general food supply in the U.S. Sebrell promoted the idea that if everyone ate a variety of different fruits and vegetables of different colors, they would have sufficient nutrients.

Vitamin A deficiency

Hippocrates recommended liver to cure night blindness major public health problem in developing world- leading cause of non-accidental blindness among the poorest countries, 500,000 children become blind each year This is one of the most devastating deficiencies in the developing world and a major public health issue. It is especially problematic for children. It increases morbidity (illness) and mortality (death) due to infectious diseases- esp. strong co-morbidity with measles. Must be careful with upper limits because it's fat soluble- is toxic in high doses (such as is found in polar bear livers).

iodine deficiencies

Iodine def can result in formation of goiters (from increased thyroid hormone). Common in areas where soil is naturally deficient in iodine so that foods grown are also def. Found also in saltwater seafood, seaweed, iodized salt. Was common in Great Lakes region due to low amount in soil. In areas def in iodine, goiters have become a sign of beauty because the majority of women have them (although can be bad during pregnancy).

iron deficiencies

Iron def is a global problem for women and children- even in the U.S. Problems are associated with having a low amount of meat in the diet- common in high-poverty areas as well as in more affluent areas due to the pickiness of children's eating habits; also associated with parasitic infections such as hookworm. Effects on the bone in severe cases seen in pictures. Cavitations and extra bone growth can be seen (also recent research suggests that iron def anemia isn't severe enough to cause these bone changes and it could be due to genetic anemias). The phytates (antioxidants) in whole grains, legumes, and other foods also bind iron, manganese, zinc, calcium so that their absorption is reduced. Vit C actually increases the absorption of iron so drink a glass of OJ with your hamburger!

Pellagra

Niacin deficiency "rough skin" in Italian More than 10,000 people died of pellagra in 1915, American South high corn diet (untreated with alkali) 4 "D's": diarrhea, dermatitis, dementia, death preventative foods: poultry, meat, fish, enriched grains and cereals Studied by Goldberger as previously discussed. He discovered niacin cause when he noted similarities in symptoms with "black tongue" in dogs which could be cured with nicotinic acid. Niacin is abundant in corn but not biological available unless processed with alkali- many Native Americans did this but when Europeans adopted corn agriculture they did not. Another cause is Hartnip's disease, where the tryptophan (an amino acid) pathway that converts to niacin in blocked.

Clinical Symptoms

Symptoms of pellagra. mal de la rosa and casals necklace

vitamins

The first vitamins were discovered just after the turn of the 20th century. It's difficult to get too much of water soluble vitamins because the excess is excreted in the urine; however, fat soluble vitamins require ingestion of fat in order to be absorbed by the body and are not excreted in the urine- must be careful about getting too much. Although large-scale deficiencies in the U.S. are rare, less severe deficiencies of some vitamins are common (clinical versus subclinical deficiencies). Other causes of deficiencies (excluding inadequate intake) include intestinal malabsorption disorders, smoking, alcoholism, aging, and genetic conditions. Leafy greens are a great source of many of these vitamins, including vitamin K. For each of the common deficiency disorders described in the following slides, think about clinical symptoms, prevalence, high risk groups, and food sources.

Trace Mineral deficiencies zinc

These minerals are essential but in smaller amounts than major minerals. Zinc was first recognized as an essential nutrient in animals in the 1930s but not in humans until the 1960s. It's found in protein-rich food like meats and seafood, nuts, beans, wheat-germ. Babies are esp prone to def if mother's breastmilk is deficient, or they are weaned early onto non-protein-rich food (zinc stores are low at birth). Effects include loss of appetite, delayed growth, dermatitis (as in picture), and poor healing ability. Toxic effects of too much zinc include vomiting and nausea.

beriberi

Thiamin deficiency "I can't, I can't" in Sinhalese in late 19th century Asia, one of leading causes of death milled rice diet (lacks germ) peripheral neuropathy, muscle pain, enlargement of heart, edema, weight loss, confusion after 14 days on thiamin-free diet Preventive foods: pork, sunflower seeds, legumes, enriched grains and cereals Person is very weak, which is where the name comes from. Not seen in the U.S. but still seen in parts of the developing world.

Rickets

Vitamin D deficiency bone deformities caused by reduced synthesis of vitamin D3 described since ancient times, but cause identified in 1918 preventative foods: fortified milk, cod liver oil UV radiation from sunlight is best source Even though rickets is rare, a significant portion of the U.S. population is likely to be deficient (every cell in the body has a Vit D receptor). Within the last 10 years it's been linked to immune function and may be important for preventing infectious diseases and cancer (Roswell Cancer Institute in Buffalo started giving it to chemo patients 10 years ago).

Refugee and other humanitarian crises

We will discuss refugee issues later in the semester, but ensuring that refugees are well-nourished, not just given food to feed bellies and quell hunger, remains a widespread problem. Examples in Mozambique and other places where pellagra thrived in refugee camps despite clear knowledge about prevention.

Water and Major Mineral Deficiencies

dehydration from diarrhea, vomiting, fever, heavy exercise, hot weather, dry environments, high altitude more common in older adults and sick children sodium and chloride loss from dehydration (ORT) Water is most important- can only live without water for 3 days, versus many weeks without food. Dehydration very common on athletic fields in the summer but very important to use ORT or hospitalize with IV rather than treating with just water (crucial balance between water and sodium in cells). In this respect water can also be a poison if too much is consumed in a short amount of time. Calcium is reduced with aging, esp in post-menopausal women, although men can also be affected (it's also a side effect of some medications).

Vitamin B-12

especially common in older adults (20% in America), vegetarians (esp breastfed infants of vegetarians and vegans) macrocytic anemia, pernicious anemia, paresthesia, dementia preventative foods: meat, poultry, seafood, eggs and dairy products Many older adults have vitamin B-12 shots because of severity of deficiency. This has multiple causes in older adults including reduced absorption with age, lack of money to buy meat (many live on fixed incomes), difficulty with making food, and difficulty with processing food (missing teeth, etc.). Pernicious anemia, which used to be incurable and fatal, caused by this (an intrinsic factor is secreted out of the ileum which is necessary for absorption of B12)- can now be diagnosed and treated before becoming symptomatic. Causes decrease in energy. Vegetarians and, especially, vegans must take supplements.

Folate Deficiency

from low intake, inadequate absorption, increased need (pregnancy), compromised utilization can cause macrocytic anemia, decreased absorption in GI tract, diarrhea, diminished immune function, neural tube defects preventative foods: liver, legumes, leafy green vegetables, enriched grains Folic acid is the synthetic form found in supplements and fortified foods. It's recommended that all women of child-bearing age take folate, even if you aren't planning on getting pregnant, because birth defects occur within the first trimester of pregnancy, before many women know that they are pregnant. Even though good nutrition is important during pregnancy, folate is especially crucial.

vitamin a deficiency part 2

important for growth and development, cell differentiation, vision, immune function preventative foods: liver, fish, fish oils, fortified milk, eggs, dark-green and orange fruits and vegetables animal sources more common in NA, vegetable sources more common among poor in rest of world Important connection to infectious disease is the fact that it reduces immune function. Risk factors include low intake of Vit A rich foods, low body stores, decreased breast feeding, and illness. Genetically modified rice (golden rice) has beta-carotene- 12 genes that switch on).

the best method for diagnosing a vitamin or mineral deficiency

is a blood test. Unfortunately, there are issues with drawing blood, such as having an experienced person to do that, assuring a sterile environment, getting IRB approval, storing and analyzing blood samples, etc. I likely won't do this with my cohort of Maya kids in Mexico (Coba) because they would hate seeing me! (along with all of the other aforementioned reasons). Other less accurate methods for detecting micronutrient and macronutrient deficiencies include dietary recall. This is likely to be less accurate because you're relying on people accurately remembering and recounting what they ate and how much. Better to do shorter recalls (24 hrs) rather than longer ones for that reason. Also important to do throughout the year to look for seasonal issues. Growth methods not mentioned here because we'll talk about those with growth and development next week. Ethnographic methods include interviews- such as asking mothers what foods are typically eaten at breakfast, lunch and dinner- and watching what people eat (through participant observation). Food balance sheets look at population-wide data regarding foods available for consumption- not as useful for smaller studies in more confined areas.

Protein-Energy Malnutrition

lack of adequate protein and energy most devastating consequences in children children fail to grow normally, may develop diarrhea, infections, and diseases, early death 55,000 people die of hunger each day; 2/3 are children These are macronutrient deficiencies. 2 specific kinds are discussed next. Micronutrient deficiencies refer to vitamin and minerals.

Rickets is caused by a

lack of calcification of bones, so children (whose bones are growing) are esp susceptible. Vit D, which you can get from fish oil and UV radiation from the sun, passes through the liver and becomes biologically active, regulating calcium and phosphate. Cholesterol acts as a catalyst in this process. Those who have darker skin (which protects against getting too much UV radiation and skin cancer) are at greater risk. This has become a worry in the U.S, because of the use of sun block, the fact that kids don't play outside as much anymore, and for kids who don't drink milk (which is fortified with Vit D). Interestingly, people who come from northern European ancestry are more likely to have high cholesterol and require medication because having more cholesterol likely helped in this process in an area where UV radiation is very low. It wasn't a big deal when most people didn't make it to age 60 anyway (and natural selection is largely neutral after reproduction is over), but today we expect to live much longer and so interventions to lower cholesterol before deadly effects are favored.

Important considerations

seasonal availability of foods cultural taboos and beliefs regarding food accessibility of foods agency in food choices "overnutrition" (micronutrient def but overabundance of macronutrients) nutrition transition and cultural change Different foods are ripe during different times of the year, so there can be seasonal def. Important to do dietary recall over the course of the year. Also, certain foods may or may not be consumed due to religious and other cultural beliefs (such as Ida's aunt in "All My Babies" who thought that new mothers shouldn't eat meat or greens). Some foods may not be accessible due to cost and access. Also, most individuals including, to some degree, children can decide what they want to eat or not eat (like picky kids who won't eat chicken even when it's on the table). Overnutrition is a huge problem in developing countries and I have documented this in Coba as well. As part of a cultural shift away from traditional farming and toward buying packaged food, it is common to see an overabundance of calories and fat but still micronutrient def.

Riboflavin Deficiency

symptoms include cracked lips and corners of mouth, bloodshot eyes, dry and scaly skin and sore throat, poor growth subclinical def found in U.S. preventive foods: avocados, leafy greens, fish, milk, cheese, organs, mushrooms, enriched grains and cereals Riboflavin is important for energy metabolism and causes a bright yellow color in urine. Clinical signs of this rare in U.S. but it's estimated that as many as 28 million people have a sub-clinical deficiency (lack outward signs). This is probably what Maybell in the "All My Babies" film had- causes scabbing around the mouth. Will remain in whole brown rice if it's steamed prior to milling.

Scurvy

vitamin C deficiency assoc with poverty worldwide humans and other primates can't synthesize vitamin C prevents normal collagen synthesis, causing pinpoint hemorrhages, bleeding gums and joints, bone pain, depression preventative foods: citrus fruits, peppers, and green vegetables Of course we think of pirates when we think of scurvy! Very common among all sailors because of lack of fresh fruits and vegetable during long voyages. Interestingly, primates, including humans, are among the few mammals whose bodies don't naturally produce this- likely because primates have always eaten fruit so it isn't necessary to make it (any reduction in an energetically costly biological process would be favored by natural selection). Upper toxicity level is unclear and debated- it's likely that any excess is excreted in the urine.