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    • The importance of social determinants on population

    2019-06-19

    The importance of social determinants on population health is widely known. Beyond this recognition, key questions that still need to be addressed include research into how to best address social determinants through intersectoral collaboration. Pillay-van Wyk and colleagues identify this approach as necessary to the reduction of the heavy burden of violence and injury. However, this approach is also important for other causes of death, particularly non-communicable diseases, tuberculosis, and the type 1 conditions. At the first UN multistakeholder forum on science, technology, and innovation for the sustainable development goals (SDGs), the need for new partnerships and collaborations was underscored as necessary to achieve these goals. HIV infection still accounts for the greatest proportion of deaths, largely driven by the inequitable exposures that affect health and the risk of acquisition of HIV faced by black Africans who constitute most of the South African population. These data are therefore important for agenda setting to address the SDGs. To achieve the population health targets, we will need to address not only the targets related to the health goal (goal 3) but also other health-related targets across other SDGs, including goals on food security (goal 2), water and sanitation (goal 6), and healthier cities (goal 11). This will necessitate thorough evidence-based assessment of the interactions between the SDGs in different contexts. This study shows that the measurement and monitoring of mortality trends can increasingly be done in low-income and middle-income settings and highlights the importance of strengthening surveillance systems to assess the effect of intersectoral actions to improve population health. South Africa seems to have turned the tide against rapidly rising mortality caused by HIV/AIDS through the application of evidence-based interventions in the health system and beyond. Future progress will depend on addressing the triple challenges of implementing interventions to end HIV/AIDS by 2030, providing universal access to quality health care for all, and eradicating racial inequality, unemployment, and poverty. These extraordinary challenges should be matched by the resolute application of effective interventions by all sectors of society to achieve the SDGs by 2030.
    Severe acute malnutrition (SAM) is a life-threatening condition that often occurs during a critical LIMKi 3 for a child\'s growth and development. Treatment of SAM is among the most cost effective interventions to prevent childhood death. Thanks to the rapid expansion of community-based treatment programmes worldwide, every year millions of children are treated for SAM. The Article by Natasha Lelijveld and colleagues in shows that, despite treatment, the long-term survival and health of children who were previously treated in hospital for complicated SAM is suboptimum, and that more attention needs to be given to risks of chronic diseases later in life. As pointed out by the authors, this observational study does not establish a cause–effect relationship since chronic problems might be related to conditions that existed before the episode of SAM. For example, children in the case group were already severely stunted at the beginning of treatment for SAM without recovery during treatment, thus their shorter height-for-age later in life cannot be fully ascribed to the episode of SAM. Another childhood condition with long-term consequences is low birthweight, which has long-term consequences for chronic diseases and is a risk factor for malnutrition. Long-term effects are likely to be mediated by epigenetic changes arising from exposures that might be transgenerational or occur preconception, in utero, or in early life. The finding that children treated for SAM had a reduced proportion of lean tissue, which might predispose them to chronic diseases later in life, cannot be ignored. The study\'s results suggest that abnormal body composition is the result of a deficit in lean tissue rather than of excess fat tissue deposition. Lelijveld and colleagues\' findings are consistent with those of previous studies that examined children with SAM at the end of their treatment period, which also reported suboptimum recovery of lean tissues. This effect is unlikely to be related to the high fat content of diets used for nutritional rehabilitation such as the currently used ready-to-use therapeutic foods (RUTF), which provide more than 55% of their energy via fat. This proportion is similar to that of breast milk and reflects the high energy requirements of rapidly growing children who need to accumulate fat, which is the case for both children recovering from malnutrition and for healthy infants during the first months of life. The deficit in lean tissue is more likely to be related to an insufficient intake of the nutrients needed for lean tissue growth either during the treatment of the episode of SAM itself, or more importantly, during the following months when the child returns to relying on a family diet with limited dietary diversity and low intake of foods from animal sources.