AGL 26 – BASICS OF NUTRINTION IN DEVELOPING COUNTRIES



ICL - INTENSIVE CARE LANGUAGE

AGL – BASICS OF NUTRITION IN DEVELOPING COUNTRIES

ROUGH DRAFT BEFORE PUBLICATION 2012

Dr. Bob Boland & Team

MD, MPH, DBA, ITP (Harvard)

“The greatest courtesy you can give to anyone … in a developing country … is to speak to him … in his own language”

WORKPACK

DIARY

Source: JHSPH/WHO/ILO/CD/IR

Computer/audio: from:

Help: drbobboland@

Copyright: RGAB/2012

WORKPACK

CONTENTS

Item Page Number

1. Program 3

2. Part A: Case – Hariet Wison 5

3. Part B: Case – The Bean 9

4. Part C: Case – Rural Jamaica 13

5. Exercise: Bill Brown Series 21

6. Part D: Bulgar Wheat 26

7. Quiz 31

Prepared as part of the PCP – FLJI/THAILAND Training program at John Hopkins School of Hygiene and public Health by: Gail Rothe, Lynn kavalec, Linda Knierieman, John Mahonery, Lisa Rau and molly Wilson with some guidance from Dr. Mary Carnell, Dr. Adam Lisiewicz, Dr. Robert G. A. Boland and Dr. Mary Young.

AGL 26 – BASICS OF NUTRINTION IN DEVELOPING COUNTRIES

1.0 Program

Activity Mode Starting Duration

Time (Minutes)

Day 1

1. Introduction MG 8:30 15

2. Quiz IND 8:45 45

3. Part A – Study – Basic Nutrition MG/SG 9:30 60

4. Break - - 10:30 15

5. Case – Hariet Wilson SG 10:45 60

CSG 11:45 30

MG/SG 12:15 30

6. Lunch - 12:45 45

7. Part B – Study – Deficiency States MG/SG 1:30 60

8. Case – The Bean SG 2:30 45

9. Break - 3:15 15

10. Case –The Bean (Cont’d) CSG 3.30 30

MG/SG 4:00 30

11. Review and homework assignment MG/SG 4:30 30

____

Total 510

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AGL 26 – BASICS OF NUTRINTION IN DEVELOPING COUNTRIES

1. Program Cont’d

Activity Mode Starting Duration

Time (Minutes)

Day II

1. Review and Bill Brown (1-6) SG (new) 8:30 45

2. Part C – Study-Measurement & NG/SG 9:15 45

Assessment

3. Case – Rural Jamaica SG 10:00 45

4. Break - 10:45 15

5. Case – Rural Jamaica (Cont’d) CSG 11:00 30

11:30 30

6. Case – Bill Brown (7-12) MG/SG 12:00 45

7. Lunch - 12:45 45

8. Part D – Study – Nutritional SG (new) 11:30 30

9. Case – Bulgar Wheat SG 2:00 30

CSG 2.30 30

10. Break - 3.00 15

11. Case – Bulgar Wheat (Cont’d) MG/SG 3.15 30

12. Quiz IND 3.45 45

13. Review and Feedback MS/SG 4.30 30

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Total 510

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AGL 26 – BASICS OF NUTRITION IN DEVELOPING COUNTRIES

2.0 Part A – Case: Hariet Wilson

QUESTIONS ON THE CASE

1. Qutline the key facts from the story of the case.

2. What are the quantities of nutrition needed by this 17 month child in terms of : energy foods, body building food and protective foods? What minerals are needed? What are the special needs of the mother at this time: Are theses needs being satisfied?

3. What are the contributing factors to Hariet’s poor development?

4. What preventive measures are appropriate in this case?

5. As a worker in a MCH clinic where Hariet mother now brings her, what would you suggest for the mother and child now? Decide and justify your decision?

2. Part A – Case: Hariet Wilson

BACKGROUND

Hariet Wilson was the first child of the second wife of a night watchman living in Lusaka shanty-town and earning K48 a month. When she was first seen she was 17 months old, weighted 7.9 kg (normal) and had an arm circumference of 12.8 cm. (normal).

Earlier on, Hriet’s father had lived in the village, where he had tow wives, the first of whom he had divorced after three of her children had died before they were a year old. After two years in town, he had sent for his second wife, and Hariet, who was them 16 months old.

Hariet had never been a healthy child. She had measles at the age of 10 months and had had diarrheas most of the time ever since. First a nganga, a traditional practitioner, had tried to cure her by making cuts on her chest, but this had not helped.

When she arrived in town her father her father had next taken her to private doctor, who had given her injections as long as there was any money to pay for them, but these also had not cured her. She than went to the clinic, but the medicine that they gave her did not help either. Several people gave her mother advice.

At the hospital near her home in the village, they had said that breast-feeding should stop, and Hariet had been given some dried skim milk. However, Hariet’s mother neither gave her this milk nor did she stop breast-feeding, because she did not trust the hospital.

So Hariet had continued breast-feeding and was said to be very hungry. She had her own plate of nshima (about 10 teaspoons – full) and relish, but no extra milk. Even though her father earned a good wage, her mother was only given about k15 to buy food, and the family had almost no money by the middle of the month, and for the last two weeks of it their relish was usually cabbage.

Meanwhile Hariet got worse; she become thinner, and, whereas she had been walking, she not stopped crawling and law still. Her father decided that because the private doctor, the clinic and the hospital had failed, her mother must have ‘witches in her breast’ and that her milk must be bad. He was determined that Hariet should stop breast-feeding and would feed from bottle instead.

2.0 Part A – Case: Hariet Wilson

ANSWERS TO THE CASE

1. STORY OF THE CASE

a. Hariet, a child of 17 months unhealthy

b. Measles at 10 Months

c. Chronic diarrhea since measles

d. Unsuccessful treatment by traditional healer, clinic, hospital and doctor.

2. NUTRITION REQUIREMENTS

a. (1) energy food – carbohydrates

(2) needs 160 cal/kg (for child recovering from malnutrition)

X 10kg = 1600 cal for 10kg child

(3) allocation

Cal/garm Calories grams:

Protein 10% 4 1640 40

RBH 60% 4 960 240

Fat 30% 9 480 53

100% Total 1600 333

b. Minerals – iron, calcium, magnesium, iodine, phosphorous, etc.

c. Special needs of mother – iron, calcium, iodine, etc.

And 2500 cal per day

d. needs – not satisfied

3. CONSTRAINTS

a. Little money food –poor management

b. Rural to urban

c. Belief that breast milk was bad

d. Access to medical help but social/cultural barriers made medical case ineffective

4. PREVENTATIVE MEASURES

a. ORT

b. Supplemental feeding

c. Immunization

5. DECISION AND JUSTFICATION

a. Ecourage MCH clinic attendance for surveillance

b. Continue breast feeding if possible with help of traditional healer

c. Provide nutritional education and Road to Health Card

d. Provide short term supplementary feeding but avoid long term dependence

e. Concentrate on better use of local resources

6. LEARNING POINTS

a. Iron deficient diets, parasites and small intervals between births contribute to anemia and malnutrition contributes to malnutrition.

b. Risk of malnutrition is greater during times of rapid growth, stress and recovery from illness. Examples: children under 5, pregnancy, lactation, measles, respiratory infection.

c. Building blocks for good nutrition are: carbohydrates, protein, fat, vitamins, minerals and fluid.

d. Variety in the diet is important in supplying a complete diet.

e. Protein complementing allows incomplete proteins to be combined to provide high quality protein, at a low cost. Vitamin A deficiency is a major cause of blindness in developing countries.

3.0 Part B – Case: The Bean

QUESTIONS ON THE CASE

1. What were the key factors in the story of the case?

2. What types of malnutrition are present?

3. What is the: Who, What, When, Where and Why of this nutrition problem?

4. What assumptions were made by the Professor? What has happened?

5. What is needed now? As a Peace Corps Worker for the village, what would you do? Decide and justify.

3.0 Part B – Case: The Bean

A small village in the Notak Ruk region was a subsistent agricultural community. A visiting professor at the University in the capital came to the village infrequently and noticed little improvement in the general health and well-being of the population since his arrival to the area 10 years before.

At that time the diet of the village (self-supporting) consisted primarily of rice, beans and seasonal vegetables – all locally grown. The village remained remote from the expanding economic development of the capital.

The Professor was keenly aware of the value of soya beans on the international market and their high protein value compared with the local bean used in the village. Accordingly, he arranged for a supply to be made available and made some efforts to convince the community to grow soya beans instead of the local variety.

Two years later Linda Knierman, Peace Corps worker, arrived in the village on an assignment for nutritional education. She found that 80% of the children and 50% of the mothers appeared to be suffering from nutritional problems. Many of the babies had wasting, large heads and aged faces. Others had swollen bellies, edema or apathy and red hair. There was also some “dry eye”, anemia and night blindness. However, the villages were not at that time concerned with nutrition as a major social problem.

3.0 Part B – Case: The Bean

ANSWERS

3.1 STORY OF THE CASE

a. Small village, traditional diet- rice and beans

b. Introduction of new soya bean without consideration of local market

c. Two years later, malnutrition of children and mothers

3.2 TYPES OF MALNUTRITION

a. Protein, calorie malnutrition (spectrum from marasmus to kwashiorkor)

b. Specific nutritional deficiencies due to lack of vitamin A, iron, etc.

3.3 WHO, WHAT, WHEN, WHERE, WHY?

a. Who: mother and children

b. What: protein/calorie malnutrition

c. When: over 2-year period since promotion of soya bean to village

d. Where: village in Notak Ruk region

e. Why: soya bean displace local bean production and was not used as food, but sold the market

3.4 ASSUMPTIONS

a. That local bean not an essential source of protein complementing in the local diet

b. The exact food problem in the village need not be surveyed before introduction of change

c. Villages will accept and understand that soya has higher nutritional value; they will eat it as well as well it

3.5 DECISION AND JUSTIFICATION

a. Ask the villagers what they want. Identify the key problems.

b. Identify cause of malnutrition.

c. Demonstrate the cause of malnutrition to the villagers.

d. Try to return to local bean and insure adequate nutrition.

3.0 Part B – Case: The Bean

3.6 LEARNING POINTS

a. Widespread nutritional deficiencies may not be viewed as a problem but rather accepted as normal in a particular community.

b. In considering nutritional deficiencies one must focus on who, what, where, when and why.

c. It is rare to see severe forms of protein calorie malnutrition such as kwashiorkor and marasmus, however, mild and moderate forms may be widespread.

d. Malnutrition is related to the overall health and development of the community (energy for work, educational and economic progress).

e. Change of agriculture from traditional to cash crops may involve unexpected changes in health status, i.e., increase of cash, but increase of malnutrition.

f. Need to identify village culture and values before making changes.

4.0 Part C – Case: Rural Jamaica

QUESTIONS ON THE CASE

1. What are the key points of the story of the case?

2. What was the target population? What was the objective of the program? How were the C. H. A.‘s selected and trained? What measurements were used to diagnose malnutrition? What care was given? What was followed up monthly? Was this adequate?

3. What were the demographic correlates of malnutrition? Apart from weight for-age, what additional measure was associated with malnutrition? Is this valid? What verification can be made when weights-for-age appear to classify healthy children as malnourished?

4. What was the outcome of the program? Can you account for the low mortality but the same morbidity?

5. Would you change the program? Decide and justify.

4.0 part C – Case: Rural Jamaica

INTRODUCTION

At Elderslie, Jamaica, the Government of Jamaica, the University of the West Indies, and Cornell University Medical College established rural-health project in November, 1969, to evaluate local health needs and resources, and design appropriate systems of health-care delivery.

Senior medical students, together with the permanent local staff and a newly trained group of Community-Health Auxiliaries (C.H.A.) defined a demographic and disease profile of the community.

The 6,000 residents of Elderslie were mostly subsistence farmers. They lived in an isolated mountainous district of twenty-seven square miles traversed by a few poor roads, with no electricity, and an unreliable water supply.

Under these local conditions, despite the relative overall affluence of Jamaica, it was hardly surprising to find a disease pattern characteristic of a developing country. Although they comprised only 20% of the total populations, the 1,000 children under five accounted for almost one-half of all deaths in the district. Examination of their death certificates revealed that in more than two-thirds of these cases malnutrition was at least an associated cause of death.

PROJECT DESIGN

The goal of the Young-Child Nutrition programme has been to reduce mortality and improve the nutritional statue of each young child in the district. The Elderslie staff decided that the Young-Child Nutrition programme must rely on local resources and manpower, and operate at a cost the community could bear.

In view of this, it was decided that locally recruited and trained C. H. A.’ s would be the programme’s primary practitioners and that no food supplements other than dried skim milk, which was already being distributed by the Government throughout the island, would be provided.

Five men and women were selected in January, 1970, to be trained as C. H. A.’s. Their three-month training at the Elderslie health centre was supervised by a Jamaican public-health nurse. After a written and oral examination, the auxiliaries were certified b y the Government and became permanent employees of the Ministry of Health. Their education continued at weekly meetings, at which specific topics were discussed, problem cases presented, and experiences exchanged.

Although involved in various health activities in the district, the C. H. A.’s have been particularly active in the Young-Child Nutrition Programme. They performed the anthropometric examination to diagnose malnutrition, distributed dried skim milk, provided regular nutritional instruction in the home each month, and monitored each malnourished child’s progress by monthly anthropometric re-examination.

During the first year, 1150 children were examined by the C. H. A.’s A child weighing less than 75% of the standard weight-for-age according to the Harvard weight-for-age standard was judged to be seriously malnourished. (Gomez) Such children entered the “treatment” group and were assigned to the care of the C.H.A. who lived closest to the family. This auxiliary made a home visit at least monthly to reinforce sound dietary, sanitary, and hygienic practices. Specific advice on feeding was based on a protocol derived from Pan American Health Organization/World Health Organization (P.A.H.O. /W.H.O.) guidelines. For the Commonwealth Caribbean and modified to fit local conditions. Verbal and written instructions were supplemented by demonstrations of actual food preparation in the home, while the C.H.A. determined whether prompt medical attention was needed, and, if so, made immediate clinic referral. Otherwise, the mother was advised to have the child weighed and to pick up the dried skim milk each month at a field or clinic visit.

At first, mothers were urged to bring their children to the Elderslie health centre each month. It soon became apparent, however, that many mothers were unwilling to subject seemingly healthy children to long hours on hot, dusty roads. Therefore, regular monthly field clinics were established at four remote villages within the district. After this, more than 250 children (a quarter of the total population) were examined each month. Particular effort was made to have newborn children, those already ion the malnourished (“treatment”) group. And those not seen lately attend these clinics. As a result, more than 75% of all malnourished children were weighed and measured each month. At both the clinic itself and the field centers C. H. A.’s plotted each child’s weight-for-age on a Gomez graph, thus providing immediate visual feedback for the mother as well as for themselves.

A child continued in the “treatment”, or home-visit, group until he or she had maintained 75% of their standard weight-for-age for three successive months, had left the district, or had reached the age of five.

INITIAL FINDINGS

Anthropometric Survey

The Young-Child Nutrition Programme began in November, 1970. During the initial two months, 576 of about 1000 preschool children in the district were examined by C.H.A.S. Weights-for-age agreed closely with those reported earlier from another rural Jamaican community. Using the Gomez curves, 33% of the children were Gomez grade I (75-90% of the standard weight-for-age), 8% were grade II (60-75% of the standard weight) and 1% were grade III (below 60% of the Gomez standard)

Demographic Correlates

Analysis of the data obtained from these first 576 children revealed that the following characteristics were associated with malnutrition:

1. Children aged six to thirty-six months were most likely to be malnourished;

2. Those who lived farthest from the clinic were at greatest risk, regardless of their history of clinic attendance (perhaps clinic attenders were self-selected as a less-ell group);

3. Girls were three times more likely than boys to malnourished;

4. The longer a child was breast-fed, the more likely he was to be malnourished.

Malnourished children tended to express certain other characteristics more commonly than well-nourished children, but a reliable association could not be verified. The following factors were important:

1. Mothers under twenty were more likely to have malnourished children;

2. Children weighting less than six pounds at birth were at greater risk;

3. Left-arm circumference segregated a deficient population similar in size but slightly different in composition from that defined using weight-for-age standards.

Antenatal care, attendant at birth, household size, and intestinal-parasite infestation were all unrelated to the subsequent occurrence of malnutrition.

OUTCOME

Prevalence of Malnutrition

All children living in the district were encouraged to attend either field screening or clinic sessions. Thus, by design, children were continually being seen for the first time. Among these were a certain number of malnourished children. As the programme’s coverage has become more nearly complete, the children being seen, with the exception of neonates, have tended to come from more remote and poorer areas and from families less accustomed to receiving health services. Of the 187 children most recently examined for the first time, 25 (13%) were less than 75% of standard weight-for-age. A community wide effort to screen all district children at the end of the first year of the programme resulted in anthropometric examination of 676 children, among whom the frequency of malnutrition (Gomex grades II, III ) was 7%. A similar effort at the close of the second project year disclosed that 7% of 520 children under five years of age weighed less than 75% of standard weight-for-age (table I).

Malnutrition Associated Mortality

During the two years preceding the establishment of the Elderslie project, 14 children under five died each year. With the provision of regular clinical medical service by medical students, but before the start of the special programme to improve Young0-Chiold Nutrition (1969-70), mortality remained relatively constant. With the4 advent of the Young-Child Nutrition Programme (1970-72), mortality declined by 50%. This decline was particularly striking among the post-neonatal group. During the four-year period (1962-72), no child over three years of age died.

Malnutrition Associated Mortality

During the two years preceding the establishment of the Elderslie project, 14 children under five died each year. With the provision of regular clinical medical service by medical students, but before the start of the special programme to improve Young0-Chiold Nutrition (1969-70), mortality remained relatively constant. With the4 advent of the Young-Child Nutrition Programme (1970-72), mortality declined by 50%. This decline was particularly striking among the post-neonatal group. During the four-year period (1962-72), no child over three years of age died.

Source: Article in the Lancet and other materials.

4.0 Part C – Case : Rural Jamaica

ANSWERS TO THE CASE

4.1 STORY OF THE CASE

a. Remote village with malnutrition. Program objective-reduce mortality.

b. Young-child Nutrition program for under-five’s started in 1969 after demographic and disease survey.

c. Plan to diagnose malnutrition by monthly anthropometry, treat deficient children with education and food demonstration in the home, but without additional food supplement to that already provided by the government skimmed milk program.

d. Reliance on improvement of local resources management

e. Results in lower mortality, but no change in malnutrition morbidity.

4.2 TARGET POPULATION AND DIAGNOSIS OF MALNUTRITION

a. Target Population 1150 under fives

b. C.H.A.‘s selected by education and locality. Three months of training with written and oral examinations

c. Malnutrition diagnosed by Gomes measurements (weight-for-age), using 75% of Harvard standard as limit of malnutrition.

d. Care-education and food demonstration on use of local supplies and government skimmed milk.

e. Monthly follow-up of all malnourished children with home visits if necessary.

f. Adequate. This is good surveillance.

4.3 DEMOGRAPHIC CORRELATES AND MEASURES

a. demographic correlated : children aged 6-36 months, distance from the clinic, girls more than boys, breast-feeding duration, mothers under 20 years and LBW infants.

b. Additional measure – left arm circumference

c. Validity- not valid where age uncertain or LBW or short stature

d. Verification – weight-for-height/height-for-age.

4.4 OUTCOME

a. Mortality reduced by 50% due to good follow-up of acute illness.

b. Morbidity 7% after one year, but unchanged after two years. Probably lower than at the beginning, but not improvement after year 1 due to difficulty of locating new cases early enough in rural environments. Must accept some minimal level of malnutrition in LDC environment.

5. DECISION AND JUSTIFICATION

a. With limited resources and local staffing, this is a good example of preventive care which has promise of continuity, since it does not employ volunteers. Possible improvement in finding new vases earlier, nut standard generally adequate fort the total environment.

4.0 Part C – Case: Rural Jamaica

4.6 LEARNING POINTS

a. The first step in anutri9tion program is demographic/disease survey.

b. C. H. A’s may be selected and trained locally in three months or less.

c. Better to have paid C. H. A’s rather than volunteers for long-term continuity.

d. Demographic correlates of malnutrition may include: distance, age, breast-feeding, mothers under 20, LBW infants, girls more than boys.

e. Need multiple measures of malnutrition which must be correlated with the cultural environment.

f. Programs which reduce mortality may not eliminate residual malnutrition morbidity.

g. Weight for age should be sued only as an overall general assessment of community’s nutritional status. As a individual measure it does not differentiate between chronic and acute malnutrition and frequently rates as malnourished an individual who is not considered clinically malnourished.

h. Arm circumference is an indicator that is highly correlated with more complicated measures and thus can be used in field situations when efficiency is desired.

i. Many of the internationally used charts may be misleading due to the population used in establishing the standards. For example, the Harvard Scale was based on a sample of Boston children who may be quite different in stature than children from a developing country.

j. Anthropometric indicators should not be viewed as absolute definitions of nutritional status but as guides in assessment and evaluation.

k. Although quantitative measures may reveal much as to overall nutritional status of community, qualitative measures should be examined thoroughly to assess more specifically the nature of the problem.

l. In choosing an assessment technique one must take into consideration not only the accuracy and efficiency of a particular method but also the response the community may have to the method.

5.0 Exercise - Bill Brown Series

Problems for a Consultant

1. Lynn Kavalec moved into Yap District of the Western Adain Islands to develop a nutrition program that would require very little funding for a period of one year. She became discouraged when her assessments indicated a high incidence of obesity, dental carries, diabetes, cardiovascular disease, diarrhea and a multitude of other diseases. She was astonished, however, when she discovered that a large amount of each family’s income was spent on buying coca-cola. She decided upon a program to introduce change with the slogan, “Things would go better with coconuts”. Comment.

2. Linda Knierieman from the Peace Corps arrived in a small African village to help the community get a nutrition program started. She felt that she should chat with the villagers in an attempt to create enthusiasm for the program. Having examined the functional analysis in great detail she suggested to the people that a nutritional program could reduce 50% of the under 5 years of age deaths that were clearly associated with malnutrition and numerous other “facts” that she obtained from her statistics. After one year of her program and a relatively good success rate the interest suddenly declined. Why?

3. John Mahoney was working as a missionary in Sri Lanka. Upon his arrival he felt that acceptance by the people was essential to the effectiveness of any efforts toward increased health and nutrition in the village. He purchased clothing like the villagers, adopted their habits and attended all meals that he was invited to, taking extra care not to offend them by not eating everything. The people came to like him as their own, yet when he began his nutrition education coursed he found little interest or attendance.

4. Lisa Rau and her fellow Peace Corps worker, Gail Rothe, went to Thailand to study malaria. They traveled in the field together eating the same typed and quantities of food, yet Lisa gained 50 pounds while Gail became very “slim”. What may have happened?

5. The island of Fiji received a huge shipment of Bulgar Wheat, a source of grain not available in the local area. A short time later Molly Wilson and the donor representatives discovered that the Bulgar was being fed to the fish in the local ponds. Why do you suppose this happened in an area where there were so many malnourished children?

6. Jeanne Faraher, a Peace Corps member, had been working in Zaire for several years. She noticed that she was feeling extremely fatiqued and weak as of late. This condition became so pronounced that she fell one day and broke her wrist. She consumed enough iron, she said, every morning with her tea that she should not be suffering from anemia. Explanation?

7. A Peace Corps mission in Botswana launched an effort to decrease of eliminate the consumption of beer which was a favorite beverage of the women in the community. They felt that not only was it an inefficient use of family funds in a poor community but contributed to the incidence highly successful campaign against alcoholic consumption, a nutritional evaluation indicated an astonishing increase in anemia and protein deficiencies among the women. No other changes within the area seemed to explain this phenomenon.

8. Miriam Labbok was 5 months pregnant, and had just visited the clinic in Thailand. She was disturbed that she had failed to gain weight. When asked about her dietary intake, she responded she was eating as usual. Why has she not gained weight?

9. Mary Carnell arrived in a rural village, assessed the young children in the village and determined that the majority of their calories were derived primarily from carbohydrate and small amounts of protein foods. Many young children were suffering from kwashiorkor and xeropthalmia. What factors should she consider in intervention and education?

10. Adam Lisiewicz arrived at the site after Peace Corps Training and was asked to design a nutrition program based on the community. What should be his aims and methods?

11. Marshall McBean, a nutrition worker assigned to a village, reported

a 5% grade III malnutrition and high rates of grade I and II. However,

on arrival he was impressed by how well nourished the population

Appeared on a casual tour. What measurements should he check on a

representative sample to confirm his initial impressions?

12. In the country of Boland (a LDC) the IMR is 40/100. Three years ago

prior to PHC the IMR was 80/100. The decrease was attributed to late

marriage and one-child families. A province in a rural area reports

incidence of LBW infants at .5% compared with 6% in most developed

countries. Explain.

13. Camara Jones has been working in a MCH clinic for a year now and has

been trying to get mothers to supplement their 4-6 month olds with

local protein foods and continue breast-feeding. The village was

beginning to feel influence from the west, especially in the last two

months with an extensive advertising campaign by a multinational

corporation for bottle feeding. What can she do to counter the

effects of their campaign?

5.0 Exercise – Bill Brown Series

Answers

1. Too simplistic. Need to understand the culture and work not for the community.

2. Villagers expected a 50% decrease in under 5 deaths almost simultaneously with the start of the program. Taylor’s law, “A suggestion is a promise” was broken.

3. The villagers reasoned that since he ate as they did what could he teach them with respect to nutrition. Taylor’s law “You’ve got to be different to create a difference” clearly applies in this case.

4. Lisa was eating approximately the same amount of food as she did in the States (except for an occasional 5 egg omelet), yet her activity level was greatly reduced due to the depression of the heat. Gail meanwhile was sharing her food with the hook worm that had grown attached to her.

5. Wheat was not a food that the Fijians were accustomed to eating. Furthermore, they had been working on improving their local production of rice and beans and their own fish farming. Lack of integration with other sectors in the development program created this conflict of interests and goals.

6. Jeanne did in fact have anemia. Input doesn’t necessarily mean utilization. A chemical in tea reduces in half the amount of iron absorbed whereas Vitamin C doubles the amount of iron intake.

7. The beer was on of the primary sources of carbohydrates for the women. The lack of energy producing carbohydrates created an inefficient use of the small amounts of protein in the women’s diets. In addition, beer was fermented in special iron caldrons which permitted absorption of iron into the beverage.

8. Caloric needs are increased during pregnancy. Could have worms, reduced absorption.

9. Diet low in fat, therefore absorption of vitamin A was low. Also protein deficiency impairs absorption of vitamin A via the intestinal wall and the liver will not release vitamin A. Need to target population at risk and find local sources of fat, protein and vitamin A.

10. Nutrition program – aims:

a. Faster community self-reliance

b. Utilize existing local resources

c. Promote with and for mothers, focus on wisdom of child rearing producing healthy children; use understandable and available technology. Major operational objectives: a behavioral change with outcome of improved health status.

11. Nutritional measurement standard may have been wrong. Recheck weight-for-age, height-for-age, and arm circumference.

12. Statistics in LDC’s are not always reliable especially for rural areas due to poor management, auditing and reporting systems. Statistics should be regarded with some data is politically sensitive and may be withheld from publication.

13. Recognize the problems – political, cultural, social and economic. Talk to village leaders about discontinuing the campaign for bottle feeding. Provide education and cheaper, local resource utilization.

6.0 Part D – Case: Bulgar Wheat

QUESTIONS ON THE CASE

1. What are the key facts from the story on the case?

2. How would distribution of free Bulgar wheat effect the :

a. a village which received it

b. reaction of other villages

c. the Agricultural Project

d. the PHC centers

e. the health status of the population in the region

f. expectations of the total population

3. What health strategy is appropriate for the malnutrition problem

4. Decide and justify what Dr. Marshall should do.

6.0 PART D – CASE: Bulgar Wheat

INTORODUCTON

In March 1981, Dr. Marshall was suddenly asked to accept a truckload of 3 tons of Bulgar wheat (high nutritional and vitamin B value), located on a Catholic relief Services outside his office in Ilutu, in the province (lower Burundi). The wheat was offered to relieve malnutrition in the province, by special distribution to mother’s decision and a signature on his receipt form.

Dr. Marshall was a French physician with over 4 years experience in rural PHC in lower Burundi. He was the coordinator of 50 PHC centers in (government and missionary centers) in remote areas within 4hours drive of the regional hospital at Ilutu. The province has a total population of 200,000. The general environment was rural agriculture, with the usual of chronic disease, nalnutrition, and endemic disease, etc., but some progress was being made.

A special Agricultural Developmental project had been organized for the past 3years in collaboration with PHC Centers. The project was designed to encourage not only improved agricultural methods, but also a change of behavior to reduce malnutrition.

BACKGROUND

Prevalence of malnutrition was estimated to be 50% of the target population of “under 5 children” in the province. Dr. Marshall was convinced that the malnutrition was not caused by a shortage of food, but rather the sale of the crops for cash to pay for education, clothing, etc.

The local population did not perceive malnutrition as directly related to inadequate diet, rather, they related a child’s “failure to thrive” to evil spirits or some unknown misbehavior of the parents. Alternatively, they perceived malnutrition in the younger children as a necessary price to be paid for clothing and educating children. The result was high child morbidity and mortality.

Several studies confirmed this impression which was reported to the village PHC health committees and led to Agricultural and Health Education Projects. One member of a village PHC committee said “We are mad to starve our babies just to send the older children to school”. A large national donor was just beginning a general food distribution program for the Western zone of the country. Although approved by the national government, there was no agreement at the regional or local level.

BACKGROUND (CONTIUNED)

Despite the pressure by the community to accept this large quantity of free food, Dr. Marshall wondered what difference an occasional or even regular shipments of food would make to the total malnutrition problem and to the efforts already being made to help the people help themselves.

AGL 26 – BASICS OF NUTRITION IN DEVELOPING COUNTRIES

6.0 Part D – Case: Bulgar Wheat

Answers To Case

6.1 STORY OF THE CASE

a. A rural agricultural community with chronic disease and malnutrition.

b. Malnutrition is related to the sale of crops for cash to pay for education and clothing and not due to a shortage of food.

c. A three year Agricultural Development Project is organized with the PHC reduce malnutrition.

d. The community is offered 3 tons of free Bulgar wheat from CRS.

e. The donation was approved only on the national level.

6.2 EFFECTS OF DISTRIBUTION OF FREE BULGAR WHEAT

a. Promote a fatalistic attitude, by implying that the solution to the problem lies outside of the village.

b. Encourage jealousy and animosity with neighboring villages.

c. Local agriculture would be discouraged, since Bulgar wheat is not a local crop.

d. Villagers are on the threshold of an awareness of Family Planning in realizing that their younger children go hungry because of their need to educate and clothe the older children. Therefore, the wheat would discourage population control.

e. Create an unstable nutritional situation because it is a temporary, unpredictable input.

f. Encourage external dependency.

6.3 APPROPRIATE HEALTH STRATEGY

a. Try to demonstrate to the villagers the who, what, where and why of the nutritional problem.

b. Ask the villagers what they feel they need.

c. Agricultural Projects should be continued, encouraging increased local production and better use of resources.

d. A gradual approach to Family Planning should be introduced through the PHC Centres.

6.4 DECISION AND JUSTIFICATION

a. Refuse the Bulgar wheat.

b. Justification: discourage external dependency

encourage self-sufficiency

motivate local agricultural development

create stable long-term nutritional status

5. LEARNING POINTS

a. Free food is not the approach to chronic malnutrition

b. There is no easy solution t chronic malnutrition.

c. Need to determine the “Who, What, When, Where, Why” of the problem.

d. Malnutrition may not effect the fundamental causes.

e. Any abrupt changes or temporary support may do more to destabilize the copying mechanisms of the community than meet the immediate needs of the target population.

f. Food is Perishable; knowledge is permanent.

g. Health and nutrition may not be a higher priority than the other objectives (educational, politics, etc.)

h. Recognize the complexity and potential problem of refusing free food.

i. Recognize different perceptions and objectives to nutritional problems at local, regional, national and international levels.

j. Health and nutrition may not be a higher priority than other objectives (educational, cultural, political, etc.).

7.0 Quiz – A Test of Knowledge Acquired from the Programme

Estimated time: 45 minutes (Choose the most correct answer)

1. The WHO definition of health is:

eating the correct foods in ones diet.

social equity and justice for all

no alcohol, drugs, obesity or sex

physical, mental, and social well-being

2. To facilitate good nutrition in developing countries, food can be divided into:

a. energy, body building and protective

b. carbohydrates, protein, vitamins and fluids

c. energy, carbohydrates, fats and vitamins

d. carbohydrates, protein and fat

3. In the ideal proportion of caloric intake, and individual’s diet should include:

50-55%

10-15%

35-50%

65-75%

4. Energy needs vary with all of the following except:

a. race

b. body size

c. sex

d. age

5. Extreme caloric intake deficiency results in:

a. goiter

b. kwashiorkor

c. cretinism

d. marasmus

6. Alcohol is a special

a. carbohydrate

b. fat

c. protein

d. mineral

7. Vitamin A deficiency results in:

a. poor absorption

b. cretinism

c. progressive eye disease

d. goiter

8. The eight essential amino acids are those that are:

a. always found in the body

b. necessary to fight disease

c. generally not manufactured by the body

d. necessary to build protein in the body.

9. All of the following are incomplete sources of protein except:

a. meat

b. wheat

c. legumes

d. spinach

10. Breast feeding alone becomes inadequate in providing all nutrients for the child. Thus supplemental feeding must be initiated at:

a. 4-6 months of age

b. 2-3 months of age

c. 8-12 months of age

d. 1-2 months of age

11. Extreme protein deficiency results in:

a. kwashiorkor

b. goiter

c. marasmus

d. anemia

12. In a diet, complementing proteins are those proteins which are:

a. chosen to have balancing proportions of amino acids

b. chosen for getting complete proteins

c. rarely required as a substitute for animal foods

d. not necessary

13. Protein in excess of body needs:

a. replaces a deficiency in vitamins

b. is excreted because protein can only be used as protein

c. is burned or stored as an energy source

d. becomes fat

14. A deficiency of iron results in:

a. anemia

b. tetanus

c. marasmus

d. goiter

15. If supplemental foods are not given to the child with breast feeding:

a. a protein deficiency may result in the mother

b. an unnecessary expense can be avoided

c. the mother will produce larger and larger quantities of milk and will become depleted

d. breast feeding can be used as an effective contraceptive

16. In marasmus, malnutrition has developed:

a. quickly

b. over a long period of time

c. sporadically

d. immediately

17. Pure marasmus is indicated by the following characteristics:

a. rapid progressiveness, edema, pale shiny skin

b. wasting, aged face, head appears large for body

c. edema, aged face, wasting

d. goiter

18. Important food sources for vitamin A are:

a. skim milk

b. dark colored vegetables

c. yams

d. tubers

19. Goiter, which is the result of deficiency of iodine, causes:

a. kwashiorkor

b. night blindness

c. xeropthalmia

d. enlargement of the thyroid gland

20. Iodine deficiency results in cretinism which is a disease mainly in:

a. young men only

b. malnourished adults

c. old people

d. young children

21. The most useful tool in combating the effects of diarrhea is to:

a. increase iron intake

b. push large amounts of food and liquid

c. provide vitamins

d. give oral rehydration

22. For a good quantitative method for assessing nutritional status, you should use:

a. biochemical surveys

b. common indicators

c. anthropometric measures

d. mathematics

23. In the weight-for-age method of assessing malnutrition, all the following are true except:

a. varies from day to day

b. must know age

c. does not differentiate between acute and chronic

d. only describes chronic nutritional status

24. Mid-arm circumference is essentially independent of age

a. after 25 years

b. between 1-4 years

c. between 2-6 years

d. over 50 years

25. As a method for determining malnutrition, Biochemical surveys:

a. are efficient because one single test can determine extent of malnutrition

b. can aid in determining cause of malnutrition but are cost prohibitive

c. have no place

d. are scientifically valid

26. Classification of malnutrition with regard to type & prevalence is essential for establishing

a. objectives and priorities in intervention

b. what type of diseases exist in the area

c. the personnel you will need for an intervention program

d. scientific validity

27. The Waterlow method for measuring malnutrition contrasts:

a. weight-for-age vs height-for-age

b. nutritional intake vs weight-for-age

c. weight-fro-height vs height-for-age

d. chronic malnutrition us acute malnutrition

28. The Gomez method for measuring malnutrition is based on a Harvard standard.To establish its rating scale Harvard uses what percentage of weight for age?

a. 50%

b. 75%

c. 30%

d. 65%

29. All are true about the Waterlow except:

a. measures weight-for-height

b. measures prevalence of morbidity in the population

c. measures nutritional status of the population

d. measures prevalence of chronic acute malnutrition

30. All are true of the most common forms of protein-calorie malnutrition except:

a. child shorter than he should be for his age

b. child weighs less than he should weigh

c. child’s arms and legs thinner than they should be

d. child’s weight appropriate for his height

31. Under-five cards are used to record:

a. progress of an intervention program during its first five years

b. Mother’s health during her first five months of pregnancy

c. child’s health up to 5 years old

d. weight-for-height

32. The following are all true of dietary surveys except:

a. gives nutritional status

b. describes what is eaten

c. not very quantitative

d. describes dietary differences

33. The key factor for a long term success in an intervention program is

a. adequate international financing

b. self-reliance through use of local resources

c. use of trained personnel to run the program

d. local cooking facilities

34. All of the following are obstacles to good nutrition except:

a. availability of food

b. nutritional education

c. lack of animal protein

d. access to food

35. In developing Nutrition Intervention Programs, past history is generally

a. irrelevant because the political environment has changed

b. relevant to recognize the same mistakes the second time

c. relevant to avoid mistakes

d. irrelevant because technology has changed

TRUE / FALSE

36. Some nutritional intervention programs were not effective because of distorting local patterns of feeding.

37. The nutritional “needs” of a community are generally the same as what it wants.

38. A successful project aimed at reducing malnutrition in the target population will generally alleviate the poverty.

39. While self-reliance is important, it is more important to feed those in need by using massive food distribution.

40. Those who are healthy in the community are luck, and you do not need to concern yourself with them.

41. Nutritional deficiency is always recognized as an abnormality.

42. In communities, you have to be different to make a difference.

43. Appropriate technology is technology that is in congruence with the social/cultural/economic/technological needs of a community.

44. In evaluating a program, it is first necessary to establish baseline data.

45. The body uses energy for activity and growth.

46. Malnutrition is an associated cause in approximately 50% of the deaths in LDC.

47. The choice of what measurements to use for measuring malnutrition depends upon the objectives and the resources available.

48. Vitamins can be divided into three groups, fat soluble, protein soluble, and water soluble.

49. During pregnancy an additional 700 cal./day are needed.

50. A common vitamin deficiency in LDC is vitamin a deficiency.

ANSWERS

|1. |c |11. |d |21. |d |31. |d |41. |T |

|2. |a |12. |a |22. |c |32. |T |42. |T |

|3. |a |13. |b |23. |b |33. |F |43. |T |

|4. |b |14. |d |24. |t |34. |F |44. |T |

|5. |d |15. |d |25. |F |35. |F |45. |T |

|6. |d |16. |d |26. |F |36. |F |46. |T |

|7. |d |17. |d |27. |F |37. |T |47. |T |

|8. |e |18. |c |28. |d |38. |T |48. |T |

|9. |d |19. |c |29. |d |39. |T |49. |T |

|10. |c |20. |a |30. |d |40. |T |50. |T |

DIARY

EXHIBIT A - REGISTRATION & FEEDBACK

PART I Basic data:

AQGL 602 - NUTRITION

Date and location:

Name:

Title:

Organization:

Address, telephone, email

PART 2 PREVIOUS BACKGROUND

Please write 1-4 lines on your relevant training and experience in the subject area of the program.

PART 3 OBJECTIVES

Please complete the attached sheet: "Learner Objective Setting".

Then list below, your three objectives in your taking the program.

1.

2.

3.

LEARNER OBJECTIVE SETTING

1. Briefly, what is your idea of a working knowledge of the subject area?

2. Briefly describe a situation you faced in the last six months which involved the subject area. How did it arise? What did you do? What was the result? What did you feel?

3. Can you now list (below) 20 technical words, relevant to the subject area, that you need to use frequently?

4.,List three problems you want to re solve with the course

1.

2.

3.

FEEDBACK AT THE END OF THE COURSE

Grade each question out of 10 (poor 0 excellent 10):

1. Did the course meet your objectives? .../10

2. Content? .../10

3. Method? .../10

4. Challenge? .../10

5. Pre-course learning …/10

6. Quiz scores:

Quiz at beginning ... at the end ... ?

Answers you do not agree with ... ..

7. Three suggestions for course changes and improvement?

8. Your own special 10 line mini- case …and solution please?

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