[High altitude anemia: validity of definition criteria]. / Anémie en altitude: validité du critère de définition.

The effect of iron and folate supplementation on the hemoglobin response and iron status was studied in male and female equatorian medical students: 66 in Quito (2,800 m altitude) and 40 in Guayaquil (sea level). At the end of the supplementation, there was a nearly complete disappearance of biochemical evidence of iron deficiency in the two groups of students. In Quito, 30% of the men and 26% of the women increased their hemoglobin concentration by more than 1 g/dl after one month of supplementation and could be considered as true anemics, compared to 31% of the men and 29% of the women in Guayaquil. This study shows that at sea level, cut-off points defined by WHO for hemoglobin, taking as reference the impact of a supplementation trial, have a specificity of 100% but poor sensitivity (58%). For people living at high altitudes, cut-off limits adjusted for altitude seem unsuitable: the specificity is 98% but the sensitivity is 0%. Studies taking into account all the factors impacting on the hemoglobin level could be useful for defining cut-off points for high-altitude anemia better than those currently recommended.

Nutrition education.

PIP: This paper presents an overview of the experience of an International Children's Center (ICC) team following many years of work in the field of education for nutrition in developing and industrialized countries. Nutrition education, a long term intervention in which individuals of all ages are active participants who acquire the knowledge, skills, and attitude pertaining to food and nutrition in the context of socioeconomic and cultural limitations. The discussion covers the concepts of attitude, behavior, and eating conduct. Attitude is defined as a way of viewing or internal disposition adopted by any person in a specific situation. Attitudes grow out of knowledge, beliefs, and values and personal predisposition. On the other hand, behavior denotes an observable act and results in a certain manner of acting in response to external stimuli. Eating conduct is expressed differently and in varying extents depending on living conditions and dietary resources. These concepts correspond to the different degrees of information, awareness, and participation achieved by individuals during the educational program. While examination of conduct and dietary resources are necessary for any education for nutrition programs, more attention and investigation should be given to the "negotiation" phase with the people. The community must be ready to take risks, made aware of the implications of the choices to be made to the professionals and to the general public. In this issue, the ICC team highlights important points concerning nutrition education programs.^ieng

Estimación de la frecuencia de anemias nutricionales mediante un ensayo de suplementa con hierro y folatos en sujetos adultos que viven en adulto (2.800 m)

El efecto de la suplementación con una asociación de hierro y folatos sobre el estdo hematoyético y el status en hierro fue estudiado en 66 estudiantes de los dos sexos residentes en Quito (2800 m. de altitud y 40 estudiantes de la ciudad de Guayaquil (a nivel del mar). Después de un mes de suplementación, se observó la desaparición casi completa de los estigmas bioquímicos de la carencia en hierro en los estudientes de las dos ciudades. La anemia definida en función del incremento de la tasa de hemoglobina superior a 1 g/dl se observó en el 30% de los varones y en el 26% de las mujeres residentes en Quito y en el 31% y 29% respectivamente de los residentes en Guayaquil. Este estudio pone en evidencia que los límites de referencia de la hemoglobina propuestos por la O,M.S. para poblaciones asentadas a nivel del mar, tienen una buena especificidad, pero carecen de sensibilidad: 12.5% de los sujetos estudiados fueron considerados como normales siendo realmente anémicos, como lo demuestra el efecto de a suplementación. Para los sujetos que viven en altitud, los límites de referncia ajustados para la altitud correspondiente son totalmente inadecuados: todos los individuos anémicos fueron mal clasificados

Nuevo indicador de la carencia de hierro: relación hemoglobina y protoporfirina eritrocitaria

La protoporfirna es metabolismo indispensable en al síntesis del HEM, pues su presencia hace posible que el hierro en estado ferroso se incorpore en su interior mediante la acción catalítica de una enzima mitrocondrial denominada ferroquetalasa o hem sintetasa y finalmente formarse el Hem. Este hecho puede alterarse ya sea, por un estado deficitário en hierro en forma crónica o por acumulación anormal de plomo. El estudio se realiza en 199 personas de la zona rural de Sto. Domingo de los Colorados, integrado por 87 hombres (43.72%) y 112 mujeres (56.28%). Los resultados nos permiten inferir la existencia de un estado deficitario de este mineral son: niños en crecimiento rápido (lactantes, preescolares y escolares), mujeres en edad fértil y mujeres embarazadas (no consideradas en este trabajo). En este presente estudio aproximadamente el 90% de las personas pertencientes a estos grupos señalados presentan algún trastorno relacionado con el metabolismo del hierro, definido por una disminución en la concentración sanguínea de hemoglobina y un aumento en la concentración de protoporfirina eritrocitaria. Con el presente estudio pretendemos insistir en el uso de indicadores adecuados y técnicas de laboratório fáciles y fiables para determinar el estado de hierro en el organismo

Nutritional anaemia in pregnant Beninese women: consequences on the haematological profile of the newborn.

An assessment of iron and folic acid status, blood thick film and haemoglobin (Hb) electrophoresis was performed on 126 pregnant women (and their newborn infants) and in ninety-five menstruating women in Cotonou (Benin). Anaemia (according to the World Health Organization (1972] was observed in 55% of pregnant women and in 39% of menstruating women. Fe-deficiency was defined as a low serum ferritin concentration (12 micrograms/l or less), combined with a low transferrin saturation (less than 16%) or a high erythrocyte protoporphyrin level (more than 3 micrograms/g Hb), or both. A moderate elevation in the serum ferritin concentration (between 13 and 50 micrograms/l), associated with a low transferrin saturation or a high erythrocyte protoporphyrin level, or both, indicated Fe-deficiency in an inflammatory context. Fe-deficiency was present in 73% of pregnant women and in 41% of menstruating women. Folate deficiency (defined as erythrocyte folate below 160 micrograms/l) was observed in 45% of pregnant women. In pregnant women, anaemia was associated with Fe-deficiency in 83% of cases and with folate deficiency in 48% of cases. Haemoglobinopathies were mainly heterozygous and did not seem to contribute significantly to anaemia. Intensity of malaria was not related to Hb level, but Plasmodium falciparum was found in 99% of subjects. Hb concentration and mean corpuscular volume were significantly lower in babies born of Fe-deficient mothers than in babies born of Fe-sufficient mothers. Hb concentration in newborn infants was positively correlated with maternal serum ferritin.

Iron status in Ecuadorian pregnant women living at 2,800 m altitude: relationship with infant iron status.

An evaluation of iron status was performed in 84 pregnant women at delivery (and in cord blood from their newborn) and in a control group of 32 menstruating women living in Quito (2800 m altitude). Anemia as defined according to the WHO references adjusted to altitude was observed in 46% of pregnant women. Iron deficiency was defined as the combination of a low serum ferritin level (12 micrograms/l or less) and a low transferrin saturation percentage (less than 16%). A moderate elevation in the serum ferritin concentration (between 13 and 50 micrograms/l) associated with low transferrin saturation indicated iron deficiency in an inflammatory context. Iron deficiency was present in 46% of pregnant women. Anemia was associated with iron deficiency in 59% of cases. A correlation between maternal and cord blood hemoglobin was found and some iron parameters in cord blood were related to maternal iron status, and especially to maternal iron stores assessed by serum ferritin concentration.

Teaching nutrition to young children.

PIP: A participative educational approach, in which children are actively involved in improving their own health, can provide a basis for developing healthful behavior patterns. The International Children's Center has organized an international workshop on the integration of health and diet in the overall development of children 3-6 years of age. This document describes the methodology of programs developed by participants in these workshops and suggests activities for programs related to nutrition, growth, and water. The steps involved are: to make an inventory of local problems related to the health subject selected, to define the educational objectives of the program, to define the criteria for program evaluation, and to establish a varied program of children's activities. The proposed activities should stimulate children to analyze real-life situations and find solutions for themselves, to formulate and check hypotheses, and to plan their actions. The activities, all of which are based on play, make use of locally available materials rather than expensive technology. For example, an activity related to the themes of water and nutrition could be a restaurant day, in which preschool children serve food to other children. The teacher uses this as an opportunity to teach the children to recognize local foods and to serve clean water with meals. Also a part of this activity are mathematical exercises to calculate the amounts of food needed, creative activities to imitate the atmosphere of a restaurant, and code-learning exercises for the preparation of the menu and understanding of recipes.^ieng

Women's lives, mothers' health.

PIP: This document dealing with women's lives and the health of mothers identifies factors conditioning the health and nutritional status of women and girls (life expectancy at birth, maternal mortality rate, and the birthrate); considers nutritional requirements of pregnant and lactating women, weight gain during preganncy, mothers' age and number of children and interbirth interval, maternal nutritional status and breastfeeding, anemia, work and women's health, pregnancy in adolescents, abortion, the growth of small girls and its effect on future pregnancies, and sexual mutilations; and reports on actions aimed at improving the health of women as well as health problems facing rural women. The 3 key concepts of this reflection on women's lives are: women's health should be taken into account as well as children's health; the development of the whole human being should be respected, implying ongoing surveillance of the health status of women and of their children; and the overall living conditions of women within the family and society must be analyzed at the different phases of their life, so as to encourage integrated actions rather than various uncoordinated efforts. Women's health status, like the health status of everyone, depends on a multitude of socioeconomic and sanitational factors. A figure illustrates several of the many interrelations between the various factors which influence the nutritional status of all individuals. Women of childbearing age are at greater risk than other population groups, due to their reproductive function and their ability to nurse children: pregnancy, like lactation, generates metabolic changes and increases nutritional needs. Delivery itself presents a series of risks for the woman's health, and only regular surveillance of pregnancy may prevent many of these. A woman's health status and, most of all her nutritional status during pregnancy and delivery, condition her future health and ability to assume her many tasks as well as the development of her child. As far as health and development are concerned, the mother-child couple cannot be separated. More than in any other individual, there is dynamics to women's nutritional status, since it may have negative consequences for the following generation. A few examples of desirable actions aimed at promoting women's health are discussed. These actions fall into the categories of education, surveillance of pregnant women, food supplementation, planned parenthood, technology, and legislation.^ieng

The ongoing evaluation of protein-energy malnutrition.

PIP: This article, based on data obtained in Central Africa, discusses indicators of the nutritional status of population groups, decisive factors in the collective protein-energy nutritional status, and analysis of the factors determining health and nutritional status. Individual nutritional status is conceptualized as reflecting a constantly shifting balance between dietary intake, physiological requirements, and energy expenditures. It is influenced by both endogenous factors (individual genetic potential, appetite, the absorption and digestion of food, hormone balance, mental status) and exogenous factors (the family and environment). In general, the main factors influencing the nutritional status of infants and small children are nutritional status at birth, nutritional intake, infections, and parasites. The nutritional status of women is most affected by their reserves and nutritional intake, energy expenditures for farming and housework, complementary needs linked with pregnancy and lactation, and infections and parasites. Conditions such as insufficient food availability, rapid population growth, poor environmental sanitation, or an excessively dry climate can influence the nutritional status of an entire population. The approach outlined in this article aims to lead to the definition of the priorty needs of the population in terms of nutritional status and to identify those groups and individuals at greatest risk as well as the high-risk stages of life. This approach, in turn, requires use of descriptive and analytic epidemiology. The biochemical, clinical, and anthropometric indicators clearly associated with the prevalence of a symptomatic state must be defined and the risk linked with different figures for those indicators determined. Serum proteins, especially albumin, are indispensable in identifying protein malnutrition. Weight for height and height for age effectively differentiate children with a high risk of malnutrition from others. Analysis of hospital data also enables identification of those nutritional factors linked with a high risk of intrahospital mortality. Analytic epidemiology allows determination of the influence of breastfeeding, family composition, and birth intervals or nutritional status.^ieng

How to feed young children.

PIP: Changes have occurred in the ways of feeding young children in the past 20 years, both in the industrialized countries and in the 3rd world. The question arises as to whether these changes are always beneficial, particularly in the developing countries. In this discussion of how to feed young children a short reminder is provided of the recommended nutritional intakes during the 1st years of life. Subsequent discussion focuses on the following: the building, energy giving, and protective foods; slight, moderate, and severe forms of malnutrition; breastfeeding (the physiology of breastfeeding, arguments favoring breastfeeding; breastfeeding and reproduction; breastfeeding successfully, and breastfeeding and medication); and artificial feeding or substitute feeding. Nutritional intakes must cover what is spent to maintain the body under various circumstances. Children have considerable, specific food requirements. These change rapidly from week to week as the young organism adjusts to an air filled world and copes with its weight and height growth and overall development. The fantastic growth that occurs during the 1st years of life explains why the young child is so vulnerable. The child must have a nutritional intake which is both quantitatively and qualitatively appropriate to its needs. For several months the child should be given a rather monotonous liquid diet. The average energy intake for the 1st year of life should be about 110 Kcal/kg/24 hours. Protein requirements are particularly high during the 1st years of life, for children must not only maintain, repair, and replace tissue, but also provide for the growth and development of their body, i.e., the building of body tissue. An important essential fatty acid is linoleic acid, which serves as a basis for the production o other essential fatty acids. Recommended intakes for calcium, iron, and vitamin A are reviewed. Analysis of food consumption shows that some populations in developing countries have a diet based essentially on 1 staple food. Most are energy giving foods and almost all are carbohydrates. The types of malnutrition caused by deficiency and the most frequently encountered in the developing countries are protein calorie malnutrition, avitaminoses, and mineral and iron deficiencies. Toward the age of 4-6 months, the mother's milk is no longer sufficient, quantitatively or qualitatively, for the satisfaction of the child's nutritional requirements and cannot ensure his/her adequate growth. In general, at this time of life the child should gradually begin to receive complemental food.^ieng