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U. Ernesto, M.B. B.CH., M.B.B.Ch., Ph.D.

Clinical Director, University of Oklahoma School of Community Medicine

A poor quality diet anxiety 33625 generic emsam 5mg with visa, often due to limited intake of animal source food as well as fruits and vegetables anxiety symptoms weak legs order 5 mg emsam otc, is one of the main causes of multiple micronutrient deficiencies which do not occur in isolation anxiety from weed cheap 5mg emsam mastercard, but rather concurrently anxiety 12 year old boy buy cheap emsam 5 mg on line. Furthermore, poor bioavailability of nutrients and diets high in plant-based food containing constituents such as phytates and polyphenols limits the absorption of iron and other trace elements. It is therefore important to take the total health environment into account and to control and/or treat any underlying disease. Target population the most vulnerable segments of the population are pregnant and lactating women, infants, young children, and adolescent girls. Infancy is the age group in which micronutrient deficiencies start and progress with potentially severe consequences later in life, yet poor nutrition starts in utero. Thus, adequate nutrition and health status should receive high priority during both pregnancy and infancy. The message is clear: a life cycle approach is required, taking the diverse requirements of the different target populations into account. Recommended intake and composition of micronutrients For efficacy of interventions, the optimal dose and composition of micronutrients is still unknown. The potential risks of interactions have to be taken into account when food fortification or supplementation programs are initiated, especially when directed to population groups with a generally poor nutritional status. Different combinations and doses as well as new delivery forms of micronutrients still need to be investigated. Deliveries through the health system It is also important to take into account existing prevention programs such as high dose vitamin A, iron/folic acid supplementation, and parasitic disease and malaria control. These programs have to be integrated and monitored carefully in new clinical trials. Duration Long-term outcomes and effectiveness is not yet fully defined with regard to nutrition, health, and general wellbeing and should receive priority. Functional outcomes as true indicators of the effects are needed and should be addressed as endpoints in studies. So too it has been learned that food-based strategies such as biofortification and dietary diversification are also important. It would seem, that although often a specific angle is emphasized or an approach advocated, the key message should be that all the recognized and documented causes and intervention approaches must work together and that supplementation, fortification (food and home), biofortification, food-based approaches, and public health measures have to be viewed and practiced as complementary to one another. For the long-term success and sustainability of nutritional anemia control programs, all the factors and options must be viewed together as a whole and be adjusted to suit the specific local conditions and requirements. This highlights the view that a key hindrance to achieving the global goals is the fact that operational components of controlling iron deficiency anemia are less well developed in comparison to research and development efforts, and that neither of these are generally linked to communication, which includes political advocacy, funding, motivation for acceptance of better nutrition practices, health education, and promotion. In fact, the greatest challenge probably does not lie in the need for more scientific research, although there are still many unanswered questions and areas for new or renewed focus, but rather in communicating and interpreting the research findings and exceptions so as to fine tune programs. Advocacy communication needs to focus on the benefits throughout the life cycle and the associated impact of interventions on improving productivity, which ultimately lead to the economic uplift of both individuals and countries. What we need are effective bridges between science and technology, service providers and political as well as financial decision makers. The problem is not the lack of knowledge about tailored solutions but rather a lack of clear political and financial commitment to undertake interventions to match the magnitude of the problem. A good explanation could be the fact that the discussion has barely shifted over the years. Energy and Gender issues continue to revolve around women and cooking fuels, which has given rise to the misconception and misunderstanding that energy and gender issues could be eliminated just by improving electrification rates, without much or any consideration for gender. The effect of this oversimplification is that gender is rarely taken seriously when energy interventions are planned and implemented and, thus, interventions which should promote inclusive and sustainable development falls short of the mark. It is therefore necessary that planners of energy interventions recognize that energy is only relevant for the services it provides. And energy services (whether for lighting, motive power or recreation) has a gender dimension as the preferences for energy services differ depending on who is using it, what it is used for, when it is likely to be needed ­ in which, at the community or household level, gender roles, the differences and preferences feature significantly. Thus, aiming to improve energy access without a gender lens (that takes into consideration these gender roles, differences and preferences driven by the socio-cultural norms or characteristics in place) is missing an opportunity for maximizing the impact of interventions, especially in situations where accessibility, availability and affordability of energy services remain a critical challenge, and the gap between energy demand and supply is severe. Furthermore, planners of energy interventions must recognize that the energy sector is a job provider and an income generating avenue for economic empowerment and poverty eradication. Also, women and men, as beneficiaries of energy interventions, should be part of the dialogue. Meaning that they should be active participants in the design processes of energy programmes and projects that aim to "improve their lives"- either as participants in the consultation processes or part of those putting the project components together.

Studies of animals deficient in zinc showed a reduction of bone marrow erythroid precursors and in plasma erythropoietin in mice and rats anxiety 7 scoring interpretation discount emsam 5 mg otc, respectively (33­35) anxiety symptoms in young adults 5mg emsam with visa. The mechanism by which zinc alters erythropoiesis is not fully understood (Figure 8 anxiety disorder discount 5mg emsam fast delivery. Whether erythroid proliferation is compromised or there is an arrest on precursor differentiation with an increase in the rate of apoptosis requires further research anxiety symptoms knee pain 5 mg emsam. However, conflicting results have been obtained when this interaction has been evaluated using different delivery systems or food matrices. The negative interaction has been found solely when both microminerals were supplied in an aqueous or saline solution (38­41). However, the threshold dose at which zinc impairs iron absorption has not been well established. We conclude that the mechanisms involved in the interaction between zinc and Fe at the absorption level are not fully understood. It has also been demonstrated that large doses of zinc inhibit copper absorption and may produce copper deficit, which indirectly could affect iron status leading to anemia (Figure 8. However, a dose response curve for the effect of zinc has not been established at the usual level of exposure and it is unlikely that zinc conditions copper deficiency at low doses. However, zinc and copper have an antagonistic interaction within the enterocyte; this is mediated by their binding to metallothionein as a storage protein, a low-molecular- weight cysteine-rich protein that has a higher capacity to bind copper than zinc (49). When large doses of zinc are provided there is a mucosal block in copper transport and metallothionein expression is induced leading to a higher proportion of dietary copper being bound to metallothionein and stored within the enterocyte. Copper bound to metallothionein lost in the gut through mucosal cell shedding may thus represent a protective mechanism to prevent toxicity from high copper exposure. The public health relevance of these interactions may have been considered of limited relevance in the past. However recent studies have shown that combined Fe and zinc supplementation was less efficacious than single supplementation with Fe in reducing the prevalence of anemia and in improving Fe status (52­54). On the one hand, it should be noted that other studies have not confirmed this potentially detrimental effect (55­57). On the other hand, three studies performed in sub- Copper and zinc interactions in anemia 105 jects presumably deficient in Fe and zinc demonstrated a larger increase in hemoglobin after combined Fe and zinc supplementation than with either Fe or zinc supplementation alone (58­60). The role of copper and zinc in anemia of infectious disease Acute infections are a well-recognized cause of mild to moderate anemia. Nonspecific, cell-mediated and humoral immunity are depressed even in mild zinc deficiency (61­63). Main findings include a decrease in natural killer cell activity and depressed function of monocytes and macrophages and alteration of neutrophil phagocytosis. In addition to alterations to the immune system, zinc deficiency may also contribute to an increased susceptibility to pathogens by changing the morphology, integrity, and function of the intestinal and respiratory mucosa. Several studies have demonstrated an increased incidence of diarrhea and acute lower respiratory infection in zinc deficiency (64). Zinc supplementation improved immunity, reduced morbidity and mortality, and shortened the time to recovery from these acute infectious diseases (62­65). Additional studies suggest that zinc supplementation probably reduces the incidence of malaria (65). Lower rates of infectious diseases among infants born to zincsupplemented mothers have been demonstrated (66). In vitro studies have suggested that zinc inhibits the replication and/or binding of several viruses to cells, yet there is no conclusive evidence that zinc deficiency increases the incidence, duration or severity of viral infections including common cold (64, 67) (Figure 8. The immunosuppressive effect observed at very high doses of supplemental zinc may be explained in part by secondary copper deficiency induced by excess zinc (68). Neutropenia is a frequent clinical manifestation of copper deficiency (14, 18, 24, 69). Uauy humans have demonstrated that copper deficiency induces impaired phagocytic activity of neutrophils, decreases the proliferative response of peripheral blood mononuclear cells to mitogens, and reduces interleukin-2 production. It also restricts secretion of interleukin-2 receptors, a marker of early T cell activation (69­72). An increased frequency of severe lower respiratory infections has been described in copper-deficient infants (73). In the developing world iron deficiency coexists with micronutrient deficiencies and infection, and zinc and copper deficiencies could be a contributor factor in the increased frequency of infections (Figure 8.

Anemia measured by hemoglobin (g/dL) Anemia Children 6­59 months Children 5­11 years Children 12­14 years Non-pregnant women above 15 years Pregnant women Men (above 15 years) Mild Moderate Severe <11 anxiety symptoms every day buy emsam 5mg with amex. Iron is also found in many essential iron dependent enzymes and other biochemically active iron compounds anxiety symptoms gastrointestinal purchase emsam 5mg on line. During the second half of pregnancy the iron required cannot be easily met by diet (9) anxiety symptoms racing heart generic 5 mg emsam overnight delivery. Even most healthy women do not have sufficient body stores of iron only to support an average pregnancy anxiety symptoms yahoo purchase 5 mg emsam. Studies have shown that mild iron deficiency anemia among those who are not physically active the functional significance of iron deficiency 49 stores. The additional amount is essential and is very often well beyond that made available through common diets, especially those common for women in many developing countries. Even though pregnant women have been shown to absorb more iron from foods, a high prevalence of anemia during the third trimester of pregnancy has been consistently shown. In the United States approximately 30% of pregnant women from lower income groups are found to be anemic (11). Moderate (Hb 70­90 g/L) and severe (Hb <70 g/L) anemia are associated with increased maternal and child mortality and infectious diseases (12). Increased risk of maternal death may be related to several factors, including cardiac failure during labor with severe anemia to lower tolerance of hemorrhagic blood loss during childbirth. Moderate to severely anemic pregnant women also appear to have slower healing times and increased risk of infection. Based on epidemiologic studies, anemia during early pregnancy has been associated with preterm (13, 14) and low birth weight; both factors are associated with greater risk of fetal and neonatal death. Favorable pregnancy outcomes occur 30­45% less often in anemic mothers, and infants of anemic mothers are less likely to have normal iron reserves (5). In summary, a pregnant woman who is anemic has a significantly higher risk of maternal mortality, prenatal infant loss, and prematurity. Her infant is at greater risk of death, and is more likely to be below normal birth weight and to be born with poorer iron stores. Such an infant is more likely to become iron deficient and anemic before six months of age. Depending on the age at which anemia occurs and its severity, some developmental deficits can be improved or even corrected with iron treatment, but with iron deficiency in infancy some cognitive and social differences can remain permanent (15). The risk of iron deficiency is high during infancy because only about 50% of the iron requirement of a normal six month old can be obtained from breast milk, and by this age the stores received at birth are likely to have been used to support normal functions and growth even in children born at term of well nourished mothers. If the mother is anemic and/or the child is of low birth weight, the stores are depleted much earlier. Where well fortified infant cereals are available and affordable, they provide the required iron, as does iron fortified infant formula. Scrimshaw 18 16 Anemia 14 Means +/- 2 Standard deviations Hemoglobin levels 12 10 8 5 <1 12 13 14 15 16 17 18 19 20 21 22 23 24 10 11 2 3 4 5 6 7 8 9 One month age cohorts Figure 5. Cohorts of children selected by months of age from 6­24 months from more than 31,000 children for which hemoglobin had been measured found approximately 50% anemia among cohorts of children in each montly age group (see Figure 5. For infants younger than six months, especially in developing countries, several factors may lead to an iron status inadequate for normal growth and development. Studies have also found the infants of mothers suffering from anemia during pregnancy have lower iron stores at birth. Cutting the pulsing umbilical cord before iron rich cord blood is transferred to the newborn also results in lower iron in the infant at birth. Low birth weights account for up to 20% of infants in poorly nourished populations, and these infants receive low levels of iron stores based on lower overall tissue and blood volume at birth. A positive association between iron status and performance was also found in a large double blind study of 1,358 children 9­11 years the functional significance of iron deficiency 51 old in Thailand (21), where schoolchildren who were anemic had significantly lower scores in Thai language mathematics and other subjects than iron replete children. However, in this study there was no significant improvement following 14 weeks of daily iron supplementation that restored hemoglobin levels to normal. It was suggested that their iron deficiency as schoolchildren reflected the iron deficiency that they had suffered in infancy. Iron deficiency is disadvantageous to achievement of schoolchildren in various environments and across cultural groups, with serious implication for the effectiveness of education in many developing countries.

Fourteen months later anxiety reduction techniques buy discount emsam 5mg on-line, the child still has developmental delay but remains free of seizures off all antiepileptic medication anxiety symptoms for teens cheap emsam 5mg otc. Lesions were congenital or perinatal in 75% of patients anxiety symptoms 3 weeks cheap emsam 5 mg with amex, and acquired within the first 2 years of life or earlier in 90% anxiety symptoms brain fog order 5 mg emsam. A: Sagittal magnetic resonance image showing focal malformation of cortical development cerebral dysgenesis (black arrow) in the left posterior frontal lobe extending across the central sulcus (white arrow) into the anterior portion of the postcentral gyrus. The boy was 4 months old at the time of the magnetic resonance imaging, with intractable daily seizures since the first day of life after an uncomplicated full-term delivery. Seizures involved clonic jerking of the right arm and leg, with eye deviation toward the left, or opisthotonic posturing with stiffening and extension of all extremities. Ictal and interictal epileptiform discharges were localized to the left central region. Moderately severe right hemiparesis and mild developmental delay were also present. Prior to resection, electroencephalographic seizure was recorded over the lesion with intraoperative electrocorticography, and primary hand motor cortex was identified in the same area by intraoperative cortical stimulation. Postoperatively, the hemiparesis was transiently minimally worse, returning to preoperative baseline within days. Twenty-two months later, the child is making developmental progress and has had no seizures on a reduced dose of antiepileptic medication. Fourth, children may require sedation on two occasions to obtain interictal and ictal scans. Hippocampal sclerosis, the most common etiologic factor in adult candidates for epilepsy surgery, is uncommon in children. In a multicenter, predominantly adult series (2), 73% of 5446 epilepsy surgeries (excluding corpus callosotomies) were performed for nonlesional temporal lobe epilepsy, including hippocampal sclerosis. A: Axial magnetic resonance image at age 12 months, showing Sturge­Weber malformation with left hemispheric atrophy and pial angiomatosis. Starting at age 2 months, seizures occurred once or twice per day characterized by jerking of the right arm or decreased behavioral activity with bilateral eye blinking and lip smacking. Physical examination revealed right hemiparesis, right hemianopia, and developmental delay. Ictal and interictal epileptiform abnormalities were seen in multiple areas of the left hemisphere. B: Sagittal (left) and coronal (right) magnetic resonance images showing the left hemispheric disconnection performed at age 12 months. No seizures occurred during the 8 months since surgery on a reduced dose of antiepileptic medications. Surgery did not worsen neurologic deficits, and the child has progressed developmentally. B from the Cleveland Clinic Foundation (3), hippocampal sclerosis was the cause in only 12% of 62 children (3 months to 12 years of age) and in 15% of 74 adolescents (13 to 20 years of age). Although hippocampal sclerosis may begin in childhood, the typical presentation for surgical evaluation is in early adulthood. However, pediatric patients appear to have an especially high incidence of dual pathology with cortical dysplasia in addition to the hippocampal sclerosis (46). In pediatric candidates, the predominant etiologic factors are focal, multilobar or extensive hemispheric malformation of cortical development (cortical dysplasia). These were the cause of the epilepsy in 57% of adolescents, 70% of children, 90% of infants younger than 3 years in the Cleveland Clinic series (3), and 90% of infants treated surgically in the series of Duchowny and colleagues (1). Less common causes are vascular malformation, arachnoid cyst, and localized injury due to infarction, trauma, or infection (1,3). Hemispheric syndromes are also important etiologies in children undergoing epilepsy surgery in the form of hemispherectomy (47). The age-related differences in etiology result in an agerelated spectrum of surgical procedures. In pediatric series, extratemporal or multilobar resections or hemispherectomies composed 44% of the surgeries in adolescents, 50% in children, and 90% in infants (1,3). However, for each of these factors, age-related issues must be considered in light of results from an extensive presurgical evaluation.