Capacity Strengthening

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This became known as the Bengoa modification. It is seen most frequently in children one to three years of age, but it may occur at any age. Our response is critical when social structures and essential services have broken down. Update Based on the technical consultation, Geneva, Switzerland, October Assessing the iron status of populations Second edition, including Literature Reviews Assessment of iodine deficiency disorders and monitoring their elimination A guide for programme managers, Third edition updated 1st September Beyond survival Integrated delivery care practices for long-term maternal and infant nutrition, health and development Community-based management of severe acute malnutrition A Joint Statement Development of a WHO growth reference for school-aged children and adolescents Infant and young child feeding in emergencies Version 2. Biofortification- Indian success story pearl millet Mr.

Dracunculiasis eradication

Health care

However, the length of time needed in hospital or for full recovery may be longer than for children with kwashiorkor. In both conditions, as recovery continues, usually during the second week in hospital, the patient gains weight. While feeding of milk is continued, a mixed diet should gradually be introduced, aimed at providing the energy, protein, minerals and vitamins needed by the child. If the disease is not to recur, it is important that the mother or guardian participate in the feeding at this stage.

She must be told what the child is being fed and why. Her cooperation with and follow-up of this regime is much more likely if the hospital diet of the child is based mainly on products that are used at home and that are likely to be available to the family.

This is not feasible in every case in a large hospital, but the diet should at least be based on locally available foods. Thus in a maize-eating area, for example, the child would now receive maize gruel with DSM added. For an older child, crushed groundnuts can be added twice a day, or, if preferred by custom, roasted groundnuts can be eaten.

A few teaspoonfuls of ripe papaya, mango, orange or other fruit can be given. At one or two meals per day, a small portion of the green vegetable and the beans, fish or meat that the mother eats can be fed to the child, after having been well chopped. If eggs are available and custom allows their consumption, an egg can be boiled or scrambled for the child; the mother can watch as it is prepared.

Alternatively, a raw egg can be broken into some simmering gruel. Protein-rich foods of animal origin are often relatively expensive.

They are not essential; a good mixture of cereals, legumes and vegetables serves just as well. If suitable vitamin-containing foods are not available, then a vitamin mixture should be given, because the DSM and SCOM mixtures are not rich in vitamins. The above maize-based diet is just an example. If the diet of the area is based on rice or wheat, these can be used instead of maize. If the staple food is plantain or cassava, then protein-rich supplements are important.

After discharge, or if a moderate case of kwashiorkor has been treated at home and not in the hospital, the child should be followed if possible in the out-patient department or a clinic. It is much better if such cases can visit separately from other patients i. A relaxed atmosphere is desirable, and the medical attendant should have time to explain matters to the mother and to see that she understands what is expected of her.

It is useless just to hand over a bag of milk powder or other supplement, or simply to weigh the child but not provide simple guidance. Satisfactory weight gain is a good measure of progress. At each visit the child should be weighed. Weight is plotted on a chart to provide a picture for the health worker and the mother.

Out-patient treatment should be based on the provision of a suitable dietary supplement, but in most cases it is best that this supplement be given as part of the diet. The mother should be shown a teaspoon and told how many teaspoonfuls to give per day based on the child's weight.

Many supplements, especially DSM, are best provided by adding them to the child's usual food such as cereal gruel rather than by making a separate preparation. The mother should be asked how many times a day she feeds the child. If he or she is fed only at family mealtimes and the family eats only twice a day, then the mother should be told to feed the child two extra times. If facilities exist and it is feasible, the SCOM mixture can be used for out-patient treatment.

It is best provided ready mixed in sealed polyethylene bags. Most deaths in children hospitalized for kwashiorkor or nutritional marasmus occur in the first three days after admission. Case fatality rates depend on many factors including the seriousness of the child's illness at the time of admission and the adequacy of the treatment given. In some societies sick children are taken to hospital very late in the disease, when they are almost moribund.

In this situation fatality rates are high. The cause and the severity of the disease determine the prognosis. A child with severe marasmus and lungs grossly damaged by tuberculous infection obviously has poor prospects. The prospects of a child with mild marasmus and no other infection are better. Response to treatment is likely to be slower with marasmus than with kwashiorkor. It is often difficult to know what to do when the child is cured, especially if the child is under one year of age.

There may be no mother or she may be ill, or she may have insufficient or no breastmilk. Instruction and nutrition education are vital for the person who will be responsible for the child. If the child has been brought by the father, then some female relative should spend a few days in the hospital before the child is discharged. She should be instructed in feeding with a spoon or cup and told not to feed the child from a bottle unless he or she is under three months of age.

The best procedure is usually to provide a thin gruel made from the local staple food plus two teaspoonfuls of DSM or some other protein-rich supplement and two teaspoonfuls of oil per kilogram of body weight per day. Instruction regarding other items in the diet must be given if the child is over six months old. The mother or guardian should be advised to attend the hospital or clinic at weekly intervals if the family lives near enough within about 10 km or at monthly intervals if the distance is greater.

Supplies of a suitable supplement to last for slightly longer than the interval between visits should be given at each visit. The child can be put on other foods, as mentioned in the discussion of infant feeding in Chapter 6. It is essential that the diet provide adequate energy and protein.

Usually kcal and 3 g of protein per kilogram of body weight per day are sufficient for long-term treatment. Thus a kg child should receive about kcal and 30 g of protein daily. It should be noted that a marasmic child during the early part of recovery may be capable of consuming and utilizing to kcal and 4 to 5 g of protein per kilogram of body weight per day.

There is little doubt that a disorder due mainly to energy deficiency does occur in adults; it is more common in communities suffering from chronic protein deficiency. The patient is markedly underweight for his or her height unless grossly oedematous , the muscles are wasted, and subcutaneous fat is reduced.

Mental changes are common: It is difficult to attract the patient's attention and equally hard to keep it. Appetite is reduced, and the patient is very weak. Some degree of oedema is nearly always present, and this may mask the weight loss, wasting and lack of subcutaneous fat.

Oedema is most common in the legs, and in male patients also in the scrotum, but any part of the body may be affected. The face is often puffy. This condition has been termed "famine oedema" because it occurs where there is starvation resulting from famine or other causes.

It was commonly reported in famines in Indonesia and Papua New Guinea. Frequent, loose, offensive stools may be passed. The abdomen is often slightly distended, and on palpation the organs can be very easily felt through the thin abdominal wall.

During palpation there is nearly always a gurgling noise from the abdomen, and peristaltic movements can often be detected with the fingertips.

It is not uncommon for adult kwashiorkor patients to regard their physical state as a consequence of abdominal upset. For this reason, strong purgatives, either proprietary or herbal, and peppery enemas are sometimes used by these patients before they reach hospital, which may greatly aggravate the condition. The hair frequently shows changes. The skin is often dry and scaly, and may have a crazy-pavement appearance, especially over the tibia.

Swelling of both parotid glands is frequent. On palpation the glands are found to be firm and rubbery. Anaemia is nearly always present and may be severe. The blood pressure is low. There is usually only a trace of albumin in the urine. Oedema may also be caused by severe anaemia. In adult PEM there is less dyspnoea than in anaemia and usually no cardiomegaly. Other features such as hair changes and parotid swelling are common in adult PEM but not in anaemia. However, the two conditions are closely related.

In contrast to adult kwashiorkor or famine oedema, which is not very prevalent, the adult equivalent of nutritional marasmus is very common. There are five major causes. Any older child or adult whose diet is grossly deficient in energy will develop signs almost exactly like those of nutritional marasmus, and if the condition progresses it may often be fatal. In the case of famines, the condition may be termed starvation see Chapter Famines and severe food shortages resulting from war, civil disturbance or natural disasters such as droughts, floods and earthquakes may result in nutritional marasmus in children and a similar condition in adults, who suffer from weight loss, wasting, diarrhoea, infectious diseases, etc.

The second major cause of severe wasting or severe PEM in adults is infections, especially chronic, untreated or untreatable infections. The most common of these now is acquired immunodeficiency syndrome AIDS resulting from infection with the human immunodeficiency virus HIV.

As the disease progresses there is marked weight loss and severe wasting. Advanced tuberculosis and many other long-term chronic infections also lead to wasting and weight loss.

A number of malabsorption conditions cause PEM in adults and children. These diseases, of which some are hereditary, result in the inability of the body to digest or absorb certain foods or nutrients.

Examples are cystic fibrosis, coeliac disease and adult sprue. Another cause of wasting in people of any age is malignancy or cancer of any organ once it progresses to a stage not treatable by surgical excision. Cachexia is a feature of many advanced cancers. A group of eating disorders cause weight loss leading to the equivalent of PEM. The most widely described is anorexia nervosa, which occurs much more commonly in females than males, in adolescents or younger adults rather than older persons and in affluent rather than poor societies.

Other psychological conditions may also result in poor food intake and lead to PEM. Treatment of adult PEM includes therapy related to the underlying cause of the condition and therapy related to feeding and rehabilitation, when the cause makes that feasible. Thus infections such as tuberculosis or chronic amoebiasis require specific therapy which when effective will eliminate the cause of the weight loss and wasting.

In contrast, curative treatment is not applicable in advanced AIDS or cancer. Dietary treatment for adult PEM should be based on principles similar to those described for the treatment of severe PEM in children, including those recovering from kwashiorkor or marasmus. Emergency feeding and the rehabilitation of famine victims described in Chapter 24 have relevance to adult PEM. It is much more difficult than controlling, for example, iodine deficiency disorders IDD and vitamin A deficiency, because the underlying and basic causes, as described above, are often numerous and complex, and because there is no single, universal, cheap, sustainable strategy that can be applied everywhere to reduce the prevalence or severity of PEM.

Part V of this book includes various strategies to reduce the prevalence of PEM. Appropriate nutrition policies and programmes are suggested, and separate chapters deal with, for example, improving food security, protection and promotion of good health, and appropriate care practices to ensure good nutrition.

These chapters provide guidance on how to deal with the three underlying causes of malnutrition, namely inadequate food, health and care, which in Chapter 1 were included in the conceptual framework for malnutrition. Other chapters in Part V discuss solutions to particular aspects of the problem, including improving the quality and safety of foods, promoting appropriate diets and healthy lifestyles, procuring food in different ways and incorporating nutrition objectives into development policies and programmes.

Throughout Part V there is an emphasis on improving the quality of life of people, especially by reducing poverty, improving diets and promoting good health. Improving the energy intakes of those at risk of PEM is vital. In the late s and s it was thought that most PEM was caused mainly by inadequate intake of protein.

A great deal of emphasis was placed on protein-rich foods as a major solution to the huge problem of malnutrition in the world. This inappropriate strategy diverted attention from the first need, which is adequate food intake by children.

There is now much less emphasis on high-protein weaning foods and on nutrition education efforts to ensure greater consumption of meat, fish and eggs, which are economically out of the reach of many families who have children with PEM. Protein is an essential nutrient, but PEM is more often associated with deficient food intake than with deficient protein intake. In general, when commonly consumed cereal-based diets meet energy needs, they usually also meet protein needs, especially if the diet also provides modest amounts of legumes and vegetables.

Primary attention needs to be given to increasing total food intake and reducing infection. Sensible efforts are needed to protect and promote breastfeeding and sound weaning; to increase the consumption by young children of cereals, legumes and other locally produced weaning foods; to prevent and control infection and parasitic disease; to increase meal frequency for children; and, where appropriate, to encourage higher consumption of oil, fat and other items that reduce bulk and increase the energy density of foods fed to children at risk.

These measures are likely to have more impact if accompanied by growth monitoring, immunization, oral rehydration therapy for diarrhoea, early treatment of common diseases, regular deworming and attention to the underlying causes of PEM such as poverty and inequity.

Some of these measures can be implemented as part of primary health care. Nutritional anaemias are extremely prevalent worldwide.

Unlike protein-energy malnutrition PEM , vitamin A deficiency and iodine deficiency disorders IDD , these anaemias occur frequently in both developing and industrialized countries.

The most common cause of anaemia is a deficiency of iron, although not necessarily a dietary deficiency of total iron intake.

Deficiencies of folates or folic acid , vitamin B 12 and protein may also cause anaemia. Ascorbic acid, vitamin E, copper and pyridoxine are also needed for production of red blood cells erythrocytes. Vitamin A deficiency is also associated with anaemia. Anaemias can be classified in numerous ways, some based on the cause of the disease and others based on the appearance of the red blood cells.

These classifications are fully discussed in medical textbooks. Some anaemias do not have causes related to nutrition but are caused, for example, by congenital abnormalities or inherited characteristics; such anaemias, which include sickle cell disease, aplastic anaemias, thalassaemias and severe haemorrhage, are not covered here.

Based on the characteristics of the blood cells or other features, anaemias may be classified as microcytic having small red blood cells , macrocytic having large red blood cells , haemolytic having many ruptured red blood cells or hypochromic having pale-coloured cells with less haemoglobin. Macrocytic anaemias are often caused by folate or vitamin B 12 deficiencies. In anaemia the blood has less haemoglobin than normal.

Haemoglobin is the pigment in red cells that gives blood its red colour. It is made of protein with iron linked to it. Haemoglobin carries oxygen in the blood to all parts of the body. In anaemia either the amount of haemoglobin in each red cell is low hypochromic anaemia or there is a reduction in the total number of red cells in the body.

The life of each red blood cell is about four months, and the red bone marrow is constantly manufacturing new cells for replacement.

This process requires adequate amounts of nutrients, especially iron, other minerals, protein and vitamins, all of which originate in the food consumed.

Iron deficiency is the most prevalent important nutritional problem of humans. It threatens over 60 percent of women and children in most non-industrialized countries, and more than half of these have overt anaemia.

In most industrialized countries in North America, Europe and Asia, 12 to 18 percent of women are anaemic. Although deficiency diseases are usually considered mainly as consequences of a lack of the nutrient in the diet, iron deficiency anaemia occurs frequently in people whose diets contain quantities of iron close to the recommended allowances.

However, some forms of iron are absorbed better than others; certain items in the diet enhance or detract from iron absorption; and iron can be lost because of many conditions, an important one in many tropical countries being hookworm infection, which is very common.

Nutritional anaemias have until recently been relatively neglected and not infrequently remain undiagnosed. There are many reasons for the lack of attention, but the most important are probably that the symptoms and signs are much less obvious than in severe PEM, IDD or xerophthalmia, and that although anaemias do contribute to mortality rates they do not often do so in a dramatic way, and death is usually ascribed to another more conspicuous cause such as childbirth.

However, research now indicates that iron deficiency has very important implications, including poorer learning ability and behavioural abnormalities in children, lower ability to work hard and poor appetite and growth. To maintain good iron nutritional status each individual needs to have an adequate quantity of iron in the diet. The iron has to be in a form that permits a sufficient amount of it to be absorbed from the intestines. The absorption of iron may be enhanced or inhibited by other dietary substances.

Human beings have the ability both to store and to conserve iron, and it must also be transported properly within the body. The average male adult has 4 to 5 g of iron in his body, most of it in haemoglobin, a little in myoglobin and in enzymes and around 1 g in storage iron, mainly ferritin in the cells, especially in the liver and bone marrow.

Losses of iron from the body must not deplete the supply to less than that needed for manufacture of new red blood cells. To produce new cells the body needs adequate quantities and quality of protein, minerals and vitamins in the diet.

Protein is needed both for the framework of the red blood cells and for the manufacture of the haemoglobin to go with it. Iron is essential for the manufacture of haemoglobin, and if a sufficient amount is not available, the cells produced will be smaller and each cell will contain less haemoglobin than normal. Copper and cobalt are other minerals necessary in small amounts. Folates and vitamin B 12 are also necessary for the normal manufacture of red blood cells.

If either is deficient, large abnormal red blood cells without adequate haemoglobin are produced. Ascorbic acid vitamin C also has a role in blood formation. Providing vitamin A during pregnancy has been shown to improve haemoglobin levels. Of the dietary deficiency causes of nutritional anaemias, iron deficiency is clearly by far the most important. Good dietary sources of iron include foods of animal origin such as liver, red meat and blood products, all containing haem iron, and vegetable sources such as some pulses, dark green leafy vegetables and millet, all containing non-haem iron.

However, the total quantity of iron in the diet is not the only factor that influences the likelihood of developing anaemia. The type of iron in the diet, the individual's requirements for iron, iron losses and other factors often are the determining factors.

Iron absorption is influenced by many factors. In general, humans absorb only about 10 percent of the iron in the food they consume. The adult male loses only about 0.

On an average monthly basis, the adult pre-menopausal woman loses about twice as much iron as a man. Similarly, iron is lost during childbirth and lactation. Additional dietary iron is needed by pregnant women and growing children. The availability of iron in foods varies greatly. In general, haem iron from foods of animal origin meat, poultry and fish is well absorbed, but the non-haem iron in vegetable products, including cereals such as wheat, maize and rice, is poorly absorbed.

These differences may be modified when a mixture of foods is consumed. It is well known that phytates and phosphates, which are present in cereal grains, inhibit iron absorption. On the other hand, protein and ascorbic acid vitamin C enhance iron absorption.

Recent research has shown that ascorbic acid mixed with table salt and added to cereals increases the absorption of intrinsic iron in the cereals two- to fourfold. The consumption of vitamin C-rich foods such as fresh fruits and vegetables with a meal may therefore promote iron absorption. Egg yolk impairs the absorption of iron, even though eggs are one of the better sources of dietary iron. Tea consumed with a meal may reduce the iron absorbed from the meal.

The normal child at birth has a high haemoglobin level usually at least 18 g per ml , but during the first few weeks many cells are haemolysed. The iron liberated is not lost but is stored in the body, especially in the liver and spleen. As milk is a poor source of iron, this reserve store is used during the early months of life to help increase the volume of blood, which is necessary as the baby grows.

Premature infants have fewer red blood cells at birth than full-term infants, so they are much more prone to anaemia. In addition, iron deficiency in the mother may affect the infant's vital iron store and render the infant more vulnerable to anaemia. A baby's store of iron plus the small quantity of iron supplied in breastmilk suffice for perhaps six months, but then other iron-containing foods are needed in the diet.

Although it is desirable that breastfeeding should continue well beyond six months, it is also necessary that other foods containing iron be introduced into the diet at this time. Although most solid diets, both for children and adults, provide the recommended allowances for iron, the iron may be poorly absorbed. Many people have increased needs because of blood loss from hookworm or bilharzia infections, menstruation, childbirth or wounds.

Women have increased needs during pregnancy, when iron is needed for the foetus, and during lactation, for the iron in breastmilk. It is stressed that iron from vegetable products, including cereal grains, is less well absorbed than that from most animal products.

Anaemia is common in premature infants; in young children over six months of age on a purely milk diet; in persons infected with certain parasites; and in those who get only marginal quantities of iron, mainly from vegetable foods. It is more common in women, especially pregnant and lactating women, than in men. In most of the world, both North and South, the greatest attention to iron deficiency anaemia is directed at women during pregnancy, when they have increased needs for iron and often become anaemic.

Pregnant women form the one group of the healthy population who are advised to take a medicinal dietary supplement, usually iron and folic acid. Pregnant and lactating women are a group at especially high risk of developing anaemia. It is only in recent years that the prevalence and importance of iron deficiency apart from anaemia has been widely discussed.

Clearly, however, if the causes of iron deficiency are not removed, corrected or alleviated then the deficiency will lead to anaemia, and gradually the anaemia will become more serious. Increasing evidence suggests that iron deficiency as manifested by low body iron stores, even in the absence of overt anaemia, is associated with poorer learning and decreased cognitive development.

International agencies now claim that iron deficiency anaemia is the most common nutritional disorder in the world, affecting over 1 million people. In females of child-bearing age in poor countries prevalence rates range from 64 percent in South Asia to 23 percent in South America, with an overall mean of 42 percent Table Prevalence rates are usually considerably higher in pregnant women, with an overall mean of 51 percent.

Thus half the pregnant women in these regions, whose inhabitants represent 75 percent of the world's population, have anaemia. Unlike reported figures for PEM and vitamin A deficiency, which are declining, estimates suggest that anaemia prevalence rates are increasing. In most of the developing regions, and particularly among persons with anaemia or at risk of iron deficiency, much of the iron consumed is non-haem iron from staple foods rice, wheat, maize, root crops or tubers.

In many countries the proportion of dietary iron coming from legumes and vegetables has declined, and rather small quantities of meat, fish and other good sources of haem iron are consumed. In some of the regions with the highest prevalence of anaemia the poor are not improving their dietary intake of iron, and in some areas the per caput supply of dietary iron may even be decreasing year by year.

In many parts of the world where iron deficiency anaemia is prevalent it is due as much to iron losses as to poor iron intakes. Whenever blood is lost from the body, iron is also lost.

Thus iron is lost in menstruation and childbirth and also when pathological conditions are present such as bleeding peptic ulcers, wounds and a variety of abnormalities involving blood loss from the intestinal or urinary tract, the skin or various mucous membrane surfaces.

Undoubtedly one of the most prevalent and important causes of blood loss is hookworms, which can be present in very large numbers. The worms suck blood and also damage the intestinal wall, causing blood leakage. Some million people in the world are infested with hookworms.

Other intestinal parasites such as Trichuris trichiura may also contribute to anaemia. Schistosomes or bilharzias, which are of several kinds, also cause blood loss either into the genito-urinary tract in the case of Schistosoma haematobium or into the gut. Malaria, another very important parasitic infection, causes destruction of red blood cells that are parasitized, which can lead to what is termed haemolytic anaemia rather than to iron deficiency anaemia.

In programmes to reduce anaemia actions may be needed to control parasitic infections and to reduce blood loss resulting from disease as well as to improve dietary intakes of iron. Anaemia resulting from folate deficiency is less prevalent than that from iron deficiency or iron loss. It occurs when folate intakes are low and when red cells are haemolysed or destroyed in conditions like malaria. The anaemia of both folate and vitamin B 12 is macrocytic, with larger than normal red blood cells.

Folic acid or folates are present in many foods including foods of animal origin e. Iiver and fish and of vegetable origin e. Vitamin B 12 is present only in foods of animal origin. In most countries vitamin B 12 deficiency is uncommon. Haemoglobin in the red blood cells is necessary to carry oxygen, and many of the symptoms and signs of anaemia result from the reduced capacity of the blood to transport oxygen. The symptoms and signs are: These symptoms and signs are not confined to iron deficiency anaemia but are similar in most forms of anaemia.

Most occur also in some other illnesses and thus are not specific to anaemia. Because none of the symptoms seem severe, dramatic or life threatening, at least in the early stages of anaemia, the disorder tends to be neglected.

An experienced health worker can sometimes make a preliminary diagnosis by examining the tongue, the conjunctiva of the lower eyelid and the nailbed, which may all appear paler than normal in anaemia. The examiner can compare the redness or pinkness below the nail of the patient with the colour beneath his or her own nails.

Enlargement of the heart may result and can be detected in advanced severe anaemia. Oedema usually occurs first in the feet and at the ankles. There may also be an increased pulse rate or tachycardia. Occasionally the nails become relatively concave rather than convex and become brittle. This condition is termed koilonychia. Anaemia is also reported to lead both to abnormalities of the mouth such as glossitis and to pica abnormal consumption of earth, clay or other substances.

What is surprising is that many persons with very low haemoglobin levels, especially women in developing countries, appear to function normally. With chronic anaemia they have adapted to low haemoglobin levels.

They may indeed do reduced work, have fatigue and walk more slowly, but they still give the appearance of performing their normal duties even though severely anaemic.

Severe anaemia can progress to heart failure and death. Anaemia, as well as producing the symptoms and signs discussed above, also leads to a reduced ability to do heavy work for long periods; to slower learning and more difficulty in concentration by children in school or elsewhere; and to poorer psychological development. A very important aspect of anaemia in women is that it markedly increases the risk of death of the mother during or after childbirth.

The woman may bleed severely, and she has low haemoglobin reserves. There is also an increased risk for her infant. The diagnosis of anaemia requires a laboratory test. In this respect it differs from the serious manifestations of PEM, vitamin A deficiency and IDD; kwashiorkor, nutritional marasmus, advanced xerophthalmia, goitre and cretinism can all be diagnosed with some degree of certainty by skilled clinical observation. Consequently, whereas few district hospitals and practically no health centres have laboratories set up to test, for example, levels of serum vitamin A or urinary iodine, most are able to do haemoglobin or haematocrit determinations.

These tests require quite cheap apparatus and can be performed by a trained technician, nurse or other health worker. Determinations of haemoglobin or haematocrit levels are the most widely used in the diagnosis of anaemia. It is now realized that although these tests provide information on the absence, presence or severity of anaemia, they do not provide information on the iron stores of the individual. In terms of nutritional assessment to guide nutrition planning and interventions, or for research, it may be important to know more about the iron status of an individual than can be gained from haemoglobin and haematocrit determinations.

Many methods are used to measure haemoglobin levels. These range from simple colorimetric tests to more advanced tests which require a proper laboratory.

Some new portable colorimeters can be used in the field; they are simple to use and provide reasonably accurate measurements. In the laboratory of even a moderate-sized hospital the so-called cyanmethaemoglobin method is frequently used; it is accurate and can be used to test blood collected by finger prick in the field.

The different methods and their advantages are discussed in various books, of which some are included in the Bibliography. Haematocrit level or packed cell volume PCV , i. Blood also obtained from a finger prick is placed in a capillary tube and centrifuged, usually at 3 rpm.

The centrifuge can be electric run if necessary from a vehicle battery or hand operated. A thin blood film examined under the microscope can be used to judge if the red blood cells are smaller microcytic or larger macrocytic than normal normo cytic. In iron deficiency they are microcytic and in folate or vitamin B 12 deficiency they are macrocytic. Pale cells are termed hypochromic.

Cut-off points taken from the World Health Organization WHO suggestions for the diagnosis of anaemia based on haemoglobin and haematocrit determinations are given in Table Certain other laboratory tests are useful in judging iron nutritional status rather than for diagnosing anaemia or its severity.

In recent years it has been increasingly recognized that iron status is important because mild or moderate iron deficiency, prior to the development of anaemia, may adversely influence human behaviour, psychological development and temperature control. A person whose diet is low in iron or who is losing iron goes through a period when body iron stores which are mainly in the liver are gradually depleted before he or she develops anaemia as judged by low haemoglobin or haematocrit levels see Figure 7.

Anaemia is the end stage after iron stores have been depleted. To monitor iron stores it is useful to determine serum ferritin levels, because they are the first to decline. This is not a simple or cheap test to do, and few small or medium-sized hospitals in developing countries have the ability to do it, but teaching hospitals and nutrition research laboratories sometimes can.

Unfortunately serum ferritin levels are influenced by infections, which are common in developing countries. Other determinations that may be done to evaluate iron status and which are described in textbooks include free erythrocyte protoporphyrin FEP and transferrin saturation TS Figure 7. Suggested criteria for diagnosis of anaemia using haemoglobin Hb and haematocrit PCV determinations. Changes in body iron compartments and laboratory parameters of iron status during development of iron deficiency due to a continuous negative iron balance.

The treatment of anaemia depends on the cause. Iron deficiency anaemia is relatively easy and very cheap to treat. There are many different iron preparations on the market; ferrous sulphate is among the cheapest and most effective. The recommended dose of ferrous sulphate is usually mg providing 60 mg of elemental iron twice daily between meals for adults. Iron tends to make the stools black. Because side-effects can occur, particularly involving the intestinal tract, sometimes people do not take their iron tablets regularly.

Slow-release iron capsules have become available and seem to be associated with fewer side-effects. Most capsules contain ferrous sulphate in small pellets, so the iron is slowly released.

Only one capsule or dose needs to be taken each day, but the capsules cost much more than ferrous sulphate tablets. Therefore it is unlikely that slow-release preparations will replace standard ferrous sulphate tablets for use in clinics in developing countries.

New research conducted in China suggests that ferrous sulphate is as effective when given once every week as when given once a day. If further trials confirm this observation, the finding will alter both the treatment of anaemia and the efforts to prevent it using medicinal iron supplements in prenatal clinics. In Indonesia, where vitamin A deficiency is a problem, it has been shown recently that giving vitamin A as well as iron improves the haemoglobin levels of pregnant women more than iron tablets alone.

In all cases the underlying cause of the anaemia should be sought and treated if possible. Iron dextran is the injectable preparation most commonly used. Intravenous injection is preferable. The standing rule is to give a very small test dose initially and to wait for five minutes for any sign of an anaphylactic reaction.

If there is no reaction, then mg can be given from a syringe over a period of five to ten minutes. These injections may be given at intervals over a few days. Alternatively, a total dose infusion can be provided at one time. This procedure must be employed only by doctors experienced in the technique and in calculating dosage levels.

It is common during pregnancy to provide folate as well as iron, or combined with iron, as part of the treatment of or prophylaxis against anaemia. For prevention, where anaemia is prevalent, doses of mg of iron and 5 mg of folate daily are recommended. For treatment of established anaemia, doses of mg of iron and 10 mg of folate are suggested. Successful treatment usually leads to a response in haemoglobin levels within four weeks.

Persons with iron deficiency anaemia on very poor diets should be advised to consume more fresh fruits and vegetables at mealtimes. These foods contain vitamin C, which enhances the absorption of non-haem iron in cereals, root crops and legumes. They also contain folic acid and an array of other vitamins and minerals. If it is feasible and in line with the anaemic patient's budget and culinary habits, he or she could also be advised to consume, even in small quantities, more foods rich in haem iron such as meat, especially liver or kidney.

Creating awareness of the nutritional needs of different family members and helping household decision-makers to understand how these needs can best be met from available resources are important steps in preventing iron deficiency. Iodine deficiency is responsible not only for very widespread endemic goitre and cretinism, but also for retarded physical growth and intellectual development and a variety of other conditions.

These conditions together are now termed iodine deficiency disorders IDD. They are particularly important because: In fact, as H. Labouisse wrote in when he was Executive Director of the United Nations Children's Fund UNICEF , "Iodine deficiency is so easy to prevent that it is a crime to let a single child be born mentally handicapped for this reason" quoted in Hetzel, Nonetheless this crime persists.

Endemic goitre and severe cretinism are the exposed part of the IDD iceberg. These are abnormalities that are visible to the populations where they are prevalent, and they can be diagnosed relatively easily by health professionals without the use of laboratory or other tests.

The submerged and larger part of the iceberg includes smaller, less visible enlargements of the thyroid gland and an array of other abnormalities. In many areas of Latin America, Asia and Africa iodine deficiency is a cause of mental retardation and of children's failure to develop psychologically to their full potential. It is also associated with higher rates of foetus loss including spontaneous abortions and stillbirths , deaf-mutism, certain birth defects and neurological abnormalities.

For several decades the main measure used to control IDD has been the iodization of salt, and when properly conducted and monitored it has proved extremely effective in many countries. It is also relatively cheap. Several international meetings, including the International Conference on Nutrition held in Rome in , called for the virtual elimination of IDD by the year This goal is achievable, provided the effort receives international support and real national commitment in each of the many countries where the disorders remain prevalent.

The most important cause of endemic goitre and cretinism is dietary deficiency of iodine. The amount of iodine present in the soil varies from place to place and this influences the quantity of iodine present in the foods grown in different places and in the water. Iodine is leached out of the soil and flows into streams and rivers which often end in the ocean.

Many areas where endemic goitre is or has been highly prevalent are plateau or mountain areas or inland plains far from the sea. A less important cause of IDD is the consumption of certain foods which are said to be goitrogenic or to contain goitrogens.

Goitrogens are "antinutrients" which adversely influence proper absorption and utilization of iodine or exhibit antithyroid activity. Foods from the genus Brassica such as cabbage, kale and rape and mustard seeds contain goitrogens, as do certain root crops such as cassava and turnips. Unlike goitrogenic vegetables, cassava is a staple food in some areas, and in certain parts of Africa, for example Zaire, cassava consumption has been implicated as an important cause of goitre.

Areas of the world where iodine deficiency is prevalent. Any enlargement of the thyroid gland is called a goitre. The thyroid is an endocrine gland centrally situated in the lower front part of the neck. It consists of two lobes joined by an isthmus. In an adult each lobe of the normal thyroid gland is about the size of a large kidney bean. In areas of the world or communities where only sporadic goitre occurs or where health workers see only an occasional patient with an enlarged thyroid gland, the cause is not likely to be related to the individual's diet.

Sporadic goitre may for example be due to a thyroid tumour or thyroid cancer. However, if goitre is common or endemic in a community or district, then the cause is usually nutritional. Endemic goitre is almost certainly caused by iodine deficiency, and where goitre is endemic other iodine deficiency disorders can also be expected to be prevalent. Where goitre is endemic, often large numbers of people have an enlargement of the thyroid gland, and some have enormous unsightly swellings of the neck.

The condition is usually somewhat more prevalent in females, especially at puberty and during pregnancy, than in males. The enlarged gland may be smooth colloid goitre or lumpy adenomatous or nodular goitre.

The iodine content of foods varies widely, but the amount of iodine present in common staple foods such as cereals or root crops depends more on the iodine content of the soil where the crop is grown than on the food itself. Because the amount of iodine in foods such as rice, maize, wheat or legumes depends on where they are grown, food composition tables cannot provide good figures for their iodine content.

Foods from the ocean, including shellfish, fish and plant products such as seaweed, are generally rich in iodine. In many populations, particularly in the industrialized countries of the North and among affluent groups almost everywhere, diets do not depend mainly on locally grown foods. As a result many of the foods purchased and consumed may contribute substantially to iodine intakes. For example, persons living in the Rocky Mountains of North America, where goitre used to be endemic, now do not rely much on locally produced foods; they may consume bread made from wheat grown in the North American central plains, rice from Thailand, vegetables from Mexico or California, seafood from the Atlantic coast and so on.

Similarly, affluent segments of society in La Paz, Bolivia consume many foods not grown in the altiplano, and these imported foods will have adequate quantities of iodine. In contrast, the poor in the Bolivian highlands eat mainly locally grown foods and do develop goitre. Many countries of Asia, Africa and Latin America have major iodine deficiency problems, although some countries have made great progress in reducing the prevalence of IDD. China and India, with their vast populations, still have a high prevalence of IDD.

In the Americas, endemic goitre has been largely controlled in the United States and Canada, but many Andean countries including Bolivia, Colombia, Ecuador and Peru still have relatively high endemic goitre and cretinism rates. During a survey conducted by the author in the s in the Ukinga Highlands of Tanzania, 75 percent of the people examined had goitre. This was the highest prevalence yet reported in Africa. Prevalence rates of over 60 percent have been reported from communities in many African, Asian and Latin American countries.

Generally goitre prevalence rates of 5 to But even with rates of 10 to 15 percent the need for action is important. Where prevalence rates are moderate, urgent action is needed. Where rates are severe, early action is critical see Table Enlargement of the thyroid gland is the most frequently described and most obvious clinical manifestation of iodine deficiency. Where there is a chronic dietary deficiency of iodine the thyroid often begins to enlarge during childhood, and it becomes more markedly enlarged around the time of puberty, particularly in girls.

In many areas where goitre is endemic the majority of people have some evidence of thyroid enlargement. The thyroid gland secretes hormones vital to metabolism and growth. The gland is made mainly of follicles called acini, minute sacs filled with colloid. Each sac manufactures thyroid hormones, stores them and secretes them into the bloodstream as needed. The main thyroid hormone is thyroxine.

The amount of thyroxine secreted is controlled by another endocrine gland, the anterior pituitary, and its hormone, called thyroid stimulating hormone TSH or thyrotrophic hormone. The function of the thyroid gland is somewhat similar to that of the thermostat of the heating system in a house. It controls the rate of metabolism and influences the Basal metabolic rate BMR , to some extent the heart rate and also growth in children. The normal adult thyroid gland contains about 8 mg of iodine.

In simple goitres the total iodine content might be only 1 or 2 mg even though the gland is larger than normal. Thyroxine contains 64 percent iodine. A lack of dietary iodine makes it increasingly difficult for the thyroid to manufacture enough thyroxine.

The gland enlarges to try to compensate and make more thyroxine. This enlargement is described by pathologists as a hyperplasia of the gland. It is triggered by increased production of TSH by the pituitary gland.

Microscopic examination of a gland undergoing hyperplasia shows ingrowths or invaginations of the lining epithelium into the normal architecture of the colloid-containing acini. There is an intense multiplication of cells, with an excess of colloid. This compensatory reaction is an attempt to trap more iodine, and it is partly successful. Many people with colloid goitres show no evidence of poor thyroid function. Investigation of goitre prevalence is one of the most important means of assessing whether there is an IDD problem of public health importance.

Examination of well-chosen samples of schoolchildren has often been recommended as the first step; this survey is relatively easy because schoolchildren are collected together in one place and are usually disciplined, so large numbers can be examined over a short time. To get a full picture of the prevalence in the area, however, it is important at some stage to examine a representative sample of community members of all ages and both sexes.

The thyroid gland of each person should be examined both visually and by palpation to judge its size. Visual examination informs the examiner whether a goitre is visible with the head in normal position or with the head tilted back. Palpation is usually done with the examiner sitting or standing facing the person being examined; the examiner's eyes should be level with the person's neck.

By placing and rolling the thumbs on either side of the trachea below the Adam's apple or voice box, the examiner can feel the gland and judge its size. A normal thyroid gland is considerably smaller than the last joint terminal phalanx of the thumb.

In fact a normal thyroid lobe is perhaps one-fifth that size. If each lobe is larger than this joint, then there is a goitre. Palpation from behind is recommended by some because the fingertips are then used to determine gland size, and they are more sensitive than the tips of the thumbs. It is useful to classify the goitre size using an accepted classification system. Use of the system assures reasonable comparisons by different observers and in different regions.

The main use of grading goitres is for survey purposes and to allow comparisons of goitre prevalence rates between areas. It is not possible to be completely objective, and there will seldom be complete agreement between two examiners, but there will be a reasonable measure of agreement.

Persons with goitre are more likely than others to have manifestations of poor thyroid function, especially hypothyroidism. A large goitre, and especially one that enlarges behind the upper part of the sternum, may cause pressure on the trachea and oesophagus, which may interfere with breathing, cause an irritative cough or voice changes and occasionally affect swallowing.

A mass in the neck that is consistent with an enlarged thyroid that is palpable but not visible when the neck is in normal position. It moves upwards in the neck as the subject swallows.

Nodular alteration s can occur even when the thyroid is not visibly enlarged. A swelling in the neck that is visible when the neck is in normal position and is consistent with an enlarged thyroid when the neck is palpated.

Moderate and large goitres also create an undesirable appearance and possibly difficulty with wearing certain clothes.

It has been reported that in some areas where endemic goitre is highly prevalent, goitres may be accepted as the normal condition or as a sign of beauty and people without a goitre may be considered abnormal. However, in the Ukinga Highlands of Tanzania, where prevalence was over 70 percent, the author found that the people were not pleased to have large neck swellings.

Many people had symmetrical small scars in the skin covering the goitre, which was clear evidence that they had sought local medical treatment; in East Africa treatment frequently consists of cuts and scarification of the offending area, sometimes with herbal medicines rubbed into the cuts. Clearly these people hoped their goitres would disappear. If for any reason too little thyroid hormone is produced, the BMR goes down and a condition called hypothyroidism develops, which may lead to the clinical condition called myxoedema.

In the adult this condition is characterized by coarsened features, dry skin and sometimes puffiness of the face. The person is often somewhat overweight, has a slow pulse and feels sluggish. Testing would reveal a low BMR and low levels of thyroid hormones in the blood. In contrast, an overactive thyroid gland producing more thyroid hormone than necessary produces a condition known as hyperthyroidism or Graves' disease. The adult with this condition tends to be thin and asthenic, to be nervous and to have a rapid pulse rate, particularly during sleep.

Tests reveal high thyroid hormone levels and high BMR. As stated above, persons with endemic goitre often have good compensation and do not have evidence of either hypothyroidism or hyperthyroidism.

They are said to be euthyroid, which means that they have normal thyroid function despite thyroid enlargement. However, in endemic areas rates of hypothyroidism are elevated. In many cases the hypothyroidism is mild and not as obvious as classical myxoedema, but thyroid hormone levels are low, and low BMR, lower productivity and slower mental functioning may be chronic.

It is hypothyroidism in children, however, that is of most concern for developing countries, because of the strong evidence that it causes both mental retardation and slowing of physical growth. Mental retardation ranges from very severe, which is easy to recognize, to mild, which may be difficult to diagnose. In areas with a high prevalence of IDD large numbers of children may fail to reach their intellectual potential because of impaired school performance and lower IQ than in matched groups from areas without iodine deficiency.

These children may later, as adults, fail to make as great a contribution to society and to national development as they would have made if they and their mothers had always consumed adequate amounts of iodine. Common chronic illnesses usually treated in primary care may include, for example: Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations.

In the United States, primary care physicians have begun to deliver primary care outside of the managed care insurance-billing system through direct primary care which is a subset of the more familiar concierge medicine.

Physicians in this model bill patients directly for services, either on a pre-paid monthly, quarterly, or annual basis, or bill for each service in the office. Examples of direct primary care practices include Foundation Health in Colorado and Qliance in Washington.

In context of global population aging , with increasing numbers of older adults at greater risk of chronic non-communicable diseases , rapidly increasing demand for primary care services is expected in both developed and developing countries. Secondary care includes acute care: This care is often found in a hospital emergency department.

Secondary care also includes skilled attendance during childbirth , intensive care , and medical imaging services. The term "secondary care" is sometimes used synonymously with "hospital care. Some primary care services are delivered within hospitals.

Depending on the organization and policies of the national health system, patients may be required to see a primary care provider for a referral before they can access secondary care. Physiotherapists are both primary and secondary care providers that do not require a referral. In the United States, which operates under a mixed market health care system, some physicians might voluntarily limit their practice to secondary care by requiring patients to see a primary care provider first.

This restriction may be imposed under the terms of the payment agreements in private or group health insurance plans. In other cases, medical specialists may see patients without a referral, and patients may decide whether self-referral is preferred. In the United Kingdom and Canada, patient self-referral to a medical specialist for secondary care is rare as prior referral from another physician either a primary care physician or another specialist is considered necessary, regardless of whether the funding is from private insurance schemes or national health insurance.

Allied health professionals , such as physical therapists , respiratory therapists , occupational therapists , speech therapists , and dietitians , also generally work in secondary care, accessed through either patient self-referral or through physician referral.

Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital. Examples of tertiary care services are cancer management, neurosurgery , cardiac surgery , plastic surgery , treatment for severe burns , advanced neonatology services, palliative, and other complex medical and surgical interventions.

The term quaternary care is sometimes used as an extension of tertiary care in reference to advanced levels of medicine which are highly specialized and not widely accessed. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care. These services are usually only offered in a limited number of regional or national health care centers. Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food safety surveillance, distribution of condoms and needle-exchange programs for the prevention of transmissible diseases.

They also include the services of professionals in residential and community settings in support of self care , home care , long-term care , assisted living , treatment for substance use disorders among other types of health and social care services. Community rehabilitation services can assist with mobility and independence after loss of limbs or loss of function. This can include prosthesis , orthotics or wheelchairs. Many countries, especially in the west are dealing with aging populations, so one of the priorities of the health care system is to help seniors live full, independent lives in the comfort of their own homes.

There is an entire section of health care geared to providing seniors with help in day-to-day activities at home such as transportation to and from doctor's appointments along with many other activities that are essential for their health and well-being. Although they provide home care for older adults in cooperation, family members and care workers may harbor diverging attitudes and values towards their joint efforts.

This state of affairs presents a challenge for the design of ICT information and communication technology for home care. Because statistics show that over 80 million Americans have taken time off of their primary employment to care for a loved one, [17] many countries have begun offering programs such as Consumer Directed Personal Assistant Program to allow family members to take care of their loved ones without giving up their entire income.

With obesity in children rapidly becoming a major concern, health services often set up programs in schools aimed at educating children about nutritional eating habits, making physical education a requirement and teaching young adolescents to have positive self-image. This information is translated into report cards that are generated by quality organizations, nonprofit, consumer groups and media.

This evaluation of quality is based on measures of:. Health care extends beyond the delivery of services to patients, encompassing many related sectors, and is set within a bigger picture of financing and governance structures.

A health system , also sometimes referred to as health care system or healthcare system is the organization of people, institutions, and resources that deliver health care services to populations in need. The health care industry incorporates several sectors that are dedicated to providing health care services and products. As a basic framework for defining the sector, the United Nations' International Standard Industrial Classification categorizes health care as generally consisting of hospital activities, medical and dental practice activities, and "other human health activities.

In addition, according to industry and market classifications, such as the Global Industry Classification Standard and the Industry Classification Benchmark , health care includes many categories of medical equipment, instruments and services including biotechnology , diagnostic laboratories and substances, drug manufacturing and delivery.

For example, pharmaceuticals and other medical devices are the leading high technology exports of Europe and the United States. The quantity and quality of many health care interventions are improved through the results of science, such as advanced through the medical model of health which focuses on the eradication of illness through diagnosis and effective treatment.

Many important advances have been made through health research, biomedical research and pharmaceutical research , which form the basis for evidence-based medicine and evidence-based practice in health care delivery. In addition, the results of health services research can lead to greater efficiency and equitable delivery of health care interventions, as advanced through the social model of health and disability , which emphasizes the societal changes that can be made to make populations healthier.

Health services research is also aided by initiatives in the field of artificial intelligence for the development of systems of health assessment that are clinically useful, timely, sensitive to change, culturally sensitive, low burden, low cost, built into standard procedures, and involve the patient. There are generally five primary methods of funding health care systems: In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries.

For example, social health insurance is where a nation's entire population is eligible for health care coverage.

This coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, the system is allowed to operate.

For example, in Poland , the costs of health services borne by the National Health Fund financed by all citizens that pay health insurance contributions in amounted to The right to health services in Poland is granted to The management and administration of health care is another sector vital to the delivery of health care services. Health information technology HIT is "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making.

However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques.

Informatics is yet another integral aspect of HIT. There are multiple purposes for the use of HIT within the health care industry.

Further, the use of HIT is expected to improve the quality of health care, reduce medical errors and health care costs to improve health care service efficiency. All of the services were founded in , based on legislation passed by the Labour Government that had been elected in with a manifesto commitment to implement the Beveridge Report recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease". The NHS was born out of a long-held British ideal that good healthcare should be available to all, regardless of wealth.

At its launch by the UK minister of health, Aneurin Bevan , on 5 July , had at its heart three core principles: From Wikipedia, the free encyclopedia. This article is about the provision of medical care. For other uses, see Health care disambiguation. For the health journal, see Medical Care journal. Primary health care , Ambulatory care , and Urgent care. Health system and Health systems by country.

Health care industry and Health economics. Medical research and Nursing research. List of health care journals , List of medical journals , and List of nursing journals. For a topical guide to this subject, see Healthcare science. Health care system , Health policy , and Universal health care. Health information technology , Health information management , Health informatics , and eHealth. Healthcare in the United Kingdom. Healthcare in the United States.

Nutrition Landscape Information System (NLiS)