Global and regional child mortality and burden of disease attributable to zinc deficiency.

BACKGROUND/OBJECTIVES: Zinc is an essential micronutrient and deficiency can lead to an increased risk for infectious diseases and growth retardation among children under 5 years of age. We aimed to estimate disease-specific and all-cause mortality attributable to zinc deficiency. SUBJECT/METHODS: We estimated the prevalence of zinc deficiency in Latin America, Africa and Asia, where based on zinc availability in the diet and childhood stunting rates, zinc deficiency is widespread. The relative risks of death among zinc-deficient children for diarrhea, malaria and pneumonia were estimated from randomized controlled trials. We used the comparative risk assessment methods to calculate deaths and burden of disease (measured in disability-adjusted life years, DALYs) from each of these three diseases attributable to zinc deficiency in these regions. RESULTS: Zinc deficiency was responsible for 453,207 deaths (4.4% of childhood deaths), and 1.2% of the burden of disease (3.8% among children between 6 months and 5 years) in these three regions in 2004. Of these deaths, 260,502 were in Africa, 182,546 in Asia and 10,159 in Latin America. Zinc deficiency accounted for 14.4% of diarrhea deaths, 10.4% of malaria deaths and 6.7% of pneumonia deaths among children between 6 months and 5 years of age. CONCLUSIONS: Zinc deficiency contributes to substantial morbidity and mortality, especially from diarrhea. Zinc supplementation provided as an adjunct treatment for diarrhea may be the best way to target children most at risk of deficiency.

Effects of bovine serum concentrate, with or without supplemental micronutrients, on the growth, morbidity, and micronutrient status of young children in a low-income, peri-urban Guatemalan community.

OBJECTIVE: To determine the effects of dietary supplements containing bovine serum concentrate (BSC, a source of immunoglobulins) and/or multiple micronutrients (MMN) on children's growth velocity, rates of common infections, and MN status. DESIGN: Randomized, controlled, community-based intervention trial. SETTING: Low-income, peri-urban Guatemalan community. SUBJECTS: Children aged 6-7 months initially. INTERVENTIONS: Children received one of four maize-based dietary supplements daily for 8 months, containing: (1) BSC, (2) whey protein concentrate (WPC, control group), (3) WPC+MMN, or (4) BSC+MMN. RESULTS: There were no significant differences in growth or rates of morbidity by treatment group. Children who received MMN had lower rates of anemia and (in the group that received WPC+MMN) less of a decline in serum ferritin than those who did not, but there were no differences in other biochemical indicators of MN status by treatment group. CONCLUSIONS: MMN supplementation reduced anemia and iron deficiency in this population, but the MMN content and source of protein in the supplements did not affect other indicators of MN status, growth or morbidity.

Chronic conditions and risk of in-hospital death.

OBJECTIVE: This study examined the relationship of in-hospital death and 13 conditions likely to have been present prior to the patient's admission to the hospital, defined using secondary discharge diagnosis codes. DATA SOURCES AND STUDY SETTING: 1988 California computerized hospital discharge abstract data, including 24 secondary diagnosis coding slots, from all general, acute care hospitals. STUDY DESIGN: The odds ratio for in-hospital death associated with each of 13 chronic conditions was computed from a multivariable logistic regression using patient age and all chronic conditions to predict in-hospital death. DATA EXTRACTION: All 1,949,276 general medical and surgical admissions of persons over 17 years of age were included. Patients were assigned to four groups according to the mortality rate of their reason for admission; some analyses separated medical and surgical hospitalizations. PRINCIPAL FINDINGS: Overall mortality was 4.4 percent. For all cases, mortality varied by chronic condition, ranging from 5.3 percent for coronary artery disease to 18.6 percent for nutritional deficiencies. The odds ratios associated with the presence of a chronic condition were generally highest for patients in the rare mortality group. Although chronic conditions were more commonly listed for medical patients, the associated odds ratios were generally higher for surgical patients, particularly in lower mortality groups. CONCLUSIONS: Studies examining death rates need to consider the influence of chronic conditions. Chronic conditions had a particularly significant association with the likelihood of death for admission types generally associated with low mortality rates and for surgical hospitalizations. The accuracy and completeness of discharge diagnoses require further study, especially relating to chronic illnesses.

Malnutrition and mortality during recent famines in Ethiopia: implications for food aid and rehabilitation.

The 1972-73 and 1984-85 famines varied significantly among different populations within famine areas at the regional, community and household levels. Political and social factors were crucial in this pattern. Evidence from both pastoral and farming areas indicates that the development of community-based resources may be less disruptive socially and economically and result in less morbidity and mortality than dependence on relief shelters. Areas needing further study are identified.

General theory of paradigms in health.

In Costa Rica, three sequential health paradigms have been identified over the last 50 years. The first began to develop during the 40's and has been called that of the deficiency diseases, since with a diachronic approach it placed excessive emphasis on malnutrition. The second began in 1970 and it is known as that of the infectious diseases, since through a holistic or synchronic approach, it underlined the importance of infections in high rates of morbidity and mortality. The third and last is the paradigm of the chronic diseases, it appeared in the 80's and is presently in process, doing battle with the chronic ailments, life styles, and environment, and it also utilizes a holistic approach. The recognition of these three paradigms has permitted Costa Rica a rapid advance in improving the health of its population, to the point that with a per capita outlay of $130 (US dollars), it has indices similar to those of the industrialized nations. This particular experience could be useful for other less-developed countries that are still applying the paradigm of the deficiency diseases.

PIP: Costa Rica's health care experience is explained in terms of 3 sequential paradigms. The 1st malnutrition paradigm (1940-69) considers the causes of ill health as poverty, ignorance, exploitation, and food shortages. The problems are malnutrition, parasitosis, infectious diseases, high mortality, high rates of hospitalization, and requiring health and hospital based services. The strategies were to improve diet through food distribution, create nutrition departments within the Ministries of Health, increase the number of doctors and nurses, and politicize medicine. Socialism was the model and economic growth and industrialization were seen as prerequisites. Curative medicine was practiced. The attitude was hopelessness is being able to solve problems and acceptance of the status quo. The 2nd infectious disease paradigm (the 1970s) focused the causes as infectious diseases, intestinal parasitosis, unwanted pregnancy, low birth weight, artificial feeding, and limited health services supply, which were given priority. Primary health care for all and health sector reform were some of the strategies. Healthier families were thought to contribute more to economic and social development. Full health services were promoted and the politicization of medicine was reduced. The attitude changed to one of being able to solve one's own problems. The National Health System began to evolve based on a holistic approach where the environment and the life cycle were integrated. Implementation of the national framework was replicated at the regional and local levels; institutions and programs were integrated in a synchronic approach so that the effects of infection, malnutrition, and fertility on human growth and development were considered. Infant mortality dropped by 70%, and infectious diseases were eliminated or greatly reduced. The 3rd chronic disease paradigm (1980s) assumes the causes to be unwanted children, insufficient prenatal and maternity care, inadequate environmental conditions, inadequate life style, and social pathology. The approach is holistic. The philosophical base is the development of individual responsibility and efficient use of science and technology; health contributes to democracy and peace. Prevention, cure, and rehabilitation are equal. The application to other countries must consider that there are more technological options but fewer resources. Rigid and dogmatic plans will not work.

Levels, trends, differentials and causes of child mortality-a survey.

This paper attempts to give an overview of current levels of child mortality prevailing in the world. It also examines trends and socioeconomic differentials in child mortality for selected countries and regions of the world. Lastly it reviews data on causes of child death and related environmental factors. The paper concludes that despite the fact that child deaths are frequently avoidable, mortality differentials between the developed and developing regions of the world are more pronounced in childhood (ages one to under five years) than at any other time of life. While some developing countries have substantially reduced the level of mortality in childhood, in others it remains very high. In contrast, in most developed countries child death rates are now so low, that they no longer serve as useful measures of public health.