Is Nutrition playing a role in Tanzania´s top causes of deaths and disabilities? How important it is?

   Tanzania, officially the United States of Tanzania, located in East Africa, has a population of 65.5 million inhabitants registered in mid-2022, an increase of 8.8 million inhabitants since 2019. A population, which, like any other, is subject to the geographical situation, economy status, education level, the environment (culture, traditions, religions, etc.), genetic predisposition, and genetic expression (that starts from the interaction of both), among all the other factors like political policies, strategical plans and … of course, last but not least: Nutrition.
"All factors interaction defines what is common for that study population"
   If we talk about health and have a look to Tanzania´s top 10 causes of death (a comparison stablished between 2009 and 2019 - most recent update), we can see the changes over time and the important role that Nutrition and lifestyle play in it (Fig.1). The causes of most death and disabilities combined are presented in (Fig.2), as well as their risk factors in (Fig.3).



   With only malaria as the exception where nutrition and lifestyle changes do not play an important role, we can name all the others, where they participate in prevention or treatment as well.

   Starting from the bottom, cirrhosis liver (14th leading cause of death worldwide and rising from position 11 to 10 in this top) is a late stage of hepatic fibrosis that has resulted in widespread distortion of normal hepatic architecture. Is characterized by regenerative nodules surrounded by dense fibrotic tissue.  In parts of Asia and Africa, cirrhosis often results from endemic chronic hepatitis B, but also can be result from chronic alcohol abuse, hepatitis C, and non-alcoholic steatohepatitis (NASH), etc. In general, treatment is supportive and includes stopping injurious drugs, providing nutrition (including meeting energy and protein requirements and supplemental vitamins and minerals), and treating the underlying disorders and complications. All alcohol and hepatotoxic substances must be avoided (lifestyle changes).

   Congenital disorders cause a further 170.000 deaths of children between the ages of 1 month and 5 years (WHO-2023). The most common severe congenital disorders are heart defects, neural tube defects and Down syndrome. Compared to 2009, it fell from position 8 to 9 and has a decrease of 9.5% of deaths per 100k. Although congenital disorders may be the result of one or more genetic, infectious, nutritional or environmental factors, it is often difficult to identify the exact causes. Some congenital disorders can be prevented. Vaccination, adequate intake of folic acid or iodine through fortification of staple foods or supplementation, and adequate care before and during a pregnancy are examples of prevention methods.

   Going down from position 5 to 8 we have diarrheal diseases. Diarrhea is loose, watery stools three or more times a day. Diarrhea may be acute, persistent, or chronic. The augmented water content in the stools is due to an imbalance in the physiology of the small and large intestinal processes involved in the absorption of ions, organic substrates, and thus water. The medical nutritional treatment of diarrheal diseases is based in reintroducing food intake early and progressively, once a good state of hydration and electrolyte balance has been ensured. Feeding should be introduced within the first 6h after starting rehydration and, at most, 24h later. Frequent and light meals are usually better tolerated, and the consumption of whole fruits, vegetables, legumes, fried foods and animal fats should be postponed until the end of recovery. Stews, fried, coffee (stimulant of the gastro-colic reflex and peristalsis), sausages and salty dishes will be suppressed, because they irritate the digestive mucosa. Sugar alcohols, lactose, fructose, and large amounts of sucrose can worsen osmotic diarrhea. A balanced diet with moderate amounts of soluble fiber is recommended. Probiotics supplementation could be helpful in recovery as well.

   Ischemic heart disease, also known as coronary artery disease (CAD), involves impairment of blood flow through the coronary arteries, most commonly by atheromas (atherosclerosis). Clinical presentations include silent ischemia, angina pectoris, acute coronary syndromes (unstable angina, myocardial infarction), and sudden cardiac death. With a marked increase of 1.8% of deaths per 100k compared to 2009 it rise from position 9 to 6. Lifestyle changes and nutrition are very important in prevention; they are focused on modifying risk factors like high blood levels of LDL-cholesterol and C-reactive protein (CRP), low blood levels of HDL-cholesterol, obesity, diabetes mellitus, smoking, physical inactivity, etc.

   Mycobacterium tuberculosis is an intracellular parasitic bacterium and causative agent of Tuberculosis (TB), a chronic and progressive infection that most commonly affects the lungs. TB goes down from position 4 to 5 in the top with a decrease of more than 10% (13.1%) of deaths per 100k compared to 2009 and has a mutual interaction with nutrition. Malnutrition is common in these patients and nutritional supplementation is necessary (eg., energy, proteins, vitamins and minerals requirements). Active TB is associated with weight loss and cachexia. In the short term, malnutrition increases the risk of infection and early progression of said infection to produce active TB. In the long term, the risk of reactivation of TB disease increases. It can also decrease the effectiveness of anti-TB drug treatment, which has to be maintained for several months. A multivitamin and mineral supplement that provides 50-150% of the dietary reference intake (DRI) is helpful, because these patients have higher requirements that cannot be met by diet alone.

   Going up in the top from position 7 to 4 we have strokes, which are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Modifying risk factors through lifestyle changes (eg., stopping cigarette smoking) and medications (eg., for hypertension) can help delay or prevent subsequent strokes. Other stroke prevention strategies are chosen based on the patient's risk factors [abdominal obesity, dyslipidemia, obstructive sleep apnea, diabetes, insulin resistance, excess alcohol consumption, lack of physical activity, high risk diet (eg., high in saturated fats, trans fats and calories), psychosocial stress (eg., depression), etc.]

   HIV (human immunodeficiency virus) is a virus that attacks the body’s immune system, affecting his ability to fight infections and diseases that can ultimately lead to death. If HIV is not treated, it can lead to AIDS (acquired immunodeficiency syndrome). Sexual transmission is the most common route of transmission, and injection drug use is the second. The drugs used to treat HIV [antiretroviral treatment (ART)] have improved quality of life and increased life expectancy. Some ART drugs can cause diarrhea, fatigue, gastroesophageal reflux, nausea, vomiting, dyslipidemia, and insulin resistance. Energy, protein and micronutrients requirements are higher in HIV/AIDS (especially during an infection), that´s why an adequate and balanced nutritional intake is essential to maintain a healthy immune system and prolong life. Nutrition also focuses on treatment and prevention of obesity, wasting syndrome and HIV-associated lipodystrophy syndrome. Deaths from HIV/AIDS stop being number 1 in the top to occupy position number 3 compared to 2009.

   Infections of the lower respiratory tract (climbing from position 3 to 2 compared to 2009) include bronchitis, bronchiolitis and pneumonia. These syndromes, especially pneumonia, can be severe or fatal. Patients with aspiration pneumonia may have dysphagia, so swallowing evaluation by a speech therapist will be necessary before oral consumption is allowed. Nutritional interventions for the prevention of aspiration pneumonia and its treatment when it exists in the patient in the acute care setting are as follows: Direct tube feeding into the small intestine rather than the stomach for those at high risk for aspiration, administer continuous feedings instead of bolus feedings, elevate the head of the patient's bed to 30-45º, use prokinetic drugs, minimize the use of sedatives, and optimize oral hygiene with a chlorhexidine mouthwash. Diet textures and fluid viscosities may need modification to prevent increased aspiration. If the patient has dysphagia and should not take anything orally, then enteral nutrition will be the preferred route of feeding.

   In the number 1 position of the top is neonatal disorders, a disturbance of normal state of body, organs and abnormal function of a newborn. This study brought mainly data on neonatal preterm birth, encephalopathy due to birth asphyxia and trauma, sepsis and other infections, haemolytic disease, neonatal jaundice and other neonatal disorders. Nutrition could have a positive impact controlling chronic diseases like hypertension and diabetes, both, preterm birth risk factors.


CAN WE DO SOMETHING ABOUT IT ? ... YES

   Analyzing data showed in Fig.3 we can stablish a direct relationship between nutrition and lifestyle changes and seven risk factors that drive the most death and disabilities, four of them classified as behavioral risks (malnutrition, tobacco, alcohol use and dietary risks) and the other three classified as metabolic ones (high blood pressure, body mass index and fasting plasma glucose).


Fig.3-Modified from: https://www.healthdata.org/research-analysis/health-by-location/profiles/tanzania
Related publication:  https://doi.org/10.1016/S0140-6736(20)30752-2 

   
   Of the seven risks list above, there is a marked increasing trend over the years in dietary risks, high body mass index, high blood pressure and high fasting plasma glucose. This is very worrying because a high body mass index, excluding patients with high muscle mass, is talking about being overweight or obese; high fasting plasma glucose, could lead to pre-diabetes and diabetes and is also related to overweight and obesity, as well as high blood pressure (hypertension) (the greater the overweight and obesity, the greater the insulin resistance and difficulty controlling blood pressure).

   Malnutrition (deficit or excess), for its part, depends on healthy food choices along with other factors, it cannot be taken only as a behavioral risk (eg., it also depends on food availability and accessibility, etc...) but these choices constitute a starting point. Some risks like tobacco and alcohol use are decisions and with the proper addiction intervention (if applicable) can been treated. So, as we can see, it is in our hands to make a change and lead a healthy lifestyle, including healthy food choices (varied, complete, sufficient, innocuous and balanced diet) and physical activity. Nutrition, of course should focus not only on treatment, if possible, but on early prevention to avoid all these situations.


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