Lessons Learned

Ingredients of adolescent school-based drug prevention programs needed to reduce, prevent or delay adolescent substance abuse are presented in the historical context of three meta-analyses. Non-interactive programs showed only a 4% reduction in prevalence rate, while Interactive programs showed a 21% reduction in prevalence rate. Small Interactive programs were found to be most successful; most probably due to program protocol being more closely followed. Essential program content and necessary features of the successful Interactive programs are identified.     

Iron Fortification of Milk

The fortification of a prepared milk formula with iron (12 mg. per reconstituted quart) has been shown to maintain hemoglobin and serum iron concentrations at normal levels in both full-term and premature infants.     

Iron Fortification of Flours in Venezuela

This paper reviews a conference about the impact of the iron fortification program in Venezuela; it was presented at the Pan American Health Organization regional technical meeting: "Iron Fortification: Where Are We in Terms of Iron Compounds," held in Washington January 10–12, 2001. Some of the data presented were published in the American Journal of Clinical Nutrition , including stimulating results about the impact of fortification of precooked corn and white wheat flours, as well as the prevalence of anemia and iron deficiency in the Venezuelan population. This article reports results from three surveys carried out in 1997, 1998, and 1999 on the same age and socioeconomic group that had been evaluated in 1990, 1992, and 1994. This article also shows the impact of iron fortification programs and the influence of other factors on the prevalence of iron deficiency and anemia during the last 7 years.     

Health Communications in Rural America: Lessons Learned from an Arthritis Campaign in Rural Arkansas

CONTEXT: Lack of awareness about diseases and associated risk factors could partially account for some rural health disparities. Health communications campaigns can be an effective means of increasing awareness in these areas. PURPOSE: To review findings and lessons learned from a rural health communications campaign. METHODS: The health communications campaign titled "Physical Activity. The Arthritis Pain Reliever," developed by the Centers for Disease Control and Prevention, was implemented in a rural Arkansas county to promote awareness about arthritis and the beneficial effects of physical activity among residents 45-64 years of age with arthritis. The campaign was implemented through radio spots, print ads in local newspapers, and distribution of brochures and posters. A survey of 193 residents with arthritis assessed the reach of the campaign.Findings:Whereas 86% of respondents reported having seen or heard the messages related to arthritis during the 13-week period of the campaign, only 11% recalled messages from the "Physical Activity. The Arthritis Pain Reliever" campaign. Challenges faced during campaign implementation included limited fiscal resources, distrust, and staff and time constraints. CONCLUSION: Challenges to health communications campaigns in rural areas can decrease campaign reach and effectiveness. If resource constraints exist, leveraging partnerships and building trust among residents of the community are important for achieving campaign success.     

Iron Compounds for Food Fortification: Guidelines for Latin America and the Caribbean 2002

Iron deficiency is the most prevalent micronutrient deficiency in the world today. It affects millions of individuals throughout the life cycle, particularly infants and pregnant women, but also older children, adolescents, and women of reproductive age. Living organisms require iron for their cells to function normally. Iron is needed for the development of vital tissues - including the brain - and for transporting and storing oxygen in hemoglobin and muscle myoglobin. Iron deficiency anemia is the severe form of iron deficiency. It can result in low resistance to infection, impaired psychomotor development, and cognitive function in children, poor academic performance, as well as fatigue and poor physical/work endurance. In addition to the above, iron deficiency anemia in pregnancy can result in a low-birth-weight infant. Three intervention strategies are available to prevent iron deficiency and, therefore, iron deficiency anemia. These are supplementation, dietary diversification, and both targeted and untargeted food fortification. Nineteen countries in the Americas have a national food fortification program, in which iron and other micronutrients are added to at least one widely consumed food that is often wheat and/or corn flour. Table 1 shows the iron compounds added to the flours. Each iron compound has different properties and characteristics, which influence its bioavailability, as is discussed later. A number of countries also currently implement fortification programs targeted to specific groups of the population, primarily infants and young children age 6 to 24 months and school-age children.     

Preventing Iron Deficiency Through Food Fortification

One way to prevent iron deficiency anemia in developing countries is through the fortification of food products with iron. In addition to avoiding undesirable color and flavor changes, the main challenge is to protect the fortification iron from potential inhibitors of iron absorption present in commonly fortified foods.     

Staple Food Fortification with Iron: a Multifactorial Decision

Iron deficiency is not restricted to infants and pregnant women; it also affects school-age children, adolescents, elders, and even adult males in developing countries, including those of Latin America. Therefore, interventions with extensive coverage are suitable to prevent and to control this deficiency. Fortification of staple foods is an adequate strategy to provide additional iron to populations. However, unlike fortification with vitamin A, iodine, and B vitamins, food fortification with iron has not been very successful. Iron is a reactive compound, whose level in foods is limited because iron causes negative changes in the original properties of the food that is being fortified. This feature combined with the low absorption of iron compounds used for fortification - usually not higher than 10% - makes prevention of iron deficiency through food fortification of very few commodities a great challenge. This review will cover several factors that need to be taken into consideration to plan, understand, evaluate, and make a decision about fortification of staple foods with iron. Included is a discussion regarding bioavailability, technologic compatibility, and cost effectiveness. To conclude, the review mentions additional advantages of fortifying staple foods with iron and the indispensable need to combine this strategy with other interventions. All of these factors must be considered before launching a field efficacy trial, which should be the ultimate proof for a decision made wisely and with possibilities of success.     

Iron Nutrition in Schoolchildren of Western Mexico: The Effect of Iron Fortification

In Mexico, food fortification is used as a strategy to combat micronutrient deficiencies. However, little is known about the effects of food fortification in vulnerable populations. This study was carried out in a population of school children believed to be at risk of various micronutrient deficiencies, including iron. The study aimed at determining iron status of children, and identifying and quantifying the sources of iron intake and the presence of relevant enhancers and inhibitors of iron absorption in the diet. The iron status and dietary iron intake was assessed of schoolchildren aged 3-14 years in western Mexico. Hemoglobin, serum ferritin, and transferrin saturation percentages were used to evaluate the iron status in a school-based sample of 762 children. Dietary data were collected from 607 children using semi-quantitative food frequency questionnaires. The overall prevalence of anemia and iron deficiency was 3.7% and 4%, respectively. Iron intake ranged from 1.9 to 3.3 times the recommended daily allowance, with fortified iron accounting for 72% of the total iron intake. Although iron fortification of staples such as maize flour in Mexico for more than a decade most likely contributed to reducing the prevalence of anemia and iron deficiency, the relatively large amounts of iron consumed could eventually lead to problems related to excessive iron intake in some children. Nutritional guidelines for iron fortification in Mexico should be defined and put into practice.     

Lessons Learned from Two School Tuberculosis Investigations

We describe the results from tuberculosis (TB) contact investigations of two high-school students. Following the development of active TB in two foreign-born students, contact investigations were performed to detect contacts with active TB disease or latent TB infection (LTBI). The two students developed pulmonary TB within 2 years of immigrating to the United States. Among household contacts, no case of active TB was identified; however, LTBI was identified in 7 of 20 persons screened (35%). Of the 104 high-risk school contacts identified, no cases of active TB disease were found, but 7 (9.3%) were diagnosed with LTBI. An additional 683 low-risk contacts were screened and 9 (1.5%) were positive. Schools and Public Health departments needs to be prepared for outbreak investigations and should screen only persons with a high risk of exposure to the index case with active TB in an attempt to identify secondary infections. Those persons with a low risk of exposure should not be screened.     

Iron Nutrition in Schoolchildren of Western Mexico: The Effect of Iron Fortification

In Mexico, food fortification is used as a strategy to combat micronutrient deficiencies. However, little is known about the effects of food fortification in vulnerable populations. This study was carried out in a population of school children believed to be at risk of various micronutrient deficiencies, including iron. The study aimed at determining iron status of children, and identifying and quantifying the sources of iron intake and the presence of relevant enhancers and inhibitors of iron absorption in the diet. The iron status and dietary iron intake was assessed of schoolchildren aged 3–14 years in western Mexico. Hemoglobin, serum ferritin, and transferrin saturation percentages were used to evaluate the iron status in a school-based sample of 762 children. Dietary data were collected from 607 children using semi-quantitative food frequency questionnaires. The overall prevalence of anemia and iron deficiency was 3.7% and 4%, respectively. Iron intake ranged from 1.9 to 3.3 times the recommended daily allowance, with fortified iron accounting for 72% of the total iron intake. Although iron fortification of staples such as maize flour in Mexico for more than a decade most likely contributed to reducing the prevalence of anemia and iron deficiency, the relatively large amounts of iron consumed could eventually lead to problems related to excessive iron intake in some children. Nutritional guidelines for iron fortification in Mexico should be defined and put into practice.     

Research Participant Recruitment in Hispanic Communities: Lessons Learned

Hidden/special populations such as new immigrants are hard-to-reach due to issues such as stigma, discrimination, fear of immigration authorities, and cultural norms. Such factors can affect the recruitment of participants for behavioral research, especially research which addresses stigmatizing conditions such as HIV/AIDS. This research involved a qualitative approach and methods. The study identified contextual factors as well as attitudes, experiences and beliefs affecting HIV risk among recent Hispanic immigrants in New York. During the course of this research, challenges to participant recruitment were identified which were related to the environments, characteristics of the populations, and the sensitive nature of the topic to be studied. Strategies including exploratory fieldwork and sensitivity to participants’ fear of “the system” were effective in recruiting individuals from this population. The authors discuss the strategies which facilitated recruitment of research subjects from these new Hispanic immigrant communities and the importance of behavioral research among these vulnerable communities.     

Lessons Learned in Nutrition Therapy in Patients With Severe COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has reached worldwide, and until a vaccine is found, it will continue to cause significant morbidity and mortality. The clinical presentation of COVID-19 ranges from that of being asymptomatic to developing a fatal illness characterized by multiple organ involvement. Approximately 20% of the patients will require hospitalization; one-quarter of hospitalized patients will develop severe COVID-19 requiring admission to the intensive care unit, most frequently, with acute respiratory failure. An ongoing effort is being made to identify the patients that will develop severe COVID-19. Overall, patients present with 3 different phenotypes of nutrition risk: (1) the frail older patient, (2) the patient with severe ongoing chronic illness, and (3) the patient with severe and morbid obesity. These 3 phenotypes represent different nutrition risks and diverse nutrition interventions. This article explores the different potential approaches to nutrition intervention in patients with COVID-19, evaluating, in this process, the challenges faced in the implementation of guidelines written by different societies.     

Epilogue: Lessons Learned About Evaluating Health Communication Programs

Systematic evaluation research is needed to develop, implement, refine, and sustain effective health communication programs. Yet, evaluation research is not always well integrated into health communication intervention activities or even budgeted as part of health promotion efforts. If included in health promotion programs, evaluation research is often conducted superficially, after the fact, and does not provide the strategic information needed to make sure that health communication programs achieve their important goals. To rectify this problem, it is important to reassert and institutionalize the value of evaluation research in health promotion efforts. It is important to mandate that all major health communication programs are guided by robust evaluation research data. It is also important to help health promotion experts to conduct rigorous and revealing evaluation research as well as help them use evaluation research data to guide the development, refinement, and implementation of health communication programs. This Epilogue to this special section on Evaluating Health Communication Programs presents specific propositions that charts the course for using evaluation research to promote public health and recommends next steps for achieving this goal.