All-for-Health: Health-for-All    
All-for-Health: Health-for-All Michael Golden 25.03.98
Re: "All-for-Health: Health-for-All Linley Karltun 26.03.98
Re: "All-for-Health: Health-for-All" Deepti Chirmulay 27.03.98

Date: Wed, 25 Mar 1998 09:17:22 +0000

From: Michael Golden

Subject: Ngonut: "All-for-Health: Health-for-All"


Dear Ngonuts,

The comment by James Olsen for UNICEF, kindly forwarded by Joanne Csete is important. I think that it is also a specific instance of a general consideration in terms of nutritional requirements of those who live in a contaminated environment.

Aflatoxin, other mycotoxins, bacteria and their endotoxins are common in food throughout much of the world, particularly where there is poverty, where cheaper foods are of necessity eaten, where spoiled foods are not discarded, where fuel is scarce and where foods are kept from one meal to the next.

Aflatoxin is metabolized by the enzyme system in the liver (in a single electron step) to give a free-radical called an epoxide which is the metabolite which damages the constituents of cells and may damage DNA. In theory the anti-oxidant status of the person taking the toxin will determine whether it does damage or not: hence the importance of vitamin A and carotene. But what about the other anti-oxidants? Vitamin E, selenium, sulphur-containing amino acids (to make glutathione), vitamin C are also likely to be important in this regard; certainly, they will protect against other damaging toxins that are inevitably ingested by the poor. And yet we think about vitamin C, for example, only in its ability to prevent outbreaks of overt scurvy. Scurvy is the result of loss of a different action of vitamin C (as a reducing agent in the cross-linking of elastin and collagen) not of the loss of this anti-oxidant function. The anti-oxidant function is lost at a level where there will be no scurvy!

And we routinely ignore vitamin E and selenium etc in our nutritional assessments. Selenium, for example, is likely to be low where-ever there is iodine deficiency (leaching), where the soil contains a lot of iron (unavailable to plants) and "red dirt" is very common, where there is a water-logged soil (very common in the wet tropics), and yet it is ignored.

A combined Iodine/selenium deficiency gives a much bigger goiter and a much worse thyroid status than single I deficiency because selenium is needed to convert thyroxine into its more active metabolite - data which is well know and ignored by public health nutritionists. Vitamin E is likely to be even more precarious in all those who have a low fat diet and vitamin A deficiency, because there is no precursor for vitamin E, analogous to carotene. These are some of the "forgotten nutrients" that are critical to health, and their status has not been investigated.

However, the main point I wish to make is in terms of "requirements". We generally think of requirements in terms of the physiological experiments that have been made in the rich countries on normal volunteers, deliberated by expert domestic committees and published for these populations. We then extrapolate these requirements to those in the developing world. But if I am living in a world with ubiquitous fungal and bacterial contamination of my food, high levels of insecticides coming from my bed net or sprayed onto my walls (if I am lucky), high chlorine levels in my water (if I am lucky): and I also have the chronic stress of malarial parasites, intestinal helminths, schistosomes in my liver or bladder and entamoeba in my colon, then what is my requirement for the anti-oxidant nutrients, including vitamin A and carotene? I would suggest that the "requirement" for all these nutrients is much higher if one lives in a contaminated environment than if one lives in Cambridge (either UK or MIT). The answer is that we do not know how much higher this requirement is. Why is this not on the research agenda? What is the metabolism of vitamin C is someone with schistosomiasis for example? In the meantime I think that it would be prudent to increase the RDAs for these "protective" nutrients by a factor (how much?) for those areas of the world where additional protection is almost certainly desirable. Such "factors" have been added to trace element requirements for those eating high phytate/fibre diets, in the recent WHO publication, but additional needs for "protection" were not included. Perhaps the forthcoming WHO committee on vitamins will address this point.

I also think that there is a lot more to good nutritional health than giving extra vitamin A, iodine and iron - nutrients chosen largely on the basis of having overt and easily recognised clinical signs. They are critically important - but then so are the ignored nutrients. I also think that many of the vehicles for fortification that are being developed for A,I,Fe should be used to carry more than one nutrient that is commonly deficient - there is lots of data to suggest that about 20% have folate deficiency and up to 50% riboflavin deficiency, but we cannot easily see this in clinical signs. Reading reviews I am saddened by the opening sentence of many dealing with specific nutrient deficiencies where the claim is made, for that nutrient, that its deficiency is "the most important" in the world. The only nutrients that are really important to me and the ones that I do not have - in truth most poor people have multiple deficiencies and they are all important for health.

I propose that "All-for-Health: Health-for-All" should be the nutritionists slogan - smile


Best wishes,

Prof. Michael H.N.Golden | INTERNET Dept of Medicine and Therapeutics | Tel +44 (1224) 681 818 ext 52793/53014 Univ of Aberdeen, Foresterhill | Tel(direct) +44 (1224) 663 123 527 93

AB9 2ZD. Scotland, (UK) | Fax +44 (1224) 699 884

Date: Thu, 26 Mar 1998 18:56:29 +0000

From: Linley Karltun

Subject: Re: Ngonut: "All-for-Health: Health-for-All"


Dear Ngonuts,

The comments made by Mike Golden with regards to aflatoxins, mycotoxins and bacteria being common in foods especially where poverty prevails should not be taken lightly.

I vividly recall how difficult it was for us to throw away the mouldy groundnuts when I was growing up in rural Malawi. One pounded them anyway and threw them in the relish just to get a flavour of fat and a variation from green vegetables cooked only with salt. In the course of doing fieldwork in rural Malawi, I have observed that this practice is till going on. This is not because of ignorance but because of poverty, the scarcity of groundnuts and the cost of alternative products such as oils when on the market when and if available.

Some of these problems are exacerbated by the lack of proper post-harvest storing facilities. A classical example in Malawi is the poor maize granaries. By the time two months or more have gone by, stored maize kernels have started to mould or weevils and other pests have attacked them. You will not find people throwing away food because there lives depend on it. There has been strong propagation for the use of pesticides such as "acteric" for storing foods such as beans and maize, however with the larger part of the population being illiterate there is no telling what sort of mistakes are being made.

In an earlier communcation to all NGONUTS, Claudio Schuftan MD had some food for thought titled INCOME GENERATION ACTIVITIES FOR WOMEN,THE NINTH ESSENTIAL ELEMENT OF PRIMARY HEALTH CARE?: AN IDEA WHOSE TIME HAS COME! I couldn't agree more with him. For far too long has "health implied in it its simplest form, health care". There is more and more evidence especially with the use of qualitative research methods, showing that not only is the role of women crucial, but also non-health activities, as bizzare as they may sometimes look and sound.

All-for Health: Health -for-All, it doesn't sound bad at all and can we practice it?

Kind regards,


Linley Chiwona-Karltun

Department of Public Health Sciences

Division of International Health Care Research SE-171 76 STOCKHOLM SWEDEN

Telephone: +46 8 5177 6493 OR +46 18 471 2217 Fax: +46 8 311590 OR +46 18 559505

Date: Fri, 27 Mar 1998 18:13:14 +0000

From: BAIF

Subject: Re: "All-for-Health: Health-for-All"


Dear NGOnuts,

It's time 'Health for all' is practiced! There is enough talk about integrated action for health / nutrition / women's development and even child CARE. However, when it comes to policy and programme design, it is always sectoral with no provision for linkages across sectors. Even the impacts are measured in terms of sectoral process indicators!

Can we influence policy and programmes in this direction?

Deepti Chirmulay

BAIF, 134/1, Warje, Pune 411029, INDIA.