Introduction

Hello Everyone!

This is our first official blog post. It is a month and a bit until we leave. Woohoo! Below you will find the proposal for our trip. Hopefully it will give you a better understanding of what we plan to accomplish while we are in Uganda.

Thanks so much for checking our blog out! More posts will come as our departure date draws near.

Talk to you later,
Jo-Anna and Sarah

Research Proposal:
Nutritional evaluation of children with and without angulatory bone deformity in two regions of Uganda

Introduction:
During his time in Uganda, Dr. Norgrove Penny, a local paediatric orthopaedic surgeon, identified a large number of children presenting with orthopaedic surgery reconstruction whose disability was caused by malnutrition, as well as another large number where malnutrition contributed towards disability and medical care. In his rehabilitation centres, he began nutrition projects to try and combat this. Stemming from his observations and correspondence with other orthopaedic surgeons and paediatricians, Dr. Penny would like us to go out into Ugandan communities in association with Christian Blind Mission International (CBM) and their national partners and do a basic survey of the diets of children with and without angular bone deformities.

From our evaluation of the children’s diets, we hope to submit a paper for publication demonstrating evidence for the role of micronutrient deficiency in angulatory bone deformity. Within the publication, we will make practical suggestions for improving the dietary needs of children emphasizing ways to obtain proper nutrients in a socio-culturally acceptable and geographically viable manner. We will also prepare simple nutritional pamphlets and posters for the benefit of caretakers and a more thorough dietary proposal for distribution to physicians, and medical workers in Uganda. Our aim is to educate and increase awareness of the relationship between angulatory bone deformity and malnutrition as a means of prevention.

Review of Literature:
There are several essential nutrients for survival and good health. Some nutrients are synthesized within the human body, while others must be consumed. Malnutrition results from inadequate dietary intake or inability to fully utilize consumed food due to illness. In children, malnutrition increases the risk of disease and early death (7). Uganda is affected by this condition as a large proportion of children are malnourished.

Research has shown that angulatory bone deformities can be traced to insufficient micronutrient consumption. Rickets is an angulatory bone disease common in developing countries and caused by inadequate mineralization in growing bones. This results in skeletal deformities such as bow legs and knock knees (5). While sometimes caused by hereditary syndromes, renal disease, or use of medication, rickets is predominantly attributed to nutritional insufficiency in developing countries, making it one of the most frequent childhood diseases (2).

The leading cause of rickets is vitamin D deficiency, referred to as vitamin D deficiency rickets. Vitamin D is synthesized in the skin upon exposure to sunlight. However, rickets is also observed in regions with high sun exposure, such as Uganda. Therefore, children's skin has ample ability to produce enough vitamin D to stave off rickets (4). Rickets can still occur, however, due to inadequate dietary calcium; this form of rickets is known as calcium deficiency rickets (2). Without calcium, uptake of vitamin D is not possible. In Africa and other developing regions, evidence that large numbers of children with angulatory bone deformities suffer from calcium deficiency rather than vitamin D deficiency is being accumulated by orthopaedic practitioners and paediatricians (4).

Rickets can be devastating for children, who may experience delays in learning to walk, pain and fractures, and crippling deformi­ties. A diseased child can also pose a great burden for immediate family members and the community. Early treatment provides better results for disabled children, in addition to being less expensive and less constraining (5).
Significant research has been done in Bangladesh by a team of orthopaedic surgeons. In Bangladesh, diets primarily consist of rice, with little emphasis on calcium rich foods such as dairy products and leafy green vegetables. While surgical procedures and braces are used to treat children with debilitating rickets, the researchers strongly promote prevention through community based awareness. This has been identified as one of the most effective measures against the incidence of rickets (2).

For prevention of rickets in Bangladesh, researchers suggested the addition of calcium supplements such as lime to staple foods like rice and bread (2). Also promoted is the recommendation of heath experts that a child should be breast fed exclusively for the first six months, followed by introduction to other foods rich in vitamin D and calcium, particularly eggs, dairy products, leafy vegetables, and small fish (1).
In Nigeria, insufficient dietary calcium intake, rather than vitamin D deficiency, appears to be the cause of rickets. The average intake of calcium among Nigerian children is far below the U.S. recommended daily allowance for children (3). In a study, they found that children with rickets who received calcium healed faster than children receiving vitamin D alone. This group postulates that rickets should be preventable through increasing dietary calcium intake in at risk age groups. The researchers are now investigating how to obtain locally available sources of calcium which will increase dietary calcium in a manner that is culturally acceptable and affordable to most families (6).

We postulate that malnutrition is important in the incidence of angular deformities in Uganda, as has been observed in Bangladesh and Nigeria. The first step to examine this relationship will be to perform research in the form of a community level survey. We wish to assess the diets of children with and without angular bone deformities to determine nutrient intake. Additionally, we will determine which Ugandan foods would be most suitable to include in diets of young children to improve nutrient calcium intake. Suggestions made would emphasize practical and culturally acceptable ways to satisfy the dietary micronutrient needs of children.

Our desire is to promote the prevention of disability by educating members of the community. Ideally, this research would lead to future studies aimed at more precise evaluations of the nutritional status of Ugandan children.

Objectives
1) To survey the diets of children under ten with and without bone deformities in Uganda.
2) To analyze and review the nutrient content of the diets of children under age ten using Ugandan resources and existing knowledge.
3) To submit a paper for publication providing evidence for the role of micronutrient deficiency, particularly with respect to calcium, in angulatory bone deformity prevalence in Uganda.
4) To make feasible suggestions for improving the dietary needs of children in order that they might obtain proper nutrients in a socio-culturally acceptable and geographically viable manner.
5) To produce simple nutritional pamphlets and posters for caregivers in native languages and a more thorough dietary proposal for distribution to physicians and medical workers with the aim of educating caregivers of the relationship between angulatory bone deformity and malnutrition.

Methodology:
We want to survey the nutritional habits of children ages ten and below with and without angular bone deformities in two Ugandan districts, Mbarara and Kumi. In Mbarara, a district with both urban and rural centres, an important food staple is matoke. Contrastingly, in Kumi, a primarily rural district, sorghum, and millet serve as dietary staples. These staples contain very little micronutrients.

The survey is heavily based on that used by the Convergence Rickets Group in Bangladesh. It will be conducted with the caretakers of sample children and used to collect demographic, anthropometric (height, weight, and middle upper arm circumference) and nutritional information (types, volumes, and preparation method) for each child, after obtaining informed consent. The survey includes a 24 hour food recall, diet history questionnaire, and food frequency questionnaire.

Surveys will be conducted with the assistance of community based rehabilitation (CBR) workers in both Kumi and Mbarara. CBR workers are locally trained by specialists to help disabled individuals and their families through personal and social assistance, promoting integration of disabled individuals into their families and communities, as well as through home based services. Employment of CBR workers will allow for survey translation at time of conduction.

The survey will begin in February 2010 in Kumi district and continue until the end of March. Our contact at Kumi Hospital is Dr. John Ekure. Kumi Hospital runs with the support of CBM, a non-governmental organization. This organization will assist in providing CBR workers. Participants will be surveyed within Kumi, as well as in outlying remote villages. Collaboration with the nutrition department at Kumi Hospital will allow us to come up with feasible food suggestions for increased dietary micronutrient uptake.

For the months of April and May, we will be in Mbarara district. Here we will work in cooperation with Organized Useful Rehabilitation Services (OURS), another community based rehabilitation program run with the assistance of CBM. Children within the OURS facility come from all over western Uganda. We will also travel with CBR workers to surrounding villages.

Our project is being conducted through collaboration with individuals and medical professionals from Ugandan institutions and organizations.

Estimated Duration:
The interviews are scheduled to occur from February 2010 until June 2010. The first two months (February and March) will be spent in Kumi at Kumi Hospital. The third and fourth month (April and May) will be spent in Mbarara with the OURS CBM program. Data analysis will be ongoing while in Uganda and upon return to Canada.

References:

(1) Combs GF, Hassan N. The Chakaria food system study: household-level, case–control study to identify risk factor for rickets in Bangladesh. Eur J of Clin Nutr 2005; 59:1291–1301.

(2) Craviari T, Pettifor JM, Thacher TD, Meisner C, Arnaud J, Fischer PR, the Rickets Convergence Group. Rickets in Bangladesh. J Health Popul Nutr 2008;26(1):112-121.

(3) Graff M, Thacher TD, Fischer PR, Stadler D, Pam SD, Pettifor JM, Isichei CO, Abrams SA. Calcium absorption in Nigerian children with rickets. Am J of Clin Nutr 2004;80(5):1415-1421. (4) Thacher TD, Fischer PR, Strand MA, Pettifor JM. Nu­tritional rickets around the world: causes and future directions. Ann Trop Paediatr 2006;26:1-16.

(5) Thacher TD, Fischer PR, Pettifor JM. The usefulness of clinical features to identify active rickets. Ann Trop Paediatr 2002;22:229-37.

(6) Thacher TD, Fischer PR, Pettifor JM, Lawson JO, Isichei CO, Reading JC, Chan GM. A comparison of calcium, vitamin D, or both for nutritional rickets in Nigerian Children. The New Engl J of Med 1999;341(8):563-568.

(7) WHO. 2000. Turning the tide of malnutrition: responding to the challenge of the 21st century. Geneva, Switzerland. (WHO/NHD/00.7)