'Here is bread, which strengthens man's heart, and therefore called the staff of life' Introduction The number of plant species which nourish humanity is remarkably limited. Most of the 195,000 species of flowering plants produce edible parts which could be utilized by man; however less than 0.1% or fewer than 300 species are used for food. Approximately 17 plant species provide 90% of mankind's food supply, of which cereal grains supply far and away the greatest percentage (tables 1, 2). From table 1, it can be shown that the world's four major cereal grains (wheat, maize, rice and barley) contribute more tonnage Table 1. The world's top 30 food crops (estimated edible dry matter) Million metric tons 1 Wheat 468 2 Maize 429 3 Rice 330 4 Barley 160 5 Soybean 88 6 20 Cordain to humanity's food supply than the next 26 crops combined. Eight cereal grains: wheat, maize, rice, barley, sorghum, oats, rye, and millet provide 56% of the food energy and 50% of the protein consumed on earth [1]. Three cereals: wheat, maize and rice together comprise at least 75% of the world's grain production (table 1). It is clear that humanity has become dependent upon cereal grains for the majority of its food supply. As Mangelsdorf [2] has pointed out, 'cereal grains literally stand between mankind and starvation'; therefore, it is essential that we fully understand the nutritional implications of cereal grain consumption upon human health and well being. Modern man has become so dependent upon eating cereal grains (grass seeds) that it has prompted at least one author [3] to say that we have become 'canaries'. However, this has not always been the case. For the vast majority of mankind's presence on this planet, he rarely if ever consumed cereal grains [4]. With the exception of the last 10,000 years following the agricultural 'revolution', humans have existed as non-cereal-eating hunter-gatherers since the emergence of Homo erectus 1.7 million years ago. Although the first anatomically modern humans (Homo sapiens) appeared in Africa ?90,000 years ago, humans prior to the mesolithic period (~15,000 years ago) like other primates rarely if ever utilized cereal grains [4]. Post-pleistocene (~10,000 years ago) hunter-gatherers occasionally consumed cereal grains; however these foods were apparently not major dietary components for most of the year [5]. It is apparent that there is little or no evolutionary precedent in our species for grass seed consumption …

https://eatmeatdrinkwater.files.wordpress.com/2015/04/cereal-grains-by-loren-cordain.pdf

Cereal grains: humanity's double-edged sword.

Thiamine is an essential micronutrient that plays a key role in energy metabolism. Many populations worldwide may be at risk of clinical or subclinical thiamine deficiencies, due to famine, reliance on staple crops with low thiamine content, or food preparation practices, such as milling grains and washing milled rice. Clinical manifestations of thiamine deficiency are variable; this, along with the lack of a readily accessible and widely agreed upon biomarker of thiamine status, complicates efforts to diagnose thiamine deficiency and assess its global prevalence. Strategies to identify regions at risk of thiamine deficiency through proxy measures, such as analysis of food balance sheet data and month-specific infant mortality rates, may be valuable for understanding the scope of thiamine deficiency. Urgent public health responses are warranted in high-risk regions, considering the contribution of thiamine deficiency to infant mortality and research suggesting that even subclinical thiamine deficiency in childhood may have lifelong neurodevelopmental consequences. Food fortification and maternal and/or infant thiamine supplementation have proven effective in raising thiamine status and reducing the incidence of infantile beriberi in regions where thiamine deficiency is prevalent, but trial data are limited. Efforts to determine culturally and environmentally appropriate food vehicles for thiamine fortification are ongoing.

/pdf/thiamine-deficiency-disorders-diagnosis-prevalence-and-a-4m2mweoi3t.pdf

Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs

Aims To determine the prevalence rate, clinical features, risk factors, and clinical outcome of foot ulcers in diabetes patients admitted to Muhimbili National Hospital, Dar es Salaam, Tanzania.



Methods A prospective cohort study of newly hospitalized, adult diabetes patients with foot ulcers was conducted during January 1997 to December 1998 (study period). Detailed clinical and epidemiological data were recorded for each patient, followed by a comprehensive physical examination. Clinical outcome was documented.



Results Of 627 diabetes patients evaluated during the study period, 92 (15%) had foot ulcers. Of these 92 patients, 30 (33%) were selected for surgery (minor and major amputations); the rest were managed conservatively. Patients who underwent surgery were more likely than those who did not to have gangrene (P < 0.001) or neuropathy (P < 0.01). On stratification by severity of ulcers, patients with Wagner score ≥ 4 were significantly more likely than those < 4 to have neuroischaemic foot lesions (P < 0.001) or delayed presentation to hospital (P < 0.001). The overall mortality rates for amputees and non-amputees were similar (29%); the highest in-patient mortality rate (54%) was observed among patients with severe (Wagner grade ≥ 4) ulcers who did not undergo surgery.



Conclusions Diabetic foot ulcers are associated with significant morbidity and mortality in Tanzania. Mortality rates among patients with severe ulcers remain high despite surgery. Thus, surgery undertaken during the less severe stages of ulcers may improve patient outcome. Education of patients should underscore the importance of foot care and consulting a doctor during the early stages of foot ulcer disease.

Clinical outcome of diabetes patients hospitalized with foot ulcers, Dar es Salaam, Tanzania.

We review the epidemiology of foot and hand sepsis in adult diabetes patients in Africa. Limb sepsis in these patients is associated with significant morbidity and mortality. The pathogenesis of diabetic foot infections in these patient populations appears to be similar to that for patients in industrialized countries-ulcers and underlying peripheral neuropathy being the most important risk factors. Prevention of peripheral neuropathy through aggressive glycaemic control may be the most important primary control measure for foot infections. The tropical diabetic hand syndrome (TDHS) is being increasingly seen in diabetes patients in certain parts of Africa. The syndrome is acute, usually follows minor trauma to the hand, and is associated with a progressive synergistic form of gangrene. The major risk factors for TDHS are unknown but recent data suggest poor glycaemic control is associated with poor outcome. Treatment of TDHS requires aggressive surgery. Hence, preventive efforts for both foot and hand sepsis include aggressive glucose control, and education on hand and foot care and the importance of seeking medical attention promptly at the earliest onset of symptoms.

The epidemiology of diabetic limb sepsis: an African perspective

Diabetes mellitus reached epidemic proportions in much of the less-developed world over a decade ago. In Africa, incidence and prevalence rates of diabetes are increasing and foot complications are rising in parallel. The predominant risk factor for foot complications is underlying peripheral neuropathy, although there is a body of evidence that confirm the increasing role of peripheral vascular disease. Gangrene and infections are two of the more serious sequelae of diabetic foot ulcer disease that cause long-standing disability, loss of income, amputation or death. Unfortunately, diabetes imposes a heavy burden on the health services in many African countries, where resources are already scarce or cut back. Reasons for poor outcomes of foot complications in various less-developed countries include the following: lack of awareness of foot care issues among patients and health care providers alike; very few professionals with an interest in the diabetic foot or trained to provide specialist treatment; non existent podiatry services; long distances for patients to travel to the clinic; delays among patients in seeking timely medical care, or among untrained health care providers in referring patients with serious complications for specialist opinion; lack of the concept of a team approach; absence of training programs for health care professionals; and finally lack of surveillance activities. There are ways of improving diabetic foot disease outcomes that do not require an exorbitant outlay of financial resources. These include implementation of sustainable training programmes for health care professionals, focusing on the management of the complicated diabetic foot and educational programmes that include dissemination of information to other health care professionals and patients; sustenance of working environments that inculcate commitment by individual physicians and nurses through self growth; rational optimal use of existing microbiology facilities and prescribing through epidemiologically directed empiricism, where appropriate; and using sentinel hospitals for surveillance activities. Allied with the golden rules of prevention (i.e. maintenance of glycaemic control to prevent peripheral neuropathy, regular feet inspection, making an effort not to walk barefooted or cut foot callosities with razors or knives at home and avoidance of delays in presenting to hospital at the earliest onset of a foot lesion), reductions in the occurrence of adverse events associated with the diabetic foot is feasible in less-developed settings.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1742-481X.2007.00376.x

Challenges for management of the diabetic foot in Africa: doing more with less

A register of diabetic patients attending the Royal Victoria Hospital, Banjul, The Gambia, was kept and data on hospital admissions recorded over a 1-year period. Two hundred and sixty-nine patients (110 men, 159 women) were registered of whom 66 (25%) were receiving insulin. Seventy-five patients (28%: 40 men, 35 women) were newly diagnosed. There were significant differences in age (p less than 0.001) and obesity (p less than 0.001) between men and women and between patients with different types of diabetes. There were 95 hospital admissions (5.2%) related to diabetes, as were a fifth of medical out-patient attendances. Ketoacidosis was the major cause of death while foot infections were more common (p less than 0.01) in women. Diabetes imposed a heavy burden on the health services of The Gambia, a small developing country in West Africa; more than 3.6% of the annual health budget was spent on the treatment of diabetic patients.

Diabetes Mellitus in The Gambia, West Africa

Thirty-eight patients with beri-beri (13 dry, 14 wet and 11 mixed type) were seen at the Royal Victoria Hospital, Banjul, The Gambia, in 1990–1991, with a peak in September–October (25 cases) during the latter half of the rainy season. They were all non-confined residents of urban areas. Overt risk factors were pregnancy (6), alcohol (5), fevers (4), chronic disability (4), and exercise (2). Four patients (10·5%) died. The potential for large outbreaks of beri-beri exist in many urban areas of West Africa where polished rice is the staple diet.

Urban beri-beri in The Gambia, West Africa

Twenty-seven patients with peripartum cardiac failure were seen at the Royal Victoria Hospital, Banjul over a 2-year period while one further patient presented 6 months after delivery with a cerebral embolus secondary to a dilated cardiomyopathy. Five (18%, P less than 0.001) patients had twin pregnancies. Seventeen (63%) patients attended for follow-up, of whom eight had evidence of continuing cardiac dysfunction and required treatment with diuretics; two patients were known to have died. In five asymptomatic patients the electrocardiogram had reverted to normal and three patients had further pregnancies without relapse. The bipolar distribution of onset of symptoms in relation to pregnancy was suggestive of two different pathological processes. There was no evidence that cultural habits played any significant part in the aetiology of peripartum cardiac failure in The Gambia.

M. Rolfe

Papers

Diabetes Mellitus in The Gambia, West Africa

Urban beri-beri in The Gambia, West Africa

Peripartum cardiac failure in The Gambia.