Nutrition Recommendations and Interventions for Diabetes

Assessment & Accountability

NLiS Country Profile: Afghanistan
There's even tips about dealing with a painful period. Water, Sanitation and Hygiene. To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence. Training course and workshop activities included demonstrations of the application and maintenance of the provided equipment. Department of Agriculture introduced the Food Guide Pyramid.

The Food Exchange System

Supplemental Nutrition Assistance Program (SNAP)

For each national priority selected for United Nations country team support, the UNDAF results matrix gives the outcome s , the outcomes and outputs of other agencies working alone or together, the role of partners, resource mobilization targets for each agency outcome and coordination mechanisms and programme modalities.

The nutrition component of the UNDAF reflects the priority attributed to nutrition by the United Nations agencies in a country and is an indication of how much the United Nations system is committed to helping governments improve their food and nutrition situation.

The indicator is "strong", "medium" or "weak", depending on the degree to which nutrition is being addressed in the expected outcomes and outputs in the UNDAF. UNDAF documents follow a predefined format, with a core narrative and a results matrix. The matrix lists the high-level expected results 'the UNDAF outcomes' , the outcomes to be reached by agencies working alone or together and agency outputs. The results matrix the UNDAF document was used to assess commitment to nutrition , because it represents a synthesis of the strategy proposed in the document and is available in the same format in most country documents.

The outcomes and outputs specifically related to nutrition were identified and counted. The outputs were compared with the evidence-based interventions to reduce maternal and child under nutrition recommended in the Lancet Nutrition Series Bhutta et al.

The method and scoring are described in detail by Engesveen et al. What are the implications? A weak nutrition component in the UNDAF document does not necessarily imply that no United Nations agency in the country is working to improve nutrition ; however, unless such efforts are mentioned in strategy documents like the UNDAF, they may receive inadequate attention from development partners to ensure the necessary sustainability or scale-up to adequately address nutrition problems in the country.

The multisectoral nature of nutrition means that it must be addressed by a wide range of actors. Basing such action in frameworks for overall development contributes to ensuring the accountability of United Nations partners.

Interventions for maternal and child under nutrition and survival. The Lancet Engesveen K et al. SCN News , Nutrition component of poverty reduction strategy papers. The poverty reduction strategy approach was introduced in to empower governments to set their own priorities and to encourage donors to provide predictable, harmonized assistance aligned with country priorities.

The PRSP should state the development priorities and specify the policies, programmes and resources needed to meet the goals. It is prepared by governments in a participatory process involving civil society and development partners, including the World Bank and the International Monetary Fund, and should result in a comprehensive, country-based strategy for poverty reduction.

The indicator is "strong", "medium" or "weak", depending on the degree to which nutrition is addressed in the PRSP, in terms of recognition of under nutrition as a development problem, use of information on nutrition to analyse poverty and support for appropriate nutrition policies, strategies and programmes. The papers were systematically searched for key words to identify the parts that concerned nutrition , food security , health outcomes and interventions that would be relevant for the World Bank method.

In order to classify the commitments to nutrition in the PRSPs, a scoring system was developed, which is described in more detail by Engesveen et al. The emphasis given to nutrition in PRSPs reflects the extent to which the government considers it essential to improve nutrition for poverty reduction and national development. In other words, it can be an indication of the government's priority for improving nutrition. A strong nutrition component in a PRSP means that the government considers nutrition a priority for poverty reduction and national development.

A weak nutrition component in the document does not necessarily imply that no government department is working to improve nutrition ; however, unless such efforts are mentioned in strategy documents like PRSPs, they may not be sufficiently sustainable or be scaled-up to adequately address nutrition problems in the country.

Basing such action in frameworks for overall development contributes to ensuring the accountability of relevant government departments. Sources and further reading. Poverty reduction strategy papers.

Assessing countries' commitment to accelerate nutrition action demonstrated in poverty reduction strategy paper, UNDAF and through nutrition governance. SCN News , , Shekar M, Lee Y-K. Mainstreaming nutrition in poverty reduction strategy papers: What does it take?

A review of the early experience. Health, Nutrition and Population Discussion Paper, Landscape analysis on countries' readiness to accelerate action in nutrition , This indicator is a description of the strengths and weaknesses of various aspects of nutrition governance in countries.

The following 10 elements or characteristics are used to assess and describe the strength of nutrition governance: These elements were identified by countries as key elements for successful development and implementation of national nutrition policies and strategies during a review of the progress of countries in implementing the World Declaration and Plan of Action for Nutrition adopted by the International Conference on Nutrition, the first intergovernmental conference on nutrition Nishida et al.

The components of the composite indicator have been identified by countries as important for determining the completeness of national nutrition plans and policies Nishida, Mutru, Imperial Laue , For instance, a national nutrition plan and policy was considered to provide the political basis for initiating action. In many countries, official government endorsement or adoption of a national nutrition plan or policy facilitated its implementation. The role of an intersectoral coordinating committee in implementing national nutrition plans and policies was also considered crucial, although the nature i.

Another important element was considered to be regular surveys and other means of collecting data on nutrition. A periodically updated national nutrition information system and routinely collected data on food and nutrition were considered important for evaluating the effectiveness of national nutrition plans and policies and identifying subsequent actions.

Strategies for effective and sustainable national nutrition plans and policies. Modern aspects of nutrition , present knowledge and future perspective.

Basel , Karger Forum for Nutrition 56 , This indicates whether a government has adopted legislation to monitor and enforce the International Code of Marketing of Breast-milk Substitutes, which helps create an environment that enables mothers to make the best possible feeding choice, based on impartial information and free of commercial influences, and to be fully supported in doing so.

This indicator is defined on the basis of whether a government has adopted legislation for effective national implementation and monitoring of the International Code of Marketing of Breast-milk Substitutes. The Code is a set of recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats. The Code aims to contribute "to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution" Article 1.

Improper marketing and promotion of food products that compete with breastfeeding often negatively affect the choice and ability of a mother to breastfeed her infant optimally. The Code was formulated in response to the realization that such marketing resulted in poor infant feeding practices, which negatively affect the growth, health and development of children and are a major cause of mortality in infants and young children.

Breastfeeding practices worldwide are not yet optimal, in both developing and developed countries, especially for exclusive breastfeeding under 6 months of age. In addition to the risks posed by the lack of the protective qualities of breast milk, breast-milk substitutes and feeding bottles are associated with a high risk for contamination that can lead to life-threatening infections in young infants.

Infant formula is not a sterile product, and it may carry germs that can cause fatal illnesses. Artificial feeding is expensive, requires clean water, the ability of the mother or caregiver to read and comply with mixing instructions and a minimum standard of overall household hygiene. These factors are not present in many households in the world.

Frequently asked questions , These indicators provide information on national policies for legal entitlement to maternity protection, including leave from work during pregnancy and after birth, as well breastfeeding entitlements after return to work. Since the International Labour Organization ILO was founded in , international labour standards have been established to provide maternity protection for women workers.

Key elements of maternity protection include: The right to cash benefits during absence for maternity leave is intended to ensure that the woman can maintain herself and her child in proper conditions of health and with a suitable standard of living. The source of benefits is important due to potential discrimination in the labour market if employers have to bear the full costs. The right to continue breastfeeding a child after returning to work is important since duration of leave entitlements generally is shorter than the WHO recommended duration of exclusive and continued breastfeeding.

A composite indicator on maternity protection is included as a policy environment and capacity indicator in the core set of indicators for the Global Nutrition Monitoring Framework. It currently uses the ILO classification of compliance with Convention on three key provisions leave duration, remuneration and source of cash benefits , but an alternative method taking into account higher standards as stated in Recommendation as well as breastfeeding entitlements is under development.

The ILO periodically publishes information on the above key indicators, including the assessment of compliance with Convention No. However, an alternative method is under development which may use a scale to indicate the degree of compliance is under development.

This method will also take into account higher standards for leave duration and remuneration in Recommendation , as well as breastfeeding entitlements within both the Convention and Recommendation. Pregnancy and maternity are potentially vulnerable time for working women and their families.

Expectant and nursing mothers require special protection to prevent any potential adverse effects for them and their infants. They need adequate time to give birth, to recover from delivery process, and to nurse their children. At the same time, they also require income security and protection to ensure that they will not suffer from income loss or lose their job because of pregnancy or maternity leave.

Such protection not only ensures a woman's equal access and right to employment, it also ensures economic sustainability for the well-being of the family. Returning to work after maternity leave has been identified as a significant cause for never starting breastfeeding, early cessation of breastfeeding and lack of exclusive breastfeeding.

In most low- and middle-income countries, paid maternity leave is limited to formal sector employment or is not always provided in practice. The ILO estimates that more than million women lack economic security around childbirth with adverse effects on the health, nutrition and well-being of mothers and their children.

Maternity cash benefits for workers in the informal economy. Rollins et al Why invest, and what it will take to improve breastfeeding practices? Database of national labour, social security and related human rights legislation.

The legislative data are collected by ILO through periodical reviews of national labour and social security legislation and secondary sources, such as the International Social Security Association and International Network on Leave Policies and Research; as well as consultations with ILO experts in regional and national ILO offices around the world. The composite indicator on maternity protection included in the Global Nutrition Monitoring Framework is currently defined as whether the country has maternity protection laws or regulations in place compliant with the provisions for leave duration, remuneration and source of cash benefits in Convention Documentation for the maternity protection database http: Degree training in nutrition exists.

What does the indicator tell us? This indicator reflects the capacity of a country to train professionals in nutrition in terms of having national higher education institutions offering training in nutrition. This indicator is defined as the existence of higher education institutions offering training in nutrition in the country.

Higher education training institutions include universities and other schools offering graduate and post-graduate degrees in nutrition or dietetics, including public health nutrition, community nutrition, food and nutrition policy, clinical nutrition, nutrition science and epidemiology.

Trained nutrition professionals work at facilities including health facilities as well as at population and community levels and may influence nutrition policies, and designing and implementation of nutrition intervention programmes at various levels. They also play an important role in training of other health and non-health cadres to plan and deliver nutrition interventions in various settings. It is recognized that availability, within a country, of sufficient workforce with appropriate training in nutrition will lead to better outcomes for country-specific nutrition and health concerns.

A competency framework for global public health nutrition workforce development: World Public Health Nutrition Association. Registering as Registered Nutritionist. Building systemic capacity for nutrition: Nutrition is part of medical curricula.

This indicator reflects the inclusion of maternal, infant and young child nutrition in pre-service training of health personnel. This indicator is defined as the existence of pre-service training in maternal, infant and young child nutrition for health personnel. The survey investigates training in three key areas of maternal, infant and young child nutrition, namely growth monitoring and promotion, breastfeeding and complementary feeding, and management of severe or moderate acute malnutrition.

The first two of these three training topics are relevant for all forms of malnutrition, whereas the third topic only pertains to undernutrition. Training on other topics e.

Adequate training of health professionals is essential to ensure that nutrition activities are included in their regular health care activities. Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition. Nutrition Journal ; Trained nutrition professionals density. The focus of the nutrition professional indicator is on individuals trained to pursue a nutrition professional career, described in most countries as dieticians or nutritionists including nutrition scientists, nutritional epidemiologists and public health nutritionists.

These individuals are trained sufficiently in nutrition practice to demonstrate defined competencies and to meet certification or registration requirements of national or global nutrition or dietetics professional organizations.

Dieticians and nutritionists may complete the same training and perform the same functions in some countries but not others. This indicator is defined as the number of trained nutrition professionals per , population in the country in a specified year.

Validation of the indicator has shown that it can predict several maternal, infant and young child nutrition outcomes. Global nutrition monitoring framework: Density of nurses and midwi ves. Nurse and midwife density indicates whether nurses and midwifery personnel are available to address the health care needs of a given population.

It is the number of nursing and midwifery personnel and density per 10 population. These personnel include professional nurses, professional midwives, auxiliary nurses, auxiliary midwives, enrolled nurses, enrolled midwives and other personnel, such as dental nurses and primary care nurses.

Traditional attendants are not counted here but as community or traditional health workers. There is no gold standard for a sufficient health workforce to address the health care needs of a given population.

It has been estimated, however, that countries with fewer than 25 health-care professionals counting only physicians, nurses and midwives per 10 population fail to achieve adequate coverage rates for selected primary health care interventions that are priorities in the Millennium Development Goals.

The World Health Report Working together for health. The World Health Report papers. G ross domestic product per capita and annual growth rate.

GDP per capita purchasing power parity is the GDP divided by the midyear population, where GDP is the total value of goods and services for final use produced by resident producers in an economy, regardless of the allocation to domestic and foreign claims. It does not include deductions for depreciation of physical capital or depletion and degradation of natural resources.

Purchasing power parity indicates the rate of exchange that accounts for price differences across countries, allowing international comparisons of real output and incomes. Purchasing power parity rates allow standard comparisons of real prices among countries, just as conventional price indexes allow comparisons of real values over time; use of normal exchange rates could result in over - or undervaluation of purchasing power.

GDP per capita annual growth rate is defined as the least squares annual growth rate, calculated from constant price GDP per capita in local currency units. Higher income is usually associated with lower rates of mal nutrition. Improving income however, reduces mal nutrition to only a small degree World Bank On the basis of the correlation between growth and nutrition , it is estimated that a sustained per capita economic growth of 2.

These estimates suggest that countries cannot depend on economic growth alone to reduce mal nutrition within an acceptable time.

Repositioning nutrition as central to development. A strategy for large-scale action , Human solidarity in a divided world , Official development assistance received net disbursements as a percentage of Gross Domestic Product GDP is a measure of the flow of aid, private capital and debt in comparison with the value of goods and services produced within the country. This indicator is official development assistance received as a percentage of the GDP. Net official development assistance consists of grants or loans to countries or territories from the official sector, with the main objective of promoting economic development and welfare, at concessional financial terms.

GDP is the total value of final goods and services produced within a country's borders in a year, regardless of ownership. When official development assistance makes up a large proportion of the GDP, a country is highly aid dependent, with the risk of unpredictable aid and donor-driven aid programmes.

This can affect the resources allocated to nutrition , which are often not a donor priority in the sector-wide aid strategies promoted by the Paris Declaration Paris Declaration on Aid Effectiveness: This indicator identifies countries with low income and food inadequacy.

A country is classified by the UN Food and Agriculture Organization FAO as 'low-income food-deficit' for analytical purposes on the basis of low income and food inadequacy, and the status is agreed by the country itself. The classification applies to countries that have a per capita income below the ceiling used by the World Bank to determine eligibility for International Development Association assistance and for year terms determined by the International Bank for Reconstruction and Development, applied to countries included in World Bank categories I and II.

The second criterion is based on the net i. Trade volumes of a broad range of basic foodstuffs cereals, roots and tubers, pulses, oilseeds and oils other than tree crop oils, meat and dairy products are converted and aggregated by the calorie content of individual commodities. The third criterion, which is self-exclusion, is applied when countries that meet the above two criteria specifically request to be excluded from the low-income food-deficit category. In order to avoid too frequent changes of low-income food-deficit status, usually reflecting short-term, exogenous shocks, an additional factor is taken into consideration.

This factor, called 'persistence of position', postpones the 'exit' of a country from the list even if it does not meet the low-income or the food-deficit criterion, until the change in its status is verified for 3 consecutive years. In other words, a country is taken off the list in the fourth year after confirming a sustained improvement in its position.

During these 3 years, the country is considered to be in a transitional phase. The rationale behind the low-income food-deficit classification is that being both food deficit and having a low income at the same time means that the country lacks the resources not only to import food but also to produce sufficient amounts domestically.

It is the combination of these two factors that makes these countries both food insecure and susceptible to domestic and external shocks, which could affect the nutrition al status of vulnerable populations. The low-income food-deficit list is intended to capture this aspect of the food problem.

In comparison with countries in other classifications commonly used for analytical and operational purposes, e. Committee on World Food Security. Rome , June Averaged aggregate governance indicators. The world governance indicators of the World Bank Institute define governance as the traditions and institutions by which authority in a country is exercised. This includes the process by which governments are selected, monitored and replaced; the capacity of the government to formulate and implement sound policies effectively; and the respect of citizens and the state for the institutions that govern economic and social interactions among them.

The world governance indicators measure six broad definitions of governance, capturing the key elements of this definition: The averaged aggregate governance indicators in the NLIS country profile represent the aggregated average of the six world governance indicators. The indicators represent the views of thousands of stakeholders worldwide, including respondents to household and firm surveys and experts from nongovernmental organizations, public sector agencies and providers of commercial business information.

The NLIS averaged aggregate governance indicators are calculated from the average of the z scores a measure of standard deviations away from the mean of the six world governance indicators.

Each of the six indicators are expressed as the standard normal units, ranging from around The higher the score a country has, the better the assessment has it received regarding the six governance elements. Policy-makers, civil society groups, aid donors and scholars around the world increasingly agree that good governance affects development. This consensus has emerged from a proliferation of empirical measures of institutional quality and governance, the investment climate and research World Bank Institute, For nutrition , the importance of good governance is reflected in the UNICEF conceptual framework of factors in the "control and management of resources influenced by political and ideological structures in society'' Jonsson Good governance is also recognized by countries themselves in the Voluntary Guidelines to support the progressive realization of the right to adequate food in the context of national food security FAO as an essential factor for sustained economic growth, sustainable development, the eradication of poverty and hunger and the realization of all human rights, including the right to adequate food.

Voluntary guidelines to support the progressive realization of the right to adequate food in the context of national food security , Towards an improved strategy for nutrition surveillance.

Food and Nutrition Bulletin , United Nations Standing Committee on Nutrition. The fifth report on the world nutrition situation: The Worldwide Governance Indicators: Methodology and Analytical Issues September Gender inequality index GII. The Gender Inequality Index is a composite measure reflecting inequality in achievements between women and men in three dimensions: It varies between zero when women and men fare equally and one when men or women fare poorly compared to the other in all dimensions.

The Gender Inequality Index is designed to reveal the extent to which national human development achievements are eroded by gender inequality, and to provide empirical foundations for policy analysis and advocacy efforts. Low status restricts women's opportunities and freedom, giving them less interaction with others and fewer opportunities for independent behaviour, restricting the transmission of new knowledge and damaging their self-esteem and expression.

It is a particularly important determinant of two resources for care: Low status restricts women's capacity to act in their own and their children's best interests. There is a demonstrated association between women's status and malnutrition in children. Human Development Report Gender and Human Development.

Challenges for the 21st century: Gender Parity Index in primary level enrolment. This indicator of gender equality is also an indicator of Millennium Development Goal 3: The ratio of girls to boys, the gender parity index, in primary education is the ratio of the number of female students enrolled at the primary level of education to the number of male students. To standardize the effects of the population structure of the appropriate age groups, the gross enrolment ratio for each level of education is used.

The gross enrolment ratio is the number of students enrolled in primary, secondary and tertiary education, regardless of age, as a percentage of the population of official school age for the three levels. Associated with this is the common concern of developed countries, usually importers of aquaculture products from developing countries, as to the unqualified use of chemicals and drugs in disease treatment in production, and in disease prevention in quarantine and food inspection systems. Although much scientific progress has recently been made in the field of fish pathology, knowledge of fish disease and fish health management techniques differ not only among various countries but also among fish disease study institutions within any particular country.

The recent understanding of interrelationships between fish disease and such issues as fish nutrition, genetics and environment provides much useful application to the management of fish disease problems in aquaculture. Because of its role in worldwide aquaculture and fisheries development, FAO is well suited to execute an international programme for the dissemination of methodologies on fish disease diagnosis, prevention and treatment to interested countries. Recognizing the urgency of containing increasing fish disease problems, the FAO International Conference of World Aquaculture, held in in Kyoto, Japan, recommended that the strengthening of international cooperative efforts for the resolution of such problems be made a high priority in aquaculture development.

The project was conceived as a result of requests made by governments to hold national and international training courses on fish disease diagnosis. An international network of information on fish disease, closely related to the activities of the International Office of Epizootics OIE on epizootic diseases and to the Codex Alimentarius Commission's monitoring of drug and chemical use in aquaculture for disease prevention, was also recommended for incorporation in the project.

FAO assistance was thus requested in two primary areas: The Project Document was signed on 1 April and the project became operational in June , with project implementation carried out directly from FAO Headquarters. Counterpart contributions were separately arranged by means of a Letter of Agreement between FAO and the host institute of the concerned government for each project activity.

The development objective of the project was to provide developing countries with an improved capacity to diagnose and treat fish disease in aquaculture. The immediate objective of the project was to improve the capacity of developing countries to develop aquaculture through improved mechanisms for the diagnosis and control of diseases of culture organisms. Project implementation focused primarily on three activities: Detailed arrangements for the first two activities were made directly with each host institute representing its government.

The FAO Representation office in the country, if present, assisted in coordination between the government and its host institute. During the project period, fish disease diagnosis services were established in nine fish disease institutes, and 11 fish disease diagnosis training courses and workshops were held, of which five were international two in the Czech Republic and one each in Poland, Chile and Viet Nam and six were national two each in China, Viet Nam and Thailand.

Limited budgetary provisions restricted the selection of host countries, made according to the following criteria. For Central Europe and South America, selected host countries had significant aquaculture activities as well as fish disease research facilities and capabilities which could be upgraded to become fully functional in fish disease diagnosis.

The provision of basic items of equipment for fish disease diagnosis was an important project activity. Based on firsthand knowledge of requirements, the items provided to the host institutes see Appendix 3 were intended to adequately equip them for fish disease diagnosis activities by the end of the project.

Training course and workshop activities included demonstrations of the application and maintenance of the provided equipment. Six national training courses and five international workshops on fish disease diagnosis were conducted in collaboration with 11 host institutes in China, Viet Nam, Thailand, the Czech Republic, Poland and Chile see Appendix 2.

The training programme covered general fish and shellfish pathology and diagnosis technology, with emphasis on the standardization and dissemination of diagnostic techniques and on-farm diagnosis of fish and shrimp diseases.

The recommended techniques took into consideration the limited equipment facilities available in developing countries. Increased weight, especially in the form of belly fat, and high sugar intake are also high risk factors for heart disease.

Elevated amounts of Low-density lipoprotein LDL cholesterol, is the primary factor in heart disease. In order to avoid all the dangers of sugar, moderate consumption is paramount. Since the Industrial Revolution some two hundred years ago, the food processing industry has invented many technologies that both help keep foods fresh longer and alter the fresh state of food as they appear in nature.

Cooling is the primary technology used to maintain freshness, whereas many more technologies have been invented to allow foods to last longer without becoming spoiled. These latter technologies include pasteurisation , autoclavation , drying , salting , and separation of various components, all of which appearing to alter the original nutritional contents of food.

Pasteurisation and autoclavation heating techniques have no doubt improved the safety of many common foods, preventing epidemics of bacterial infection. But some of the new food processing technologies have downfalls as well. Modern separation techniques such as milling , centrifugation , and pressing have enabled concentration of particular components of food, yielding flour, oils, juices, and so on, and even separate fatty acids, amino acids, vitamins, and minerals.

Inevitably, such large-scale concentration changes the nutritional content of food, saving certain nutrients while removing others. Heating techniques may also reduce food's content of many heat-labile nutrients such as certain vitamins and phytochemicals, and possibly other yet-to-be-discovered substances. In addition, processed foods often contain potentially harmful substances such as oxidized fats and trans fatty acids. A dramatic example of the effect of food processing on a population's health is the history of epidemics of beri-beri in people subsisting on polished rice.

Removing the outer layer of rice by polishing it removes with it the essential vitamin thiamine , causing beri-beri. Another example is the development of scurvy among infants in the late 19th century in the United States. It turned out that the vast majority of sufferers were being fed milk that had been heat-treated as suggested by Pasteur to control bacterial disease. Pasteurisation was effective against bacteria, but it destroyed the vitamin C.

As mentioned, lifestyle- and obesity-related diseases are becoming increasingly prevalent all around the world. There is little doubt that the increasingly widespread application of some modern food processing technologies has contributed to this development.

The food processing industry is a major part of modern economy, and as such it is influential in political decisions e. In any known profit-driven economy, health considerations are hardly a priority; effective production of cheap foods with a long shelf-life is more the trend.

In general, whole, fresh foods have a relatively short shelf-life and are less profitable to produce and sell than are more processed foods.

Thus, the consumer is left with the choice between more expensive, but nutritionally superior, whole, fresh foods, and cheap, usually nutritionally inferior, processed foods. Because processed foods are often cheaper, more convenient in both purchasing, storage, and preparation , and more available, the consumption of nutritionally inferior foods has been increasing throughout the world along with many nutrition-related health complications.

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