Who is nutritionally vulnerable in Bosnia-Hercegovina?

Impact of armed conflict on cardiovascular disease risk: a systematic review

OBJECTIVES

Prolonged armed conflict may constrain efforts to address non-communicable disease in some settings. We assessed the impact of armed conflict on cardiovascular disease (CVD) risk among civilians in low/middle-income countries (LMICs).

METHODS

In February 2019, we performed a systematic review searching Medline, Embase, PsychINFO, Global Health and Web of Science without language or date restrictions. We included adult, civilian populations in LMICs. Outcomes included CVDs and diabetes, and eight clinical and behavioural factors (blood pressure, blood glucose, lipids, tobacco, alcohol, body mass index, nutrition, physical activity). We systematically reanalysed data from original papers and presented them descriptively.

RESULTS

Sixty-five studies analysed 23 conflicts, and 66% were of low quality. We found some evidence that armed conflict is associated with an increased coronary heart disease, cerebrovascular and endocrine diseases, in addition to increased blood pressure, lipids, alcohol and tobacco use. These associations were more consistent for mortality from chronic ischaemic heart disease or unspecified heart disease, systolic blood pressure and tobacco use. Associations between armed conflict and other outcomes showed no change, or had mixed or uncertain evidence. We found no clear patterning by conflict type, length of follow-up and study quality, nor strong evidence for publication bias.

CONCLUSIONS

Armed conflict may exacerbate CVDs and their risk factors, but the current literature is somewhat inconsistent. Postconflict reconstruction efforts should deliver low-resource preventative interventions through primary care to prevent excess CVD-related morbidity and mortality.

PROSPERO REGISTRATION NUMBER

CRD42017065722.

Methods of nutrition surveillance in low-income countries

BACKGROUND

In 1974 a joint FAO/UNICEF/WHO Expert Committee met to develop methods for nutrition surveillance. There has been much interest and activity in this topic since then, however there is a lack of guidance for practitioners and confusion exists around the terminology of nutrition surveillance. In this paper we propose a classification of data collection activities, consider the technical issues for each category, and examine the potential applications and challenges related to information and communication technology.

ANALYSIS

There are three major approaches used to collect primary data for nutrition surveillance: repeated cross-sectional surveys; community-based sentinel monitoring; and the collection of data in schools. There are three major sources of secondary data for surveillance: from feeding centres, health facilities, and community-based data collection, including mass screening for malnutrition in children. Surveillance systems involving repeated surveys are suitable for monitoring and comparing national trends and for planning and policy development. To plan at a local level, surveys at district level or in programme implementation areas are ideal, but given the usually high cost of primary data collection, data obtained from health systems are more appropriate provided they are interpreted with caution and with contextual information. For early warning, data from health systems and sentinel site assessments may be valuable, if consistent in their methods of collection and any systematic bias is deemed to be steady. For evaluation purposes, surveillance systems can only give plausible evidence of whether a programme is effective. However the implementation of programmes can be monitored as long as data are collected on process indicators such as access to, and use of, services. Surveillance systems also have an important role to provide information that can be used for advocacy and for promoting accountability for actions or lack of actions, including service delivery.

CONCLUSION

This paper identifies issues that affect the collection of nutrition surveillance data, and proposes definitions of terms to differentiate between diverse sources of data of variable accuracy and validity. Increased interest in nutrition globally has resulted in high level commitments to reduce and prevent undernutrition. This review helps to address the need for accurate and regular data to convert these commitments into practice.

Variations in Disaster Preparedness by Mental Health, Perceived General Health, and Disability Status

Objectives:Chronic medical and mental illness and disability increase vulnerability to disasters. National efforts have focused on preparing people with disabilities, and studies find them to be increasingly prepared, but less is known about people with chronic mental and medical illnesses. We examined the relation between health status (mental health, perceived general health, and disability) and disaster preparedness (home disaster supplies and family communication plan).

Methods:A random-digit-dial telephone survey of the Los Angeles County population was conducted October 2004 to January 2005 in 6 languages. Separate multivariate regressions modeled determinants of disaster preparedness, adjusting for sociodemographic covariates then sociodemographic variables and health status variables.

Results:Only 40.7% of people who rated their health as fair/poor have disaster supplies compared with 53.1% of those who rate their health as excellent (P< 0.001). Only 34.8% of people who rated their health as fair/poor have an emergency plan compared with 44.8% of those who rate their health as excellent (P< 0.01). Only 29.5% of people who have a serious mental illness have disaster supplies compared with 49.2% of those who do not have a serious mental illness (P< 0.001). People with fair/poor health remained less likely to have disaster supplies (adjusted odds ratio [AOR] 0.69, 95% confidence interval [CI] 0.50–0.96) and less likely to have an emergency plan (AOR 0.68, 95% CI 0.51–0.92) compared with those who rate their health as excellent, after adjusting for the sociodemographic covariates. People with serious mental illness remained less likely to have disaster supplies after adjusting for the sociodemographic covariates (AOR 0.67, 95% CI 0.48–0.93). Disability status was not associated with lower rates of disaster supplies or emergency communication plans in bivariate or multivariate analyses. Finally, adjusting for the sociodemographic and other health variables, people with fair/poor health remained less likely to have an emergency plan (AOR 0.66, 95% CI 0.48–0.92) and people with serious mental illness remained less likely to have disaster supplies (AOR 0.67, 95% CI 0.47–0.95).

Conclusions:People who report fair/poor general health and probable serious mental illness are less likely to report household disaster preparedness and an emergency communication plan. Our results could add to our understanding of why people with preexisting health problems suffer disproportionately from disasters. Public health may consider collaborating with community partners and health services providers to improve preparedness among people with chronic illness and people who are mentally ill. (Disaster Med Public Health Preparedness. 2009;3:33–41)

Inadequacy of nutrients intake among pregnant women in the deep south of Thailand

BACKGROUND

The deep south of Thailand is an area which has been affected by violence since 2004, yet the concurrent coverage of antenatal care has remained at over 90%. Our study aimed to describe the prevalence of nutrient inadequacy among pregnant women who attended antenatal care clinics in hospitals in the study area and assess factors associated with nutrient inadequacy.

METHODS

Pregnant women from four participating hospitals located in lower southern Thailand were surveyed during January-December 2008. Nutrient intake was estimated based on information provided by the women on the amount, type and frequency of various foods eaten. Logistic regression was used to assess individual and community factors associated with inadequate nutrient intake, defined as less than two thirds of the recommended dietary allowance (RDA).

RESULTS

The prevalence of carbohydrate, protein, fat, calories, calcium, phosphorus, iron, thiamine, riboflavin, retinol, niacin, vitamin C, folic acid and iodine inadequacy was 86.8%, 59.2%, 78.0%, 83.5%, 55.0%, 29.5%, 45.2%, 85.0%, 19.2%, 3.8%, 43.2%, 0.8%, 0.0% and 0.8%, respectively. Maternal age, education level, gestational age at enrollment and pre-pregnancy body mass index and level of violence in the district were significantly associated with inadequacy of carbohydrate, protein, phosphorus, iron, thiamine and niacin intake.

CONCLUSIONS

Nutrient intake inadequacy among pregnant women was common in this area. Increasing levels of violence was associated with nutrient inadequacy in addition to individual factors.

Public health and nutrition after the Spanish Civil War. An intervention by the Rockefeller Foundation

We describe a nutritional intervention by the Rockefeller Foundation's International Health Division in Spain after the Spanish Civil War, delineating the relationships between the technicians sent by the Rockefeller Foundation and the Spanish health authorities. We analyze reports of the nutritional situation in Spain in the early 1940s and the design and outcomes of a nutrition survey conducted in a district of Madrid by American and Spanish nutritionists. This nutritional survey, which was based on food intake interviews and was complemented with anthropometric measurements, clinical examinations, and blood tests, found several symptoms and signs of malnutrition. The Rockefeller Foundation's nutritional research was an important historical precedent for later studies made in emergency situations or armed conflicts. Similar surveys have been carried out in the last several decades by distinguished academic departments of public health and epidemiology and by humanitarian aid agencies.

Identifying nutritionally vulnerable groups in case of emergencies: experience from the Athens 1999 earthquake

During emergency situations in developing countries, young children have been identified as the most nutritionally vulnerable group. Comparatively less is known regarding nutritional risk of individuals in well-nourished societies hit by a major disaster. The aim of the present study, therefore, was to assess the nutritional status of Greek people who were left homeless after the Athens 1999 earthquake. A total of 225 volunteers from two camps were surveyed for dietary intake information and surrogate measures of nutritional status. Energy consumption and anthropometric indices of the children and adolescents revealed no sign of undernourishment. On the other hand, adults and the elderly consumed considerably less energy than that required for long-term preservation of health. Short-term energy and protein deficits, however, did not jeopardise their nutritional status as it might have expected, on the basis of high body mass indexes and normal haematological and biochemical profiles that were documented. In conclusion, the results of the present study indicate that nutritional risk in the acute phase after a major emergency in a previously well-nourished population is rather low. This is especially true for younger individuals, probably due to increased provision from the family and the community. Nevertheless, older persons may face increased risk as the situation is prolonged.

Minimizing the Impact of Complex Emergencies on Nutrition and Geriatric Health: Planning for Prevention is Key

Complex emergencies (CEs) can occur anywhere and are defined as crisis situations that greatly elevate the risk to nutrition and overall health (morbidity and mortality) of older individuals in the affected area.

In urban areas with high population densities and heavy reliance on power-driven devices for day-to-day survival, CEs can precipitate a rapid deterioration of basic services that threatens nutritionally and medically vulnerable older adults.

The major underlying threats to nutritional status for older adults during CEs are food insecurity, inadequate social support, and lack of access to health services.

The most effective strategy for coping with CEs is to have detailed, individualized pre-event preparations. When a CE occurs, the immediate relief efforts focus on establishing access to food, safe water, and essential medical services.

Nutritional status and functional ability of the elderly aged 60 to 90 years in the Mpigi district of central Uganda

OBJECTIVES

This study assessed the nutritional status of the elderly and their functional ability because poor nutritional status in the elderly is associated with poor functional ability.

METHODS

Anthropometric measurements, demographic and socioeconomic data, dietary assessment by a food frequency list, and activities of daily life data were collected cross sectionally in 2002. Participants (n = 100) were randomly selected and the response rate was 95.2%.

RESULTS

The overall prevalences of undernutrition were 33.3% based on body mass index (<18.5 kg/m(2)) and 52% based on mid-upper arm circumference (<24 cm). There was a large, significant difference between prevalences of malnutrition by sex: 68% of women were undernourished (body mass index < 18.5 kg/m(2)) compared with 32.4% of men. Dietary assessment showed that intake of fish, cereals, vegetables, tubers, and legumes was moderate (three to six times/wk). Evaluation of the ability of elderly people to perform basic activities of daily living showed that 33% of subjects were independent in all activities of daily living, except for mobility and feeding. The relation between body mass index and variables associated with functional ability were significant with regard to mobility, continence, and feeding (P < 0.05).

CONCLUSION

This study found that a large percentage of older men and women are malnourished. This influenced their daily activities, especially mobility and feeding. The elderly need to be incorporated into health programs and policy.

Public nutrition in complex emergencies

Public nutrition is a broad-based, problem-solving approach to addressing malnutrition in complex emergencies that combines analysis of nutritional risk and vulnerability with action-oriented strategies, including policies, programmes, and capacity development. This paper focuses on six broad areas: nutritional assessment, distribution of a general food ration, prevention and treatment of moderate malnutrition, treatment of severe malnutrition in children and adults, prevention and treatment of micronutrient deficiency diseases, and nutritional support for at-risk groups, including infants, pregnant and lactating women, elderly people, and people living with HIV. Learning and documenting good practice from previous emergencies, the promotion of good practice in current emergencies, and adherence to international standards and guidelines have contributed to establishing the field of public nutrition. However, many practical challenges reduce the effectiveness of nutritional interventions in complex emergencies, and important research and programmatic questions remain.

Nutritional risk factors for older refugees

This study describes risk factors for poor nutrition among older Rwandan refugees. The most important areas of nutritional risk for older refugees are: physical ability and mobility; income and access to land; access to appropriate food rations; meeting basic needs such as water, fuel, shelter; equal access to essential services (food distribution, health services, mills, feeding programmes); and psycho-social trauma. Women and older elderly (> 70 years) are significantly more often in disadvantaged positions, such as having poor socio-economic status, poor health, poor mobility, lower food intake, diminished social status, respect and social network. Older refugees are at higher risk than younger refugees and at higher risk than older people in stable situations. They should remain in good nutritional and general health for their own well-being and that of their dependants. In addition to an adequate diet, a support network seems to be an important preventive aspect.

The association between nutritional status and handgrip strength in older Rwandan refugees

OBJECTIVES

To investigate the association between nutritional status and handgrip strength in older Rwandan refugees.

DESIGN

Cross-sectional study.

SETTING

Rwandan refugee camp located in Karagwe district in the north-west of Tanzania. The study was carried out in the post-emergency phase. The response rate was 85%.

SUBJECTS

A total of 413 men and 415 women aged 50-92 y participated in the study.

METHODS

Weight, height, mid-upper-arm circumference (MUAC) and triceps skinfold were obtained using standard techniques. For people with visible kyphosis, height was estimated from armspan using regression equations developed from non-kyphotic subjects within the sample. Handgrip was measured using a mechanical handgrip dynamometer. Information regarding physical activity and health status was obtained by interview and clinical screening.

RESULTS

Handgrip strength (kg) was significantly higher in men than in women (30.3+/-6.7 vs 22.3+/-5.1), and significantly lower in each older age group in both sexes. Handgrip strength was positively correlated to BMI (body mass index) and AMA (arm muscle area). The relative risk of impaired handgrip strength in individuals with poor nutritional status (BMI<18.5 kg/m(2)) compared with those of adequate nutritional status was 1.75. After controlling for potential confounders (sex, age and height), BMI remained a significant contributor to the variation in handgrip strength.

CONCLUSION

Poor nutritional status is associated with poor handgrip strength independent of sex, age and height, in this refugee population. This may indicate that underweight older people are likely to have more difficulties in functioning independently in the community. Research is needed to investigate if improving nutritional status can lead to better functional ability.

SPONSORSHIP

Department for International Development (UK) and HelpAge International.

Nutrition among older adults in Africa: the situation at the beginning of the millenium

Most Africans enter old age after a lifetime of poverty and deprivation, poor access to health care and a diet that is usually inadequate in quantity and quality. However, nutrition interventions in African countries are directed primarily toward infants and young children, as well as pregnant and lactating women. This situational analysis focuses on two key areas to identify priorities for future research and policy development: the nutritional status of older Africans and determinants of undernutrition. Based on the scant evidence available, the prevalence of undernutrition is high in older African men (9.5-36.1%) and women (13.1-27%); however, in some urban areas there is evidence that older adults are experiencing the nutrition transition. Information on micronutrient status is sparse, yet it appears that anemia related to suboptimal folate status is a particular problem. Important determinants of poor nutritional status in the elderly in the African context include inadequate household food security, war and famine, and the indirect impact of HIV infection and AIDS. The rapidly increasing size of the older population, combined with their increased burden of care-giving responsibilities and severe socioeconomic hardship, indicates an urgent need for increased attention to this group, including applied research on nutrition problems and the development and evaluation of nutrition interventions.

Complex humanitarian emergencies: a major global health challenge

Complex humanitarian emergencies have been a major political, security and public health feature of the post-Cold War world. These man-made disasters account for more morbidity and mortality than all natural and technological disasters combined. In order to deliver effective aid during complex humanitarian emergencies, international relief agencies must have a solid understanding of the political and social climates in which they are operating. In addition, they should base their health interventions on objective epidemiological data, especially standardized rates of morbidity and mortality. Most deaths during complex humanitarian emergencies are due to preventable causes, especially increased rates of infectious diseases malnutrition and violent trauma. The most appropriate health interventions are therefore based on the models of public health and primary health care, emphasizing disease prevention and health promotion. The field of humanitarian assistance has become increasingly professionalized in recent years, with its own professional standards, literature, research agenda and training opportunities. It is an unfortunate reflection on the current state of international affairs that the number of complex humanitarian emergencies and the enormous levels of suffering associated with them are unlikely to decline in the foreseeable future.

The nutritional status of older Rwandan refugees

OBJECTIVE

To assess the nutritional status of older people in an unstable situation.

DESIGN

Anthropometric and socioeconomic data were collected cross-sectionally. Body mass index (BMI), arm muscle area (AMA) and arm fat area (AFA) were calculated to evaluate nutritional status. For 41 subjects with kyphosis, height was estimated from arm span using sex-specific regression equations from the non-kyphotic group.

SETTING

The study was carried out in the post-emergency phase in a Rwandan refugee camp in Karagwe district, north-west Tanzania.

SUBJECTS

Measurements were obtained from 413 men and 415 women aged 50-92 years.

RESULTS

The prevalence of undernutrition (BMI < 18. 5) was 19.5% in men and 13.1% in women and was higher above age 60 years in both sexes: in men the prevalences were 23.2% and 15.0% (P < 0.05) and in women 15.1% and 10.9% for the older and younger age groups respectively. AMA, which is important in relation to the ability to remain active and independent, was also significantly lower in older age groups. No difference was found in AFA. The proportion with low BMI was much higher in the group with kyphosis.

CONCLUSIONS

Even in this population of older Rwandans who managed to reach the camp and survive in exile for more than a year, undernutrition does occur and is more prevalent at an advanced age. The higher prevalence of undernutrition in kyphotic people illustrates the importance of including this group in nutritional status assessments.