Global Health Final (second half terms)

The importance of nutrition

•Nutritional status has a profound relationship with health status

•Childhood underweight is the leading risk factor for death of under-5 children globally

•45% percent of all deaths in children under 5 are attributable to nutrition-related causes

•Low-cost, highly effective interventions are available to improve nutrition status

•The nutritional picture of the world has changed dramatically in the last few decades

•Nearly 31% of the world’s population is overweight or obese; most of these people are in low- and middle-income countries

•Overweight and obesity are closely linked with many noncommunicable diseases, and prevention is complex

•Nutrition is central to the achievement of the SDGs

Malnutrition

refers to those who do not get proper nutrition, whether too little, too much, or the wrong kind

Undernutrition

the three most commonly used indices for child undernutrition are:

1.- weight for age

2.- hight-for-age

3.- weight-for-height

Underweight

( weight for age) low weight-for-age; that is, two z-scores below the international reference

Stunting

(height for age) failure to reach linear growth potential because of inadequate nutrition or poor health. Stunting is measured as height-for-age two z-scores below the international reference

Wasting

(weight for height) weight, measured in kilograms, divided by height in meters squared, that is two z-scores below the international reference

Different types of childhood malnutrition

Overweight

excess weight relative to height; commonly measured by BMI among adults. The international reference for adults is as follows:

⚬ 25–29.99 for grade I (overweight)

⚬ 30–39.99 for grade II (obese)

⚬ > 40 for grade III

For children, overweight is measured as weight-for-height two z-scores above the international reference

The Determinants of Nutritional Status

Gauging nutritional status

Birthweight—a child has a low birthweight if the child’s weight at birth is below 2,500 grams

Vitamin A

•Found mostly in green leafy vegetables, yellow and orange fruits that are not citrus, and carrots

•Deficiency associated with xeropthalmia, eventually can lead to permanent blindness

•Important to growth and proper functioning of immune system; can impact severity of illness and chance of survival of pneumonia, diarrhea, and measles

xeropthalmia

disease linked with causing permanent blindness (vitamin A deficiency)

Iodine

•Found in some types of seafood and in plants that are grown in soil that naturally contains iodine

•Deficiency associated with a growth on the thyroid called a goiter and the failure to develop full intellectual potential

•Often occurs in people who live in mountainous regions where less seafood is consumed and the soil is deficient in iodine

Iron

•Found most easily in fish, meat, poultry; also in fruits, grains, vegetables, nuts, and dried beans

•Lack of iron associated with iron deficiency anemia, associated with fatigue and weakness

•Iron-deficient pregnant women have an increased risk of giving birth to a premature or low birthweight baby, or hemorrhaging and dying in child birth

Folic Acid and Calcium

•Folic acid is primarily found in leafy green vegetables and in enriched products, such as flour

•Calcium is generally found in dairy products

•Deficiencies of folic acid in pregnant women are associated with neural tube defects in their children, such as spina bifida

•Supplementation with calcium reduces the risk of hypertensive disorders of pregnancy

Pregnancy and Birthweight

•Pregnant women need a sufficient amount of protein and energy and should consume 300 more calories a day

•Iron, iodine, folate, zinc, and calcium are also important to the health of the woman and child

•The birthweight of a baby is an extremely important determinant of the extent to which a child will thrive and become a healthy adult

Infancy and Young Childhood

•“Window of opportunity” is conception to 2 years of age

•Nutritional gaps during this time can cause problems with stature, mental development, and frequent infection

•Children need sufficient protein, energy, and fats as well as iodine, iron, vitamin A, and zinc

•Children grow best and stay healthiest if exclusively breastfed for first 6 months

Undernutrition

•The rate of underweight in children younger than 5 years of age in low- and middle-income countries fell from about 28% in 1990 to about 14% in 2016

•Still - about 155 million are stunted, and more than 50 million are wasted

Nutritional State of the World (low birthweight)

Nutritional State of the World (prevalence of underweight)

Prevalence of Wasting

Prevalence of Stunting

Prevalence of Iron/Iodine Deficiency

deaths associated with undernutrition

•An important risk factor for death from other causes including diarrhea, pneumonia, measles, and other communicable diseases

•About 45% of all deaths in children under 5 years worldwide are associated with nutritional deficits

overweight and obesity

•Nearly 31% of the world’s population, 2.3 billion people, are obese or overweight

•Obesity has nearly doubled worldwide since 1980

•Childhood obesity has emerged as one of the most serious public health challenges of the 21st century

Addressing Future Nutrition Challenges

•Policy makers need to understand importance of nutrition to good health and human productivity and act accordingly

•Governments need to work with the food industry to improve the way in which foods are fortified and to be sure that processed foods are healthy

•Further research on what works

•Create partnerships of civil society, government, and the private sector

•Nutrition-specific interventions—those interventions that can have a direct impact on nutrition

•Examples: promotion of exclusive breastfeeding, micronutrient supplementation, and food fortification

Addressing undernutrition for children

Young child deaths could be reduced by about 15%  with a package of nutritional interventions for pregnant women that includes:

⚬Folic acid supplementation or fortification

⚬Balanced energy protein supplementation

⚬Calcium supplementation

PDCA Cycle

•Deming Cycle or Shewhart Cycle

•A four-step iterative process is used in continuous improvement and problem-solving.

•It’s often used in Six Sigma and other quality management frameworks to drive process efficiency and effectiveness.

Plan: establish a target for improvement

Do: implement the plan.

Check: determine whether implementation has brought planned improvement.

Act: perform and standardize the new procedures to prevent recurrence of the original problem.

the importance of women’s health

•Women face a number of unique health problems

•Poor health of women can have enormous consequences on society

•The health of children depends in many ways on the health of their mothers

•Women’s health is linked closely with the SDGs

Abortion

the premature expulsion or loss of embryo, which may be induced or spontaneous

cesarean delivery

surgical delivery through an abdominal incision

female genital mutilation

traditional practices that are all related to the cutting of the female genital organs

•An estimated 200 million females worldwide have had some form of genital cutting.

•Related to ethnicity

•It can initially cause shock, infection, or hemorrhaging

•Long-term problems include retention of urine, infertility, and obstructed labor

Hemorrhage

significant and uncontrolled loss of blood, either internally or externally, from the body.

Maternal Death

the death of a woman while pregnant, during delivery, or within 42 days of delivery.

Obstetric Fistula

an injury in the birth canal that allows leakage from the bladder or rectum into the vagina, leaving a woman permanently incontinent

Sex-selective abortion

the practice of aborting a fetus after a determination that the fetus is an undesired sex, typically female

• Skewed ratios of males to females in some countries

  • India: 900 females born for every 1,000 males

  • China: 870 females born for every 1,000 males

Sexually Transmitted Infections (STIs)

•Women are biologically more susceptible

•Risk factors for women include young age, sex with high-risk partners, and inability to negotiate condom use

•There are an estimated 530,000 cases of HPV a year that cause about 270,000 cervical cancer deaths a year

Violence and Sexual Abuse Against Women

•UNAIDS estimates 10–50% of women worldwide have been abused physically by a partner

•Can lead to injuries, unwanted pregnancy, STIs, depression, disability, and death

•Risk factors include low socioeconomic status,  young age of the male partner, and gender inequality

Maternal Morbidity and Mortality

•About 300,000 maternal deaths annually

•Almost 60% of all maternal deaths occur in 10 countries: India, Nigeria, Pakistan, Indonesia, Tanzania, Kenya, Bangladesh, Uganda, Ethiopia, and the Democratic Republic of the Congo

•Birth is the time of greatest risk for mother and baby

*A woman in a high-income country has only a 1:3,300 chance of dying a maternal death, compared to 1:36 chance for a women in Sub-Saharan Africa

The Burden of Health Conditions for Women

Biological Determinants of Women’s Health

•Iron deficiency anemia related to menstruation

•Complications of pregnancy

•Increased susceptibility to some STIs

•Health conditions, such as ovarian cancer, specific to women for biological reasons

Social Determinants of Women’s Health

•Male preference is sometimes expressed through female abortion or infanticide.

•Young female children are often fed less nutritious food than male children.

•Low social status linked to physical and sexual abuse and also depression.

•Household roles can lead to women cooking with poor ventilation indoors, which is associated with respiratory disease.

•Poverty, lack of or low levels of education, and low social status limit access to healthcare.

Leading Cause of Death for Women

Leading Cause of DALYs for Women

Leading Risk Factors for Death for Women

Leading Cause of Death Males vs. Females

Differences Between the Health of Men and Women

An analysis identified 19 conditions that disproportionately affect women —> Alzheimer’s disease is a higher-ranked cause of death for females than males, Higher rate of dietary iron deficiency among females

• Related to women’s higher life expectancy, or are a result of gender discrimination

Family Planning

•Studies show that women in regions like SSA would like to avoid pregnancy but do not have needed access to family planning

•Delaying the age at first birth, increasing birth intervals and reducing the number of births

•Family planning is a cost-effective investment to reduce maternal morbidity and mortality

The Importance of Child Health

• 5.4 million children under 5 years of age die each year — deaths are preventable

• vulnerable population

• closely linked with poverty

• insufficient progress

Key Age Terms

Perinatal: first week of life

Neonatal: the first month of life

Infant: the first year of life

Under-5: children 0–4 years old

Mortality and the Burden of Disease — children under 5 years

•99% of childhood deaths are in low- and middle-income countries

•46% of under-5 child deaths occur among neonates

•General trend is decline, but rates of decline vary considerably by region

Mortality and the Burden of Disease — Neonates/Region

Mortality and the Burden of Disease — Infants/Region

Mortality and the Burden of Disease — Infants/Income

Mortality and the Burden of Disease — Under 5 years/Region

Mortality and the Burden of Disease — pie chart children under 5

Mortality and the Burden of Disease — pie chart neonatal

Pneumonia

•Children under-5 in low- and middle-income countries average 3–6 acute respiratory infections per year

•More severe and causes higher rates of death in low- and middle-income countries

•Leading infectious cause of death globally in children under-5

Diarrhea

•Second-leading infectious cause of young child death

•Causes dehydration, loss of nutrition or wasting, and damage to the intestines

•Children under-5 in low- and middle-income countries have around 3–4 cases per year; those aged 6–11 months have almost double.

Malaria

•Leading cause of death in children under-5 in sub-Saharan Africa

•Extremely high morbidity; estimate some people in sub-Saharan Africa have about five episodes per year

HIV/AIDS

•In 2017, there were 180,000 newborns infected with HIV and more than 90% of them were in sub-Saharan Africa

•Causes 1.2% of deaths in children under-5

•A newborn has a 15–45% chance of being infected from an HIV-positive.

Measles

•Children under-5 years and vitamin A deficient or HIV-infected are more vulnerable to complications

•Deaths decreased by 80% globally 2000–2016

•Causes 1.3% of deaths in children under-5

Soil-Transmitted Helminths

•Roundworm, hookworm, and whipworm

•270 million pre-school children and 560 million school-aged children live in intense helminth transmission areas

•Infections can lead to severe morbidity, such as iron deficiency anemia

Additional Comments on Neonatal Mortality

•46% of annual under-5 deaths occur within the first month of life

•73% of deaths in first month occur in first week

•Insufficient progress in reducing neonatal death rate

Risk Factors for Neonatal, Infant, and Child Deaths

• poverty

• maternal health

• birth conditions

• environmental factors

• nutritional status

• infections

• health care access

• education

• conflict and displacement

Cost and Consequences of Child Morbidity and Mortality — Economic and Social Impact

A Best Buy in Global Health — Importance of Immunization

Case Study 1: Eliminating Polio in Latin America and the Caribbean

Case Study 2: Measles; Progress and Challenges

Case Study 3: Reducing Child Mortality in Nepal Through Vitamin A

WHO recommendations for routine immunization

Addressing Key Challenges in Child Health

Ending preventable child deaths from pneumonia and diarrhea

Community-Based Approaches to Improving Child Health

•Women’s groups to raise awareness of maternal, fetal, and neonatal issues

•Community-based promotion of hygiene, umbilical cord care, keeping the newborn warm, and exclusive breastfeeding can reduce neonatal mortality 10–40%

The Importance of Adolescent and Young Adult Health

• Important health behaviors are set during adolescence

• Burden of disease for adolescents and young adults is unique

• Important links to the SDGs

Key Definitions for Adolescence Ages

transition period early adolescence

•Physical changes during puberty (menstruation, body hair, perspiration, etc.)

•Improved ability to think abstractly, introspection

•Susceptibility to peer pressure

•Low risk perception

transition period late adolescence

•Continued physical growth

•Improvements in critical thinking, decision making

•Increased independence

•Transition into young adulthood

transition period young adulthood

•Continued physical growth, final organization of adult brain

•Enhanced reasoning and self-regulatory functions, adoption of adult roles and responsibilities

leading cause of death for adolescents low income countries

leading cause of death for adolescents lower middle income countries

leading cause of death for adolescents upper middle income countries

leading cause of death for adolescents high income countries

Leading cause of DALYs

Facts concerning differences in cause of death by sex and age group: younger adolescence

Males:

⚬11% from road injuries,

⚬ 11% diarrhea and intestinal infectious diseases,

⚬9% from drowning

Females:

⚬7% from road injuries,

⚬7% from malaria

⚬13% from diarrheal and intestinal infectious diseases,

Key Facts concerning differences in cause of death by sex and age group: older adolescence

Males:

⚬19% from road injuries,

⚬10% interpersonal violence,

⚬ 7% from self-harm

Females:

⚬10% from self-harm,

⚬9% from maternal disorders,

⚬8% from road injuries

Key Facts concerning differences in cause of death by sex and age group: young adulthood

Males:

⚬20% from road injuries,

⚬12% from interpersonal violence,

⚬10% from self-harm

Females:

⚬13% from maternal disorders,

⚬10% from self-harm,

⚬8% from road injuries

Risk Factors

Risk Factors — girls specifically

Adolescent girls in low- and middle-income countries may face particular challenges than adolescent girls face in high-income countries. These include: very time-consuming home-related chores, being married at a young age, or family barriers to continuing schooling

Early Pregnancy and Birth

•There were 44 births per 1,000 older adolescent girls worldwide in 2017

•Three million girls aged 15–19 undergo unsafe abortions every year

•Adolescent girls who give birth are at increased risk for birth complications, infant, and maternal mortality

Iron-deficiency Anemia

•Anemia is closely linked to undernutrition during childhood

•Undernutrition and stunting are prevalent in South Asia, sub-Saharan Africa, and indigenous areas in Latin America

•Leading cause of DALYs among 10 to14 -year-olds

•Long-term consequences: loss of productivity, impaired immune function, cognitive impairment

HIV/AIDS and other STIs

•Two million adolescents are living with HIV/AIDS

•In some countries, 60% of new HIV infections occur in 15 to 24-year-olds

•Concentrated in sub-Saharan Africa

•Alcohol and drug use leading to risky sexual behavior increase the risk of HIV infection

•Girls are at increased risk because of biological differences and gender norms

Other Communicable Diseases

•Increased coverage of childhood vaccinations have decreased measles infections significantly

•Diarrhea, lower respiratory infections, meningitis, and TB remain leading causes of mortality of adolescents and young adults

Noncommunicable Diseases

•Less than 1 in 4 adolescents meet the recommended guidelines for physical activity

•In some countries, as many as 1 in 3 adolescents have obesity

•Rate of smoking is decreasing among adolescents and young adults in high-income countries but increasing in middle-income countries

Mental Health

•Depression is a leading cause of DALYs and self-harm is a leading cause of deaths

•Common mental health issues include anxiety, depression, and conduct disorders

•Related risk factors include violent behavior, risky sexual behavior, and substance abuse

Road Injuries

•Road traffic injuries are the third leading cause of death among those aged 10 to 14 years, and the second leading cause of death among those aged 15-24

•Males are at increased risk because of cultural and behavioral factors

Interpersonal Violence

•A leading cause of adolescent  and young adult mortality, resulting in an estimated 180 deaths every day

•Among adolescent males in low- and middle-income countries, 1 in 3 deaths are caused by violence

•Thirty percent of girls aged 15–19 are victims of violence by a partner

Economic and Social Consequences of Adolescent and Young Adult Health Issues

•Essential to maintaining gains made in improving child health

•Health behaviors that set the foundation of adult health status are formed during adolescence and young adulthood

•Future losses to adult productivity and potential

•High costs associated with morbidity, such as, HIV and TB treatment

Health Services and Interventions for Improving Adolescent and Young Adult Health

•Requires a life-course perspective to preventing and treating health issues

•Improve educational and employment opportunities

•Promote universal health coverage to improve access of adolescents and young adults

•Make services more friendly to adolescents and young adults

•Break down data into early adolescence, older adolescence, and young adulthood to better identify group needs

The health of adolescents and young adults is central to…

preserving the gains made in child health and laying a solid foundation for the health of future adults