Nutrition in Global Health
Roadmap to the world’s nutritional health:
Causes, mechanisms, solutions
Allan J Davison PhD, Professor, Biochemist,
Faculty of Sciences, Simon Fraser University
Department of Biomedical Sciences & Kinesiology
June 2011
Prepared as part of an education project of the
Global Health Education Consortium & collaborating partners
Malnutrition overview
•Inequities in distribution  global hunger & starvation
•One billion too hungry to live productive lives - an equal
number adversely affected by overweight!
•6 major deficiencies impact health through the life
cycle: water, protein, iron, vitamin A, iodine, folic acid
•Childbearing women & their children are hardest hit
Overnutrition & inactivity  risk of heart disease, cancer,
strokes, osteoporosis, & diabetes everywhere
Globally more are fed every year, meanwhile millions
die unnecessarily
Page 2
Misconceptions abound. Check yourself
• As a reality check, and to create “teachable
moments” for what follows, we now invite you to
take a 5-minute pre-quiz
• You will be offered 10 true-or-false questions to
dispel some common misconceptions
• Some of this misinformation is spread by those who
have something to gain from it
• After completing the pre-quiz, we hope you will
continue this module with greater interest & clarity
Page 3
Prequiz here!
To get the most out of this module
If you are…..
• a nutritionist or student
of nutrition
• a student of one of the
health professions
• planning a project in
regions with severe
nutritional problems
• a public health
practitioner
You may want to …
• Pay attention to global & public health
& policy implications.
• Pay attention to perspectives &
realities in desperate situations
• Emphasize check-lists to prepare for
field work & gather information to
recommend/advocate for intervention
• Use these slides & resources in your
information / teaching sessions
Page 5
Preface: Nutrition is crucial to global health
• Among immediately modifiable factors that affect health …
nutrition is of prime importance
• At every age nutrition is a foundation for what follows
• For all nations, rich & poor, nutrition determines physical
health & development through the life-cycle, including
• Success in childbearing, cognition, socio-economic
independence, education, disease resistance, employment
• Health & economic development are contingent on
adequate food, nutritional resources & support
Page 6
Universal limitations & health consequences
•
•
•
•
We need energy for the tasks of daily life
Precursors for growth, repair, and reproduction
Food elements can be converted to tissues, but …
We can’t survive without about 15 essential mineral
elements, so they are needed in our diets, most in
trace amounts
• We can’t manufacture about 15 vitamins and 8 amino
acids, so they to are essential dietary components
Page 7
Universal limitations & health consequences
In addition: We lost key metabolic abilities our evolutionary
ancestors had. Thus we are vulnerable to 2 dietary risks:
1) In early life – a period of rapid growth, we are vulnerable to
“kwashiorkor” (protein insufficiency) because we can’t
synthesize 8 “essential” amino acids missing from our diet
2) In later life: we are vulnerable to obesity & diabetes – in part
because we can make fat from carbohydrate, but we can’t
easily convert stored fats back to carbohydrates
Note B
Page 8
Categories of nutritional status
Nutritional status is assessed as one of four
categories
1. Good nutritional status: All nutrients (right quantities, time &
place) allow optimal, growth, maintenance, & reproduction
2. Overnutrition: An excess of a nutrients (usually calories) is
being consumed, so that health is negatively impacted
3. Undernutrition: Insufficient food is consumed to allow for the
energy needs of the individual. Inevitably dietary (& then body)
protein is burned for energy. A secondary protein deficiency
ensues – thus: "protein-energy-malnutrition"
4. Malnutrition: Energy consumption is adequate, but there is an
imbalance among constituents of the diet and health is impacted
Note C
Page 9
Optimal health:
physical & mental development
reproduction, survival
Good nutritional status
Precursors
Absence of disease
Healthy diet
... food
& water
Access to ...
... perinatalcare
... health
services
# of mouths
to be fed
Foundations
Education
NB women
Geography, stability, climate
absence of conflict, natural resources
access to markets, etc
Agricultural
productivity
Economic
development
Infrastructure
non-exploitive investment
intellectual property
The goal is to see everyone self-sufficient
• People in the poverty trap live from hand to mouth, with no
opportunity to put resources aside to build a better future
• Such communities cannot access the ladder of economic
development without external help.
• The MDG promise of 0.7% of rich country GDP for aid was
chosen to eliminate extreme poverty & hunger in 3 decades
• But there are many nations that failed to meet this goal,
including both the US and Canada
• Thanks to the nations that keep their promises, widespread
hunger can be eliminated, but only after 30-50 years. This
not, however, cause for undiluted joy. See Note G.Note G
Page 11
The “poverty trap”
• Even among the richest there are some individuals so
marginalized that there seems little hope for them
The larger culture, if it cares, takes long-term responsibility
for ensuring them the necessities of life
• Globally there are communities that have been denied the
resources to ever become wealthy. Often from geography,
climate, invasion, or appropriation of natural resources
Regardless, a world community has undertaken to provide
necessities of life, & self-sufficiency to the dispossessed
Note H
Page 12
Nutrition in Global Context: Sections
1.Malnutrition: prevalence, causes, consequences 4
2.Major categories & measures of nutritional status4
3.Nutrition & crucial periods in the life-cycle; 4
4.Determinants of nutrition, dietary patterns & culture2
5.Nutrition and its relationship to disease4
6.Making hunger history - breaking the poverty-trap 3
7.Trends in nutrition, food security & globalization3
Page 13
Prevalence, causes, consequences
On completing this section you will be able to:
1.
Describe the extent of malnutrition & its impact on people of the planet, and
understand how MDGs depend on nutrition
2.
Analyze the factors that determine nutritional health
3.
Identify nutritional problems among individuals & populations, identify causes &
appropriate solutions
4.
Assess risks at various stages of the life cycle & recommend strategies for
diminishing risk
5.
Compare competing theories accounting for the inequities
6.
Predict outcomes by projecting current trends into the future
& foresee a pathway toward a world without hunger
Page 14
A vicious cycle: economics, hunger, health
Poverty  diminished
access to agricultural &
food resources 
malnutrition
nutrition
Physical & cognitive
impairment,
susceptibility to
disease, early death 
inability to earn an
income
Economic
marginalization
 inability to
provide for self or
family
Page 15
When the only tool you have is a hammer
… every problem becomes a nail
Malnutrition: “spatial & temporal myopia” sees proximate, not ultimate causes
It’s natural to focus on our immediate space-time: rash, diarrhea., edema. Then etiology:
infection, nutrition, endocrine
Meanwhile, causes further back are invisible: poverty, invasion, drought, economic
Are you bored yet? You’d better not be!
This module will reiterate the more enduring global causes, poverty & lack of will to
change the net flow of wealth from the dispossessed to the powerful. Also the ways
in which this imbalance is being overcome.
Reference: Ban-Ki Moon, Noam Chomsky, The Nation
Page 16
Routes to famine
Being landlocked
Lesotho
Having resources So.Africa Nigeria, Iraq
or being on a trade or pipeline route Israel, Afghanistan
Bad governance
To learn about the “Resource Trap”
read or google Paul Collier
Zimbabwe, Italy, USA
Externally initiated armed conflict
Dafur,
Afghanistan
Sometimes to overthrow a populist government
(Allende, Aristide) and install a puppet, or bribable government
Uncertain rainfall & drought
Sahel, Palestine
Blaming the bonsai tree...
Yunus:
The astonishing background to hunger –
a world growing spectacularly rich
Next slide shows century by century growth in GDP per capita
For half a century we’ve had enough food to nourish everyone
Yet …
Why?
Almost a billion are overweight
while an equal number cannot
get enough food to sustain life.
Because the flow of wealth is
overwhelmingly from the poor to
the rich, & the rich are able to
keep it that way
BanKi Moon
Page 18
World GDP $PPP per cap
(est) 1500-2100
“Manifest destiny” of world - wealth
1
$10,000
China +
India 2040?
USA + West
Europe
Western
Europe
$5,000
China + India
India to 1500
$0
1500
2000
http://ers.usda.gov/Data/Macroeconomics/
Eliminating hunger may be the main
requirement for a world at peace
Food is a primary human drive. Lack → social instability
GW Bush
Health & economic development depend on nutrition
In the following vicious circle, note how malnutrition, ill health,
& poverty exacerbate each other
MDG 1 is elimination of extreme poverty and hunger,
most if not all the others depend on this, the primary, one
Page 20
We know in detail the causes of
hunger & how to eliminate it
We will assume you know the mechanisms in
the “poverty trap”
the “resource trap”
Unfettered free trade favours the powerful
Trickledown is overpowered by a torrent of wealth in the other direction
The cures are laid out in detail in the MDGs, MVs, Grameen Foundation
The chain of cause and effect, and influences are not rooted in the availability of
food, nor are they an accident. You must see “starve” as a transitive verb to
understand the link between extreme wealth and extreme poverty
Page 21
We know what kinds of aid work
and what kinds don’t
Aid designed to benefit the giver rather than the recipient
Fraction of the amount promised, nothing compared with warfare
Promises that evaporate
Page 22
Nutrition Module Sections
1.Malnutrition: prevalence, causes, consequences 4
2.Major categories & measures of nutritional status4
3.Nutrition & crucial periods in the life-cycle; 4
4.Determinants of nutrition, dietary patterns & culture2
5.Nutrition and its relationship to disease4
6.Making hunger history - breaking the poverty-trap 3
7.Trends in nutrition, food security & globalization3
Page 23
2 Categories & measures of nutritional status
4 slides:
• Malnutrition, undernutrition,
• Overnutrition / Overweight, Obesity
• Energy requirements: calories, carboh, proteins, fats
• macronutrients, micronutrients
Page 24
4 Determinants of nutrition, diet & culture
2 slides:
1.
Page 25
Dietary patterns across cultures
1. Hunter gatherers – the earliest category
Benefits: mixed diet, well nourished in good times
Risks: famine or drought, warfare & plunder,
resourcedepletion through population pressure
Prevalent problems: starvation, thirst,  lifeexpectancy
Note I
Page 26
Dietary patterns across cultures
2. Peasant agriculturalists – successful small scale
farmers (currently the largest group)
• Benefits: close to food sources; if no punitive taxes or rents;
usually well adapted to their traditional diets
• Risks: single crop emphasis  malnutrition, plagues
(locusts, rodents), exploitation, warfare and plunder
• Prevalent problems: vitamin deficiency, starvation,
alcoholism
Page 27
Dietary patterns across cultures
3. Indigent, landless crop planters
Benefits: Community, share with family, neighbors,
income is typically less than a dollar a day
Risks: Crop failure, drought or famine, erosion, soilexhaustion, pestilence, economic exploitation (by
landlords, seed providers, loan-sharks),
displacement, forced migration, civil unrest or
foreign invasion
Problems: multiple vitamin deficiencies, kwashiorkor
(protein malnutrition), infectious disease epidemics.
Too poor, powerless to help themselves, most ofPage 28
Dietary patterns across cultures
4. Urban slum dwellers – fastest growing group
Benefits: hope for jobs, escape from drought or
crop failure
Risks: overcrowding, poverty, poor hygiene, limited
food choice, social disruption  loss of traditional
diets, crime
Prevalent problems: deficiencies of essential
nutrients, alcoholism, obesity, kwashiorkor,
Page 29
Dietary patterns across cultures
5. Affluent urbanites – most recent category
Benefits: many food choices (appropriate and inappropriate)
Risks: inactivity along with high fat, sugar, alcohol intakes
Prevalent problems: overnutrition, obese babies and adults
diabetes (carbohydrates), cholesterol, atheroma (lipid),
strokes, heart disease diabetes, gout (uric acid - meat
sources)
Note J
Page 30
Under- & over-nutrition occur in all cultures
• Disparities in income, nutrition & health care are
increasing between countries & within groups in
the same country
In addition, in low and middle income countries
diseases of overnutrition are increasingly
common
• Obesity related disorders, including diabetes, are
now as important in some lower to middle income
Page 31
countries as in North America and the European
Also, under-nutrition occurs in many rich nations
• In rich nations, enormous wealth for some has left others
ravaged by health costs, unemployment, foreclosures
• Developed countries have marginalized cultural groups.
Hunger is common in N & S America, China & E Europe
• For example, ~49% of US children (and over 80% of black
children) require food-aid at some time during childhood
• Scandinavia & few western European countries are almost
the only exceptions
Page 32
Overnutrition is no longer limited to rich countries
Obesity is a growing problem worldwide,
particularly among those who lack resources for a
wide range of food choices.
• All too often, the cheapest foods are high calorie,
poor in nutrients, rich in sugar, salt, fat, & trans-fats
• The predominant cause of obesity is underexercising rather than overeating. On average,
overweight people eat slightly fewer calories than lean
people, but are much less active
• Obesity increases risk of many disorders, most
Page 33
Overnutrition is no longer limited to rich countries
• Previously, the poorest were almost immune to diabetes,
hypertension, gout, & atherosclerosis & heart disease
• No longer. These are growing problems, impacting health
worldwide. In the next few slides we’ll consider prevention.
• Diabetes has reached epidemic proportions threatening,
vision, kidney function, mobility, heart-health & life itself.
• A cluster of symptoms, hypertension, hyperlipidemia, and
hyperglycemia is sometimes called “metabolic syndrome”
• Each of them increases risk of heart disease, and together
the risk is greatly amplified. Read on…..
Page 34
Nutrition Module Sections
1.Malnutrition: prevalence, causes, consequences 4
2.Major categories & measures of nutritional status4
3.Nutrition & crucial periods in the life-cycle; 4
4.Determinants of nutrition, dietary patterns & culture2
5.Nutrition and its relationship to disease4
6.Making hunger history - breaking the poverty-trap 3
7.Trends in nutrition, food security & globalization3
Page 35
3 Critical periods: nutrition in the life-cycle
4 slides:
1. Perinatal nutrition: 0-6 mo: Breast vs. formula
1st 5 y Weaning & infancy –intellectual develop
2. School years; ability to learn
3. Work performance
4. Elderly
Page 36
Nutrition through the life-cycle
Stage
Risks associated with malnutrition
birth defects, birth weight, infant and peri-natal mortality, high
maternal death rate
cognitive & physical development, bone malformation
blindness, impaired immune response,
risk of infections, faster progress of HIV, in protein-energy malnutrition,
early death from causes the well-nourished would survive
Adolescence risk of infection, anemia, diabetes, problems with heart, lungs, vision,
& adult life risk of all cancers, anemia, blindness, beriberi, pellagra
This stage of life lays a foundation for later good or ill health,
osteoporosis, greatly diminished life-expectancy
Old age
few chronically malnourished persons survive to old age. Those who do
survive poor lifestyle and nutrition, often endure a very low quality of life
Prenatal &
(pregnancy)
Infancy &
early life
Page 37
Factors in perinatal nutrition
(see also Acute malnutrition module)
• Nutritional health begins in the womb – a healthy
outcome to a pregnancy requires that mother be
well nourished; good feeding must initiated early
• The most common birth defects result from a
deficiency of folic acid in the diet of the pregnant
mother, Best outcomes require folic acid
supplementation before conception!
Page 38
Factors in perinatal nutrition
(see also Module on Acute malnutrition)
• Delaying clamping the umbilical cord until it stops pulsing iron stores see:
www.naturalchildbirth.org/natural/resources/labor/labor04.htm
http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/jcco
m/en/index.html
• Ideally, babies should receive vitamins E & K injections at birth
• A baby who’s healthy at birth may experience "failure to thrive" (or "growth
faltering") in the first year of life. So …..
• Good infant feeding behaviors must start early. Most importantly, breastfeeding should be initiated within an hour of birth & maintained exclusively
for 6 months.
• Breastfeeding could prevent 1.3 million deaths each year
http://www2.unicef.org/nutrition/index_22657.html
•
Page 39
Perinatal nutrition requires attention1
• Malnutrition in pregnancy  birth defects & low
birth-weight
• Failure to thrive is an early danger sign, requiring
investigation
• Nutrition in infancy to early life impacts physical &
cognitive development. It determines immediate &
future risks of blindness, thyroid function, bone
development, & more
• Under-nutrition or deficiencies of many
micronutrients can cause failure to thrive“
Page 40
Malnutrition in early childhood
• Children are at special need because they are at
the fastest-growing stage of life. Problems an adult
could survive can be lethal to a child
• This is the most vulnerable period – a child is
developing physically & mentally. Damage can be
permanent
• Most importantly, they are unable to fend for
themselves & depend on others (parents, others)
for health & survival
• They are the planet’s future. We owe it to them & to
ourselves to ensure that they grow well, with a Page 41
Nutrition through the life cycle - adolescence
Adolescence carries risks for both poor & affluent
• Adolescent & adult patterns of food consumption
& activity
massively impact immediate & future health risks
• Adolescents are notoriously careless about
health. Their eating patterns can lead quickly to
obesity or anorexia.
Page 42
Nutrition through the life cycle - adolescence
Adolescence carries risks for both poor & affluent
• Dieting can lead to deficiencies of vit. C, protein, folic acid
in a sedentary person. Even if a good mix of foods is
consumed, total food intake may be insufficient.
• A pattern of healthy eating in adolescence sets a pattern
that can promote lifelong health
• A foundation for healthy bones is set by exercise, calcium,
& vitamin D. After early adult life, bones go slowly downhill
Page 43
Nutrition through the life cycle – adult life
Nutrition & acute & infectious diseases
• Malnutrition depletes immunity leading to increased risk &
severity of infections & parasites: AIDS, malaria, etc.
• Flagrant deficiencies of specific micronutrients can put at
risk the life & health of the mother in pregnancy & lactation
• Nutritional anaemias, pellagra, blindness, skin disorders
beriberi, scurvy, etc, can range in severity from mild to fatal
Page 44
Adult life - degenerative diseases
• In late life, risk of breast, prostatic, & most other
cancers are predicted by diet, obesity, inactivity or
smoking in adult life
• Also heart disease, strokes, osteoporosis,
diabetes
• Cancers and diabetes are now leading causes of
death & disability in low- and middle-income
countries (see Lancet August 13, 2009)
• Nearly two-thirds of the world’s 7.6 million cancerrelated deaths now occur in developing nations.
Page 45
Differential nutritional vulnerability of females
• Women are much more prone to nutritional
anaemias since they need to replace red cells lost
in menstruation
• Women are the majority of elders, increasingly so
in Asia and Africa. Osteoporosis is more common
in the elderly
• Osteoporosis is a major cause of illness, disability
and death. The annual number of hip fractures Page 46
Differential nutritional vulnerability of females
• Women suffer 80% of hip fractures; lifetime risk 30 - 40%
compared with 13% for men.
• Osteoporosis prevention (exercise, calcium, & vitamin D)
must start well before age 30 when bones still respond.
• Negative calcium balance in later life is not very responsive
to nutritional measures.
Page 47
Prevention of heart attacks and strokes
• Risk factors : hypertension, hyperlipidemias (LDL
/ “bad” cholesterol), inactivity & diabetes. All
correlated with obesity
• Smoking is the most life-shortening risk factor of
all
• These risks can be changed earlier or later, by
modification of diet & other life-style changes or
medication
Page 48
Prevention of heart attacks and strokes
• There is no easy solution to obesity. In a typical study: <10% of
people dieting, <10% of those exercising, and <15% of those
exercising & dieting, lost weight.
• However, over 80% of those who underwent stomach stapling
or banding lost weight!
• Not very encouraging, for lifestyle treatment. Many argue that
surgery to control weight should be done more often
Page 49
Measures to diminish cardiovascular risks
Lifestyle measures: have greatest impact in older
people!
• Increasing consumption of fruit & vegetables by
one to two servings can cut cardiovascular risk by
30%
• Reduction of blood pressure by 6 mm Hg reduces
stroke risk by 40% & heart attack by 15%.
Hydrochlorthiazides (diuretics) are inexpensive
and effective
Page 50
Measures to diminish cardiovascular risks
• Modest cutbacks in saturated fat & salt improve blood
pressure & lipids; & diminish risk of cardiovascular disease
• Lifestyle measures are, optimally, combined with
pharmaceutical intervention
• Best practices in the area of diabetes & cardiovascular
disease are a moving target. Anyone teaching or practicing
in this area needs skills in finding evidence-based
information in an ocean of misinformation.
Page 51
Nutrition in later life and old age
• Worldwide, the proportion of people over 60 is
increasing.
By 2025, the world will have more than 1.2 billion
older persons – two-thirds of them in low income
countries
• The foundation laid in earlier life determines risk of
diabetes, heart disease, hypertension, strokes,
osteoporosis, cancer, etc. All these bring special
nutritional concerns.
Page 52
Nutrition in later life and old age
• Old age can be cut short by many kinds of malnutrition
• Deficiencies of calcium, iron, water, vit. B12 can severely
compromise old age
• Loss of taste and smell can render the elderly at risk for food
poisoning from spoiled food
• Loss of thirst sensitivity in this age group makes dehydration
(inadequate water intake) a common cause of confusion,
headache, & occasionally kidney stones
• Prevention is better than cure, & symptomatic treatments that
are effective ,are often unavailable to the aged in LMICs
Page 53
Nutrition in Global Health
Causes, mechanisms, solutions
Nutrition is crucial to global health & MDGs
1.
2.
3.
4.
5.
6.
Overview of nutrition across humankind
Human nutrition fundamentals in global context
Top Six nutrition problems, & their solutions
Nutrition across the life cycle in rich & poor nations
Cause & effect in population nutrition
Overview and where we are now
Bridge to Part 2, Roadmap to a world without hunger
Page 55
Human Nutrition Fundamentals in Global Context
The next set of slides covers the critical skill set needed for
understanding nutritional issues in the context of global health
They are not a substitute for nutritional training, but rather a
catalog of nutritional tools applicable to problems a health
practitioner might encounter in the field
From this you can learn when to call in a nutritional expert,
what kind, & what to you might reasonably ask for & receive
If you have learned nutrition in a developed country, this may
help you to expand your knowledge of nutrition and public
health in the context of 3rd world health problems
Page 56
Dietary patterns across cultures
1. Hunter gatherers – the earliest category
Benefits: mixed diet, well nourished in good times
Risks: famine or drought, warfare & plunder,
resourcedepletion through population pressure
Prevalent problems: starvation, thirst,  lifeexpectancy
Note I
Page 57
Dietary patterns across cultures
2. Peasant agriculturalists – successful small scale
farmers (currently the largest group)
• Benefits: close to food sources; if no punitive taxes or rents;
usually well adapted to their traditional diets
• Risks: single crop emphasis  malnutrition, plagues
(locusts, rodents), exploitation, warfare and plunder
• Prevalent problems: vitamin deficiency, starvation,
alcoholism
Page 58
Dietary patterns across cultures
3. Indigent, landless crop planters
Benefits: Community, share with family, neighbors,
income is typically less than a dollar a day
Risks: Crop failure, drought or famine, erosion, soilexhaustion, pestilence, economic exploitation (by
landlords, seed providers, loan-sharks),
displacement, forced migration, civil unrest or
foreign invasion
Problems: multiple vitamin deficiencies, kwashiorkor
(protein malnutrition), infectious disease epidemics.
Too poor, powerless to help themselves, most ofPage 59
Dietary patterns across cultures
4. Urban slum dwellers – fastest growing group
Benefits: hope for jobs, escape from drought or
crop failure
Risks: overcrowding, poverty, poor hygiene, limited
food choice, social disruption  loss of traditional
diets, crime
Prevalent problems: deficiencies of essential
nutrients, alcoholism, obesity, kwashiorkor,
Page 60
Dietary patterns across cultures
5. Affluent urbanites – most recent category
Benefits: many food choices (appropriate and inappropriate)
Risks: inactivity along with high fat, sugar, alcohol intakes
Prevalent problems: overnutrition, obese babies and adults
diabetes (carbohydrates), cholesterol, atheroma (lipid),
strokes, heart disease diabetes, gout (uric acid - meat
sources)
Note J
Page 61
Nutrition Module Sections
1.Malnutrition: prevalence, causes, consequences 4
2.Major categories & measures of nutritional status4
3.Nutrition & crucial periods in the life-cycle; 4
4.Determinants of nutrition, dietary patterns & culture2
5.Nutrition and its relationship to disease4
6.Making hunger history - breaking the poverty-trap 3
7.Trends in nutrition, food security & globalization3
Page 62
5 Nutrition & disease cause vs effect
4 slides:
• Acute and chronic malnutrition;
• Socio-cultural determinants of malnutrition
• Undernutrition as contributor to much childhood
mortality / morbidity
• Micronutrient deficiencies: Iron, Vitamin A, iodine,
calcium, etc.
• Nutrition &major diseases: CV, strokes, diabetes
• Over-nutrition, obesity
Page 63
Some communities subsist in the “poverty trap”
• Even among the richest there are some individuals
so marginalized that there seems little hope for
them
The larger culture, if it is compassionate, takes
long-term responsibility for ensuring them the
necessities of life
• Globally there are communities that have been
denied the resources to ever become wealthy.
Often from geography, climate, invasion, or
appropriation of their natural resources
Note H
Regardless, a world community of compassion can
Page 64
Money? Useless - no nearby shops
• It’s hard to imagine a malnourished community and
you may want to experience field conditions in
advance
No commerce! Try it at a Medecins sans Frontieres
site:
http://www.starvedforattention.org/
• No shops to spend money in, no one to employ
anyone, no one to sell things to
• Hungry children are all too visible, and those who
didn’t survive are in tiny unmarked graves
Their needs are much more immediate than money
Page 65
If they don’t need money – what do they need?
• Short term they likely need emergency rations, safe water
In conflict zones, shelter & safety to live, plant, harvest
• Medium term they need to become self-sufficient, with:
good seeds, fertilizer, usable water, sanitation, low
technology agricultural info & resources, health services,
mosquito nets, pharmaceuticals
• Long term they need the prerequisites of sustainable
economic development - tools for development – see Part 2
• Kids need particular attention – see note below & later slides
Note F
Page 66
Top 6 global manifestations of malnutrition
We begin with a perspective, then we take each of the 6 in turn
1) Water is a food (“food” is the material we eat &
drink”)
In hot climates, we can die in a few hours from a
lack of it
2) Protein-energy malnutrition
• The machinery
of life, sculpted from 20 different
The material in this section is well reviewed at:
http://www.pitt.edu/~super1/lecture/lec0141/index.htm
amino acids
Iron, vitamin A, iodine – check the latest information at:
http://www.micronutrient.org/English/view.asp?x=1
• Deficiency
is most serious in children (time of fastest
growth):  "failure to thrive", stunted growth Page 67
Top 6 global manifestations of malnutrition (cont.)
3) Iron deficiency - prevalent in Africa and Asia
• Women & children are the most seriously affected
• In parts of Africa 60% of children have  blood iron
• About a quarter of these have symptoms of anaemia
4) Vitamin A deficiency
Over 100 million children under 5 suffer vitamin A deficiency
•In high deficiency areas vit. A tabs  child mortality by 23 %
&  child blindness by 80%. Night-blindness is an early sign
Page 68
Top 6 global manifestations of malnutrition (cont.)
5) Don’t underestimate iodine deficiency disorders
• WHO 2003: “1.6 billion people don’t get enough iodine”. This
is the major cause of preventable brain damage.
• Thanks to MDG programmes the problem is shrinking!
http://www.who.int/vmnis/iodine/status/en/index.html
In addition nutrition determines chronic disease risk
• Heart disease, osteoporosis, cancer, diabetes, strokes, etc.
We’ll go through these one at a time in the following slides and Note K lists
categories of at risk people across countries
Note K
Page 69
Top 6 global manifestations of malnutrition (cont.)
6) Folic Acid is required for healthy babies
• A deficiency causes spina-bifida – a common birth defect
• Supplements are recommended before start of pregnancy
• 50% of pregnancies are unintentional!
Women who might become pregnant, need advice
More details on these nutrients in the ensuing slides
Page 70
Water: one of our most important foods
• Adequate safe water is most important dietary
component
• 9 million worldwide have water-borne diseases
• In India, contaminated water kills 300,000 children
annually
• Problems relating to water supply & safety have
simple, relatively inexpensive solutions
• Water “ownership” is, however, contentious &
usually
follows military power (e.g. in Middle East)
http://www.who.int/water_sanitation_health/mdg1/en/index.html
• In hot humid conditions workers may need over Page
5 l 71/
The special importance of proteins
• Proteins are the machinery of life. We have no storage form.
If we must use protein “stores”, tissues lose function
• Plasma, liver and kidney lose function first. Their proteins are
the most “labile”. Then, digestive tract, muscle & heart
• Proteins are made up of 20 amino acids. 12 are nonessential and can be made from other dietary components
• 8 amino acids are “essential”. If even one is missing, no
protein can be synthesized. A protein lacking any one
essential amino acid has zero “biological value
Page 72
Dietary deficiency of proteins is deadly
• When any essential amino acid is missing, all the rest are
burned & no protein synthesis can occur – zero!
• All essential aa’s must be there at the same time. Meeting
an amino acid need 1 day later is useless
• A diet previously adequate in essential amino acids
becomes inadequate if non-essential amino acids are
removed. Because, although the body can make missing
non-essential aa, it uses up essential amino acids to do so
• Protein complementarity, de-emphasized in nutrition
courses, can be vital where protein intake is compromised
Page 73
Humans adapt to low protein intakes ...
... otherwise impact of protein deficiency would be even higher
Endocrine changes improve the recycling of proteins. As tissues
repair, the released amino acids are reused more efficiently
•In the African presentation of kwashiorkor, a child is exposed to
a protein deficient diet (ages 1 to 5) & adapts successfully
•Then a 1-week lack of protein (parent loses job, baby is fed
glucose-water only, or a gastro-intestinal infection)  kwash
•Child is treated for kwash, sent back to home to same diet, &
reaches adolescence, usually without recurrence.
Page 74
Protein & energy nutrition are inseparable
• When the diet lacks carbohydrates, it uses some amino
acids to make glucose for brain, muscle, etc.
• When a diet lacks total calories, proteins are co-opted, first
dietary, then plasma, liver, kidney, etc.
• For these reasons, a diet previously adequate in essential
amino acids becomes inadequate if carbohydrate or
calories are removed.
• Do an internet search on “protein-sparing effects of
carbohydrates” if you want to understand this further
Page 75
Protein-energy malnutrition - in adults
Tissues are raided, with the following consequences:
• Loss of plasma proteins  oedema*
• Loss of liver & kidney function  diminished inactivation &
excretion of carcinogens and toxins
• Loss of immune function  gastro-intestinal infections
• Loss of digestive tract / liver function  amino acids can’t
be utilized for proteins. No treatment can prevent death
• Loss of muscle and heart tissue  weakness, heart failure
*Oedema or edema = abnormal accumulation of fluid beneath the skin or in body cavities
Page 76
Hungry kids – difficulties in diagnosis
• Marasmic babies may not seem undernourished until a
check for “pitting oedema” reveals that what appear to be
strong arms and legs, are in reality oedematous
• Another diagnostic complication is that most deficiencies
are combined, as in protein energy malnutrition (“PEM”)
with multiple vitamin deficiencies
• The distinctions are crucial both in determining treatment,
and in determining if the underlying problem in the
community is scarcity of food, a protein, or many nutrients
Page 77
Protein malnutrition is different
• In uncomplicated kwashiorkor, only protein is lacking “Malnourished, not undernourished”
• The risk of death or permanently retarded development is
great, and the risk is increased because its easier to miss
the diagnosis
• Kwashiorkor babies may have more than adequate calories
in their diets. They may be chubby, with substantial
subcutaneous fat
• Kwashiorkor may go unnoticed even when urgent
hospitalization is needed, or when death is imminent
Page 78
Protein malnutrition: diagnosis
When there are many sick kids in a community, but
none look undernourished, be sure to look for
protein deficiency. Why?
• It’s important not to miss the diagnosis. Kwashiorkor has a high fatality
rate even with hospitalization
• The 1st symptom to present is often diarrhoea, or oedema
• The child may be treated for a gastrointestinal infection while the
underlying cause, kwashiorkor, goes undiagnosed
• Oedema is an early symptom, and may be mistaken for chubby limbs,
so test if nutrition may be compromised
Page 79
Tracking protein-energy malnutrition in kids
Failure to thrive may be an early warning of flagrant PEM in an
individual child or a community. Always investigate the
cause
• Growth charts give weight for stature / length across
age. They provide criteria to estimate severity. Proper use
requires training!
• Change in position on a chart shows effectiveness of
treatment & probability of survival
• If many children in a community show up at risk on
growth charts, authorities must be alerted to endemic
problems
Page 80
What saves lives after PEM diagnosis
• Treatment is urgent - hospitalization is preferred
• Oral rehydration solutes “ORS” have saved
millions with diarrhoea (usually the case)
• Ready-to-use foods “RTUF” rebuild wasted tissues
• Delayed physical growth is often restored in catchup growth when a good diet is provided
• Prolonged cognitive disabilities may be irreversible
Note L
Page 81
Early measures required on PEM diagnosis
• Both RTUF and ORS can be given at home in a bottle
(Wikipedia). World production of ORS is around 500
million sachets / year. Improvisation of ORS is described at
http://rehydrate.org/ors/made-at-home.htm#recipes
• Powdered milk protein in boiled water can be very helpful
as an emergency measure
• Acute fatality rate IS 10-25% even with prompt treatment
Page 82
Iron deficiency affects 500 million globally
• Iron deficiency is best diagnosed in the preclinical
stage, by measurement of transferrin saturation
• Females > males due to iron loss at menstruation ->50% of pregnant women are affected in the developing
world – 3 times as many as in developed countries
• 25% of men also are deficient in iron in the developing
world
Page 83
Iron deficiency affects 500 million globally
http://www.micronutrient.org/English/view.asp?x=579
• Causes: insufficient availability of dietary iron, or
increased iron requirements to meet reproductive
demands, haemmorhage, parasitic infections
(often concurrently).
• The result is an increasingly severe anaemia,
reduced work productivity → poverty, diminished
learning ability, increased susceptibility to
infection
Note M
For more on consequences of iron deficiency, see
Page 84
Treatment of iron deficiency:
rebuilding iron reserves
• Iron tablets are effective within weeks, but noncompliance is common. Check compliance!
• Increase iron intake through combining iron-rich
foods with agents that  iron absorption (vit C)
• Encourage availability & use of iron-fortified foods
Page 85
Treatment of iron deficiency:
rebuilding iron reserves
• Weekly / daily supplementation is recommended for
vulnerable groups in areas with widespread iron deficiency
• Treat causes of diminished iron reserves: haemorrhage,
parasites (including malaria), and hemolytic conditions.
• Be alert! Iron may be lethal in some inherited anaemias
(thalassemias, sickle cell, or Hb M) common in Africa & Asia
Page 86
Iron excess - dangerous to some
• Those with haemolytic anaemias: (eg thalassaemia –
common in people of African or Asian descent). Iron should not
be prescribed until the cause of an anaemia is known
• Where iron pots are used for cooking or beer: Siderosis: iron
deposition in liver, kidney, heart, pancreas  organ failure
• Children: Parents' iron pills are attractive to kids in developed
countries. The most common of fatal childhood poisonings
• Those with familial haemochromatosis: This common
inherited disease has symptoms similar to siderosis (above)
The first sign of this disease is often inoperable liver cancer
Note N
Page 87
Vitamin A deficiency in public health
• Vit. A deficiency is a public health problem in over
70 countries, especially in Africa, SE Asia & the W
Pacific where it affects 250 million mostly aged 04 years
• Night blindness may predict vitamin A deficiency,
with risk of permanent total blindness if it
progresses
• There is also increased risk of severe illness and
death from infections such as diarrhoeal disease
and measles
Page 88
Vitamin A deficiency & perinatal health
• Vit. A is crucial for maternal & child survival,
supplements in high-risk areas can dramatically
decrease maternal mortality*
• In pregnant women Vit. A deficiency is seen in the
last trimester when demands by unborn child &
mother are highest
• Partnerships for progress in vitamin A nutrition
In 1998 WHO, UNICEF, CIDA, USAID (ia)
launched
a global initiative in 40 countries that has
*This issue is under active investigation. For the status at time of writing see Lancet, Volume 376,
9744,million
p 873 - 874, 11
September 2010
to date avertedIssue
1.25
deaths,
by giving
Page 89
vitamin A to kids at clinics
Vitamin A deficiency & perinatal health
• Night blindness in pregnant women - an early danger sign
• In children, the cost-effective prevention is breast-feeding
• Genetically engineered high Vit. A rice crops could help
Caution: Vit. A supplements as retinol are controversial. It
can be toxic & teratogenic ( birth defects). However,
given as carotene, vitamin A supplements are safe, leading
only to an orange tinge in skin colour.
Page 90
Iodine deficiency disorders
• The world’s major cause of preventable brain
damage
In 1990: 1.6 billion people were at risk in over 100
countries,
mainly in parts of Africa and Asia where soil is
iodine-deficient
• 38 Million children have mental impairment from
lack of iodine
For latest data, see: http://www.micronutrient.org/english/View.asp?x=578
Page 91
Iodine deficiency disorders
• Consequences start before birth and continue afterward
– In utero, spontaneous abortion, congenital abnormalities
& retarded foetal development
– In early childhood and progress toward
adolescence iodine deficiency causes cretinism, an
irreversible retardation. Impacts home, school, & work
– Today we are on the verge of eliminating iron deficiency
--- a major public health triumph like getting rid of
smallpox & polio
Page 92
Toward iodine sufficiency – iodized salt
• A cost-effective low-tech therapy, iodized salt costs
just $0.05 per person per year
• UNICEF, ICCIDD (International Council for Control
of IDD),
& the salt industry have set up iodization
programmes.
Globally, 66% of households have access to iodized
salt.
• As of 2009 the number of at risk countries has been
halved!
Page 93
6 Making hunger history - breaking the
vicious cycle of the poverty-trap
To find the remedy, we must know the causes
Poverty trap
Resource trap
Then we’ll understand
what “remedies” don’t work
what is working dramatically
why hunger will become history in this century
Page 94
Page 95
Worldwide distribution of malnutrition
Over 20 million children suffer from acute malnutrition WHO.
Scientific American, Sept 2007
Page 96
Worldwide, nutritional inequities follow poverty
(as do health inequities & life expectancy)
• Globally, there is plenty of food for everyone but
…those who have more than they need find reasons
not to share
• The result – in the time you spend on this module
over 1000 children will have died of hunger
• Each day 1500 children go forever blind from lack of
vitamin A
• The poorest are 50-200x more likely to die in
pregnancy (more than half these deaths are
attributable to iron deficiency).
Note D
Page 97
“The bottom billion”
(title of a book by Paul Collier )
“The poorest of the poor” - Public health
nutritionists identify a subclass of the hungry those who try to survive on resources worth less
than $1 per day
• We define this subclass as people who don't
get enough to meet the ordinary demands of
life
• They lack the resources to earn a living, or
obtain what’s needed for normal, growth,
maintenance & reproduction
Page 98
“The bottom billion”
(title of a book by Paul Collier )
• Their lack of access to resources is such that a
significant fraction will be unable to stay alive
• They live mostly in isolated rural areas and most are
subsistence farmers
This means that what they eat this month is what they
can take out of the ground from last month's planting
Page 99
7 Malnutrition & MDGs: cause, effect, cure
3 slides:
1. Trends in nutrition, food security & globalization
2. Agricultural trends
3. Nutritional inequities - Cause & consequence
4. Food security; Prospects for having enough food
Page 100
Unhelpful misconceptions about aid
False: “Most aid money goes into the Swiss bank accounts
of corrupt African dictators”
“Aid creates dependence & impedes self-sufficiency”
“Despite all the aid $, the problems are only getting worse”
The truth is: Overwhelmingly African leaders are not
corrupt. When they are, most bribes come from the West
Well planned aid builds capacity & self-sufficiency
Overall, hunger worldwide is diminishing. MDGs go forward
because of the countries that honour their pledges!
Note E
Page 101
Page 102
Case study
• Note to authors : You could pose the case on a
PowerPoint slide, ask the student to address the question,
and then provide a supplementary note that reviews how the
case resolved, or could resolve. Several considerations:
– What actually happened?
– What factors should be considered, and their relative importance?
– Or how would you, the expert, approach answering the case? If you
opt for this response you can acknowledge that yours is just one
answer of many, that every situation is different, and that there is no
perfect answer
Page 103
Supplementary note
Note to authors : A “note” supplements the information provided on a slide. It allows the
author to provide additional text, graphics , case studies, or other resources about a topic
without filling the module with content likely to be of interest only to the more advanced or
curious learner. This slide and the next several slides are blank pages, without special
formatting. To provide a supplementary note scroll through the next several slides to see a
demonstration of how to provide a note. You can then select and erase these slides or insert
blank slides to provide a note. Do the following:
1) Prepare the slide to which you wish to append a supplementary note.
2) Immediately after that slide provide the note. Either draft the note text yourself or go to a source for
your note, select and copy it, and then paste it into a box on an otherwise blank slide. If your note is large,
paste it, select the entire note and reduce the font size so that it fits and then bring in the box margins so
that the note is contained on the slide. Add pictures or graphics as desired. When GHEC converts your
PowerPoint file into the module platform the note layout and font size will be formatted appropriately. If the
note is very long you can also provide it in a Word file, making it clear through letter codes, A, B, C, etc., the
PowerPoint slide to which it relates.
3) In processing the file GHEC will link the note to the appropriate slide and provide buttons for accessing
the note and returning to its reference slide. The following slides give examples of what can be done.
Page 104
Maternal mortality (Demonstration index slide for a note)
• Maternal health refers to the health of women during pregnancy,
childbirth and the postpartum period. While motherhood is often a
positive and fulfilling experience, for too many women it is associated
with suffering, ill-health and even death.
• The major direct causes of maternal morbidity and mortality include
hemorrhage, infection, high blood pressure, unsafe abortion, and
obstructed labor.
A click on the note
button takes viewer
to the note
Note button
Page 105
Supplementary note to the preceding slide
Every day, 1500 women die from pregnancy- or childbirthrelated complications. In 2005, there were an estimated 536
000 maternal deaths worldwide. Most of these deaths
occurred in developing countries, and most were avoidable.
(1) Improving maternal health is one of the eight Millennium
Development Goals adopted by the international community
at the United Nations Millennium Summit in 2000. In
Millennium Development Goal 5 (MDG5), countries have
committed to reducing the maternal mortality ratio by three
quarters between 1990 and 2015. However, between 1990
and 2005 the maternal mortality ratio declined by only 5%.
Achieving Millennium Development Goal 5 requires
accelerating progress.
Maternal mortality in 2005: estimates developed by WHO,
UNICEF, UNFPA and the World Bank. Geneva, World Health Organization,
2007 (http://www. who.int/reproductivehealth/publications/maternal_mortality_2005/index.html, accessed 14
August 2008).
Photo credits
Source:
http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html
Page 106
Supplementary note to the preceding slide
Source: http://www.who.int/making_pregnancy_safer/topics/maternal_mortality/en/index.html
Page 107
Supplementary note to a preceding slide
Why do mothers die?
Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these
complications develop because of their pregnant status and some because pregnancy aggravated an existing disease.
The four major killers are: severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery),
hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13%
of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of
maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia and
HIV.(2) Women also die because of poor health at conception and a lack of adequate care needed for the healthy
outcome of the pregnancy for themselves and their babies.
Page 108
Supplementary note to a preceding slide
Semmelweis's observations conflicted with the established scientific and medical opinions of the time. The theory of diseases was highly
influenced by ideas of an imbalance of the basic "four humours" in the body, a theory known as dyscrasia, for which the main treatment
was bloodlettings. Medical texts at the time emphasized that each case of disease was unique, the result of a personal imbalance, and
the main difficulty of the medical profession was to establish precisely each patient's unique situation, case by case.
The findings from autopsies of deceased women also showed a confusing multitude of various physical signs, which emphasised the
belief that puerperal fever was not one, but many different, yet unidentified, diseases. Semmelweis's main finding — that all instances of
puerperal fever could be traced back to only one single cause: lack of cleanliness — was simply unacceptable. His findings also ran
against the conventional wisdom that diseases spread in the form of "bad air", also known as miasmas or vaguely as "unfavourable
atmospheric-cosmic-terrestrial influences". Semmelweis's groundbreaking idea was contrary to all established medical understanding.
As a result, his ideas were rejected by the medical community. Other more subtle factors may also have played a role. Some doctors, for
instance, were offended at the suggestion that they should wash their hands; they felt that their social status as gentlemen was
inconsistent with the idea that their hands could be unclean.[6]:9[Note 7]
Specifically, Semmelweis's claims were thought to lack scientific basis, since he could offer no acceptable explanation for his findings.
Such a scientific explanation was made possible only some decades later, when the germ theory of disease was developed by Louis
Pasteur, Joseph Lister, and others.
During 1848, Semmelweis widened the scope of his washing protocol to include all instruments coming in contact with patients in labor,
and used mortality-rate time series to document his success in virtually eliminating puerperal fever from the hospital ward.
Note to authors: This page provides an
example of a long note associated with a
picture. The font and picture can be made
as small as necessary to fit on the slide.
They will be enlarged as necessary on the
processed note.
Page 109
Supplementary note -- Example of extensive text
Author note: You can copy/paste and reduce font size to put text in a slide. It will
later be converted by GHEC into a supplementary note
At a conference of German physicians and natural scientists, most of the speakers rejected his doctrine, including the celebrated Rudolf Virchow, who was a scientist of the highest authority of his time.
Virchow’s great authority in medical circles potently contributed to the lack of recognition of the Semmelweis doctrine for a long time.[13]
It has been contended that Semmelweis could have had an even greater impact if he had managed to communicate his findings more effectively and avoid antagonising the medical establishment, even
given the opposition from entrenched viewpoints.[18]
Page 110
Thought or discussion questions
• Note to authors: These can be very useful and may be
used at multiple locations. Two varieties:
– Thought question: This is a “stop and think” question that invites
the learner, before proceeding to the next slide, to think about the
question and perhaps provide a short answer. For example: “Before
going to the next slide take one minute to write down words or terms
that indicate the kinds of factors a donor organization will want to
consider when responding to a request for funding support by a
potential recipient.”
– Discussion question: This can be a more general question,
especially suitable for use when the module has been assigned prior
to a class.
Page 111
Special features
• Note to authors: We hope authors will make
use of some of the special features allowed in
PowerPoint and the following sections illustrate
several of them.
– Voiceovers
– Video and YouTube clips
– Hotlinks to other resources
• If you would like to use one or another of such
features but need assistance please let us
know.
Page 112
Audio voiceover
• This slide describes, and the following slide demonstrates,
an audio voiceover. You’ll need a microphone (low cost)
plugged into your computer.
– Click on the loudspeaker and hear brief text.
• Voiceovers allow you to comment or expand on a slide and,
in the process, ‘humanize’ your presence to the learner.
Clicking on the loudspeaker initiates the recording.
• Both the 2003 and 2007 versions of PowerPoint allow
voiceovers though the procedures are somewhat different.
Review the instructions and experiment a bit until you
master the technique. If you encounter problems we may
be able to help.
Page 113
Box 1 Five common shortcomings of
health-care delivery
Demonstration voiceover;
click on the loud speaker
The sound reproduction in
this example is not good. It
was done on the
microphone of a laptop. If
you can’t get good
reproduction then either
don’t use a voiceover or
ask your university’s IT
staff for help.
Inverse care. People with the most means – whose needs for
health care are often less – consume the most care, whereas
those with the least means and greatest health problems consume
the least10. Public spending on health services most
often benefits the rich more than the poor11 in high- and low income
countries alike12,13.
Impoverishing care. Wherever people lack social protection
and payment for care is largely out-of-pocket at the point of
service, they can be confronted with catastrophic expenses.
Over 100 million people annually fall into poverty because they
have to pay for health care14.
Fragmented and fragmenting care. The excessive specialization
of health-care providers and the narrow focus of many
disease control programmes discourage a holistic approach
to the individuals and the families they deal with and do not
appreciate the need for continuity in care15. Health services
for poor and marginalized groups are often highly fragmented
and severely under-resourced16, while development aid often
adds to the fragmentation17.
Unsafe care. Poor system design that is unable to ensure safety
and hygiene standards leads to high rates of hospital-acquired
infections, along with medication errors and other avoidable
adverse effects that are an underestimated cause of death
and ill-health18.
Misdirected care. Resource allocation clusters around curative
services at great cost, neglecting the potential of primary
prevention and health promotion to prevent up to 70% of the
disease burden19,20. At the same time, the health sector lacks
the expertise to mitigate the adverse effects on health from
other sectors and make the
Page 114
Quiz, format options – Author note
The next slides demonstrate six types of question options
that you can use as “pop ups” or as section and final quizzes.
Please provide your questions on individual slides inserted in
the location where you want the questions to appear. For
each question indicate the desired option style if not readily
apparent. Indicate which answer(s) are correct, and provide
short feedback answers that you want to appear when a
student’s response is not correct. Do not be concerned with
formatting; we will handle that at the time of assembling your
module.
Page 115
Quiz, format option 1
How many women die each year due to pregnancy-related
conditions?
a.
b.
c.
d.
e.
abc -- incorrect; correct answer is….
def -- incorrect; correct answer is….
ghi -- correct
jkl -- incorrect; correct answer is….
mno -- incorrect; correct answer is….
Page 116
Quiz, format option 2
Which two of the following answers are major risk factors for
pregnancy-related morbidity?
a.
b.
c.
d.
e.
abc -- incorrect; correct answers are….
def -- incorrect; correct answers are….
ghi -- correct
jkl -- incorrect; correct answers are….
mno -- correct
Page 117
Quiz, format option 3
Which word or phrase best fills in the blank?
_________ would be the most effective single measure to
reduce maternal morbidity due to hemorrhage?
a.
b.
c.
d.
e.
abc -- incorrect; correct answer is….
def -- incorrect; correct answer is….
ghi -- incorrect; correct answer is….
jkl -- incorrect; correct answer is….
mno -- correct
Page 118
Quiz, format option 4
Match each item on the left with the appropriate line on the right
•
•
•
•
•
•
Abc
Def
Ghi
Jkl
Mno
Pqr
•
•
•
•
•
•
123
456
789
987
654
321
Note: Be sure to indicate which items are linked
Page 119
Quiz option 5 – ranking
Rank the below answers starting from most important to least important
•
•
•
•
•
•
Abc
Def
Ghi
Jkl
Mno
Pqr
Note: Be sure to show the correct ranking
Page 120
Quiz option 6 – true/false
Indicate whether each answer is true or false. (When response is
incorrect a brief explanation as to why it is incorrect should be provided)
•
•
•
•
•
•
Abc [true]
Def [false]
Ghi [false]
Jkl [true]
Mno [true]
Pqr [false]
Page 121
Quiz
• Now we invite you to take the module quiz and
test your recent learning.
• This module quiz includes:
– [Add a brief reference to the respective
module quiz. How many questions, the type
and scope of questions, and any other
information and instruction for the students.]
• After completing your quiz, come back for the
summary of this module presentation.
Summary
• [Add content to your summary slide(s) ]
• [State what has been learned and if appropriate,
ways to apply the learning ]
• [Make sure you cover the most important points in
your module objectives…]
Page 123
Further readings & other resources
• Note to authors: Provide a listing, briefly
annotated if useful, of additional resources relevant
to the module’s topic. Especially useful are recent
journal reviews and good online material
• Source abc
• Source def
• Source ghi
• Source, etc.
Page 124
Acknowledgments
• Note to authors: This slide is for acknowledging
help received from persons and organizations that
were especially useful in preparating the module.
Named authors will not be listed on the “Credits”
slide
Page 125
Credits [for named authors; you can include contact
information if desired]
• [Add author 1 information]
• [Add author 2 information]
• [Add … ]
End of module
[Reserved for GHEC notes and
acknowledgment of donor organizations]
Structural elements &
instructions to authors
Page 128
Module parts (Delete this slide when no longer necessary)
•
Author note: This file provides a PowerPoint template for your module.
Duplicate each of the below template forms as necessary and replace the
illustrative text and figures with your own content. The template forms are:
– Title page
– Module goals
– List of module sections
– Learning objectives
– Section content
– Case study
– Supplementary note
– Thought or discussion questions
– Special features (voiceovers, video clips, etc.)
– Quiz (including several quiz options)
– Section or Module summary
– Further readings and other resources
– Acknowledgements
– Credits
Page 129
Module overview (Delete this slide when no longer necessary)
• Formatting. Template defaults are Tahoma 32 font for
slide titles and Arial 28, 24, and 20 fonts for lower levels of
text. Please use these defaults wherever possible but you
may deviate from them in individual slides as appropriate.
• Components. If your topic can be logically divided into
several major subtopics we suggest that each subtopic
have its own learning objectives, content, and if useful,
case study, quiz, and/or summary. Some of these
components may not be appropriate or would unduly
complicate or clutter your module and hence may be
omitted or modified to meet you needs.
Page 130
Module processing procedure (Delete this slide when
no longer necessary)
• Module submission. Send draft module to Tom Hall
(thall@epi.ucsf.edu) and to Glenn Nordehn
(gnordehn@gmail.com) for review. Use placeholder
slides, inserted immediately before the slides to which they
refer, to provide instructions for the use of special
eLearning features. Examples of such features are given
later in this file. GHEC will initiate the review process and
arrange for clarification of any questions that arise.
• Processing and posting. On completion of the initial
review and revision the module will be sent to an IT
specialist for processing your module into the appropriate
application platform and then posting on GHEC’s website.
Page 131
Module features (Delete this slide when no longer necessary)
• Your module can accommodate these features:
– PowerPoint-like slides with text, graphics and buttons that
will take viewers to supplementary notes & resources
– Ability to highlight by arrows, circles, colors or other
means selected features of any slide
– Voiceovers, in which you give audio explanations or
commentary of selected slides. Voiceovers allow you to
expand on a slide without using a lot of text.
– Video and YouTube clips. We can provide you with help
in how to add these features
– Pop quizzes and end-of-module quizzes that provide
answers, feedback and tabulation of correct answers
– Links to any URLs on the internet
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