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Clarksville TN Online is the voice of the people of Clarksville Tennessee.We take you beyond the ordinary in local news and gives the Extras: diverse political coverage including individual opinion pieces and editorial work, activism, local and regional arts and theater, municipal and county news and events, and more. [Read more]
To submit Clarksville Tennessee area news, story leads, tips, or press releases send us an email
Legendary tenor Luciano Pavarotti, 71, has died. He was considered to be the greatest tenor of his time, and retired in 2004, but was on a farewell tour when he was stricken with pancreatic cancer in 2006.
His family and closest friends gathered at his Modena home Wednesday evening as Pavarotti 's condition declined sharply. He had been treated for pancreatic cancer and was reportedly suffering from kidney failure, according to Italian news sources.
He filled his life with music, and his voice filled our lives with a beauty so intense, so overwhelming it made us cry for the sheer joy of it. Our ecstasy was mirrored in his eyes, his voice, his dazzling smile, and the sheer effervescence of his life.
This clip showcases Il Galdiatore, possibly his greatest vocal work. The slide show itself captures the essence, the heart, soul and music of this magnificent man and his larger than life career.
«Read the rest of this article»
Do you love her but she doesn't match up to your image? Is he dreamy but he's giving you mixed signals? You can be helped. Go on line and buy your tickets to Roxy Regional Theatre's live production of Grease.
This production, which debuts September 21 as the opening show in the Roxy's 25th anniversary season, features Matt Nolen of "You're the One That I Want," a TV show that gave different actors a chance to compete as Danny and Sandy.
What's cool? What's not cool? Relationship answers you've always been looking for will knock you upside the head in this live professional performance. What's that? Tell me more, tell me more, you say. It's been many years since John Travolta and Olivia Newton-John responded to those lyrics while romping across the grounds and hallowed halls of Rydell High. «Read the rest of this article»


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ANTIQUES GALORE JAMMED IN SHOW; Relics of the '20's and '30's Highlight Garden Fair
By SANKA KNOX ();
February 20, 1972,
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Artist Information
"I'd rather die living than live not at alive"
Words that Melissa Plett has come to live by. Whether she's playing solo or with her band These Guys, it's a high energy, foot stompin', country flavored good time!
Although Melissa was raised in the prairies of South Eastern Manitoba, her life was everything but simple.
At a young age, while playing in the fields, she faced a huge scare with her cousin when they were attacked by hundreds of wasps… poisoning and sending them to emergency. A few short years later, at age 13, her and this same best friend were in a traumatic ATV accident. Melissa was hospitalized for a month and a half with the left side of her body completely broken, fighting gangrene and potential amputation, and suffering a collapsed lung, leaving her fighting for her life and dealing with the death of her best friend.
Melissa may say "These things happen… everyone has their story!" but because of hers she grew up fast knowing that life can be taken at any moment, so she's been living life to the fullest ever since!
With ambition and passion for life, Melissa poured her heart out on the piano as a teenager, later was accepted to theatre school in New York, opting to study acting in Vancouver. She "fell into" radio, ran a live music venue and found herself travelling from coast to coast, from Mexico through America. Somewhere along the journey, she taught herself guitar and has been writing, performing and singing her heart out ever since, soaking in as much passion, life and stories her soul can carry.
In 2006, Melissa released a mellow and subtle EP called Repeated Stories, which revealed her heart and innermost gentle and softer side. However, after years of growth, including a showcase at the 2005 Winnipeg Folk Festival, festival gigging with trio group Little Black Dress, band make-ups and break-ups, she has finally found her own with Melissa Plett and These Guys.
Her new CD, Outside the City, shows the real Melissa Plett; A country girl who may be a little loud, a touch moody, but also extremely happy and full of energy! This girl loves to perform, entertain and tell a story with a giggle, wink, stomp, frown or a smile!
The "hint of country" in Melissa's music is directly related to growing up a truck driver's daughter, listening to the classics of Johnny Cash, Kitty Wells with a bit of soul added to the mix.
Her strong stage presence will captivate your attention while her unique and powerful voice seduces you. The stories she tells have the ability to move people, making them relate to their own life and personal history.
"Melissa Plett is a breath of fresh air. A real talent! She plays with such energy and passion it reminds me of how music used to be. Fun and full of legitimate passion. She clearly loves what she's doing and it's hard not to join in with her. Her music reaches in and touches your soul, while her voice sends shivers all the way down your spine… With the right people backing her this girl is set up to do amazing things!"
-Howard Mandshein, 92 CITI FM
"Melissa Plett's new live recording just might sweep you away with her great 'ol honest, rollin' off the cuff of your sleeve lyrics, tunes and vocals. Melissa Plett's music has the uncanny ability to make you drive to your local sock hop saloon, shake your booty and take in the exploits of this steamy story tellin' songstress."
- Joao Carvalho, Joao Carvalho Mastering
"She made a strong impression. She is a natural live performer with a strong, beautiful voice. She is totally at home on the stage."
- Jason Ringenberg, Jason and the Scorchers
"Melissa Plett is a singer-songwriter who draws on a wealth of experience and emotion that belies her youth, to craft a soulful, jazzy, country-tinged, roots/folk mélange that is as unique as it gets. Whether it's sad lyrics delivered with happy melodies
Dale Brown - Fiddle / Mandolin
Marie-Josee Dandaneau - Bass
David Pankratz - Drums
Best Friend Terri - Backing Vocals
Melissa Plett - Repeated Stories EP (2006)
Uh-Huh - Music Video
Melissa Plett - Outside the City (2010)
Title Track, Outside the City, has been featured on CBC Radio and Baby Please has been on various small town, and college radio rotations.
Melissa Plett - Manitoba (single is in pre-production to be released this summer)
Official Website
Let the good times roll!
Please click link to view!
Hootenanny Hoe-Down' in a Half Digi-Pack
[+ Show ]
When Melissa Plett throws a party, there are three things to be counted on: everyone is invited, eve...
Outside the City - CD Review
[+ Show ]
Recorded live off the floor at Private Ear Studios with local producer John Paul Peters in just thre...
Repeated Stories EP Review (March '06)
[+ Show ]
Melissa Plett Repeated Stories EP (Indie) B+ Released in January, Repeated Stories EP finds...
Repeated Stories EP Review (April '06)
[+ Show ]
MELISSA PLETT REPEATED STORIES INDEPENDENT FILE UNDER: The beginning of a beautiful friends...
Wolseley Musician males pilgrimage to Mexico
[+ Show ]
By James Turner March 15, 2007 Watching Melissa Plett interact with people at the small, b...
Approx. 45 min. in length made up of original songs with the occasional cover and my own version of a classic Johnny Cash song.
Although listed below are 2 "standard" sets, I am able to adapt longer set requirements or add a 3rd set!
Outside the City
Break Me
Thanks A Lot - (Neko Case)
Ode to Grand Forks
Murder Hill Road
Eyes that Didn't Cry
Those Blue Eyes
Fist City - (Loretta Lynn)
Baby Please
If Grandma Could Sing
Gotham City
Walk the Line - (Johnny Cash)
The Gambler - (Kenny Rogers)
Hound Dog - (Elvis)


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With college costs soaring, many families are looking hard at the potential payoff of various schools and degrees.
To be sure, few dispute the economic value of an undergraduate degree: Research from the Georgetown University Center on Education and the Workforce shows that students with undergrad degrees will earn more than $1 million more during their working years than those with high school degrees alone.
At the same time, many families are questioning whether they can justify paying more than $50,000 a year for tuition, especially if the student is targeting a career with modest earnings potential and/or if he will have to go into hock to earn that degree.
In this week's Discuss forum thread, I asked Morningstar.com readers to address the extent to which return-on-investment considerations had factored into their decision-making about college--for themselves or for their children.
Not surprisingly, responses varied far and wide. Several posters--and I'll put my 18-year-old self in that camp--said ROI never came up when discussing college or choice of major. Acquiring knowledge is valuable regardless of the financial payoff, these posters believe. Others said that they had considered ROI and adjusted college plans accordingly.
Yet, others said that the individual--not his degree or alma mater--is the most influential factor in an individual's success, so parents and students shouldn't get overly hung up on the prestige of a school if a young person has talent and discipline. Posters also weighed in on the skyrocketing cost of college and noted that alternative (and cheaper) routes to higher education beckon.
To read the complete thread or share your own take on this question, click here (http://news.morningstar.com/articlenet/article.aspx?id=616203).
'Going to College Changes a Person'
A contingent of posters believes that college's main benefits aren't financial at all, and therefore calculating a return on investment isn't a worthwhile exercise.
GregLee wrote, "You might as well ask the ROI for attending church on Sunday. It's not something people do for the money, though it surely does impact the bottom line. The purpose is social or spiritual. A college degree has become an essential credential for a respectable, middle-class life in our society."
Dlprice--speaking from experience after sending four kids through school--agreed that the return on an investment in higher education goes way beyond dollars and cents. "All four kids are greatly changed for their experiences," she wrote. "They are more broad-minded, analytical, and politically/socially/globally aware. Like having children, going to college changes a person in a way that's hard to describe to those who haven't experienced it. Not all impressive ROIs can be measured in financial terms."
Marimoore, also speaking from experience, agreed. "My husband and I paid for our three children's college education with the belief that college will teach them to think clearly, communicate effectively, and connect with the great thinking of the ages. Vocational school, whether it be law school, business, medical school, comes after. Their lives would be richer and more fulfilled if they became an educated handyman or educated corporate executive. ROI was not and is still not a factor in our belief in a college education."
FidlStix, who received a Ph.D. in physical science, agreed that some of the best returns on higher education can't be quantified. "Looking back, I'd say the ROI of my education is inestimable, not from a narrow dollar perspective, but from the panorama of an ability to think critically and delve deeply into concepts only collaterally related to physical science--including researching stocks and funds for investing."
Several posters were unequivocal: ROI considerations had played no role in their college decision-making process, perhaps because tuition was a lot lower back in the day.
Peter5 was one such respondent, but said that the return has been there all the same. "Neither my parents nor I did any calculations prior to or after college to figure out the ROI. In the 1980s it was just expected that I would go to college (my parents had both gone to college as did most of their friends, and so on) and that the expense would be worthwhile. And indeed it has been, in spades."
'Any Grad Can Succeed or Fail'
Numerous posters were skeptical about a return on investment for college expenditures simply because each person is so different.
In Bubbygator's view, the individual matters a lot more than his degree or alma matter. "It's difficult to 'personalize' the ROI on a four-year-degree," this poster wrote. "The bachelor's degree, in whatever, is simply the key to open the door. Once you get inside the door, what you make of your opportunity depends on you, not that piece of paper. There have been large-number studies of this question, and results categorized to certain types of schools/degrees. But on a personal basis, any grad can succeed or fail based on what he does after college."
On the same page is Jomil, who wrote, "I believe that the prestige of your alma mater can open doors to employment, but job availability, contacts, resume, and personality are probably more important."
A story from Catherine72 testifies to the importance of the individual rather than where the degree is from in shaping one's career trajectory. "I have my master's in chemistry," she wrote. "For the undergraduate portion, I was on scholarship. I had to choose between a 'lesser' school with full scholarship and a 'better' school with only a half scholarship. I choose the full scholarship. When I tried to enter the field, where I had attended may have negatively influenced if I was accepted for an interview. But my personality/creativity/intellect could get me the job. Once I had my first job--it was easy from there."
'Getting the Most Out of the Meager Bucks Available to Me'
Other respondents, however, said that ROI considerations were in the mix when helping their children make decisions about college, or when making their own decisions.
Among the most pragmatic of posters was rllucky, who wrote, "Whatever type of post-secondary education is chosen, it has to be a field of study that can get someone a good paying job and that is relatively affordable. The costs have skyrocketed over time so it makes no sense to attend an Ivy League or other high cost private school to become a school teacher etc., unless they want to practice medicine or law, then the pedigree matters. The lower-cost public universities do more than an adequate job of preparing students for the workforce. I went to a public university, got a great education, and have a decent paying job, with virtually no debt after I graduated. From an ROI perspective, it was the best investment that I ever made."
Cliff, too, was motivated by ROI considerations when pursuing higher education, even though ROI may not have been in the vocabulary. "Without a doubt, getting the most out of the meager bucks available to me at the time hugely influenced not only where I studied but what I studied. I was the oldest of a large bunch of kids, therefore the first out of the nest. In our family, when you were 18, you got handed your pillow and got a pat on the back and an invite to Thanksgiving dinner."
Ridg0008 chose a field that was of great interest, but economic considerations were definitely in the mix, too. "My choice of major [physics] was certainly influenced by job prospects, and I went to a large land-grant university in my home state rather than go into debt to attend a private school. I also didn't rely just on the school in terms of assessing job prospects: I talked to people in the field, and reviewed job openings."
For bnorthrop, maturity brought ROI considerations (and not just financial ones) to the fore. "I attended seven institutions of higher education in five states over many years. I was driven solely by the desire to learn particular subjects, not to get a degree. However, when I finally settled down, it became clear that a degree would open doors to more opportunities with higher satisfaction and compensation. That motivated me to finish my degree which led to a rewarding career in, ironically, higher education. My investment in a college education will allow me an early retirement and expanded resources to pursue other interests. I consider my ROI to have paid handsomely."
Evolence didn't have ROI considerations in mind when making decisions about his own education, but he will certainly encourage his kids to do so. "I hope to instill in [my son] that college is not about learning, not about making friends, and not about studying something that you think is 'fun." College should be about investing in your future, with the ultimate goal being to create opportunities in satisfying employment that will pay far better than other job opportunities. So if you are going to pay for the investment, think about what it will get you in the long run. Philosophy is a great field to study, but in terms of employment prospects. Do you want to work at Starbucks the rest of your life?"
Danielle and her spouse offered their kids a choice that factored in ROI considerations. "We told our two college students (and the third who is still in high school) that we would only be willing to pay full freight at an 'elite' private (high return) or an in-state public school (low investment). Otherwise, they would need merit aid."
The Dragonpat clan also considered career path when determining whether to pony up for tuition with a higher sticker price. "I guess that there was more than just ROI that went into the decision, but it was a factor. I paid out-of-state tuition for my oldest daughter. If she had been attending art school (what my second daughter studied), I would not have paid the $45,000 a year it cost to send her out of state to Michigan, but [my first] daughter studied engineering."
Educator PatrickBr, in a lengthy post that's a must-read for anyone who's interested in this issue, also has ROI (and other) considerations in mind when he counsels students about their next steps. "I've certainly encouraged students to finish up, not start new programs, drop out if they seem to be adrift, and forgo that loan that will make the unnecessary trip to Australia or somewhere else possible. And others, I have helped them to find or get scholarships, take more efficient paths to graduation that include paying internships and jobs, all with an eye toward keeping them away from long-term debt. That to my mind is the best financial ROI--minimize the 'I $' part so that whatever R is, it is a good investment."
'U.S. Universities Have All but Priced Themselves Out of the Market'
Other posters said that because of rising college tuition costs, ROI considerations are necessary--and the math may not add up in some instances.
Danielle opined, "The ROI I experienced having graduated med school in 1988 with debt less than the cost of a new car isn't reasonably going to be duplicated by my kids. The current cost of a college degree compared to future earnings is simply astronomical--there just is no comparison. It's a whole different calculus."
Alpro1 agreed that funding college is a growing challenge. "College is outpricing itself and unless some changes are made soon the next generation will not be able to afford it."
Owing to skyrocketing costs at traditional four-year universities, Michaeltbf expects to see innovation in the decades ahead, "U.S. universities have all but priced themselves out of the market. As the price of all education continues to rise much faster than inflation, the number of degrees that will EVER deliver a positive return gets smaller each year. In fact, universities may well be the future buggy whip industry as more and more knowledge becomes free for the taking on the Internet, like from the Kahn Academy."
Indeed, Carrie is anticipating that the college experience for students a decade from now may well be different from what it is today. "With the rise of MOOCs [massive open online courses], higher education is changing so quickly, I have no real idea what the lay of the land will be in nine years."
- Personal Finance - Career & Education
- Investing Education
- undergraduate degree


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chau1027 Posts:7 Followers:0 game of the week 2 Replies | 495 Views On 11/27/2011 11:14 AM in NFL game of the week will be carolina -3.5 ,colts team is already giving up their season,time to make a big money good luck. 0 1 See Voters Post Reply Follow Member Share Post Comment Advanced Mode Post Comment
btb Posts:2212 Followers:140 11/27/2011 02:22 PM Good luck like Caro and the over myself. Panthers gave them some easy points Newton needs to step up second half » Last 30 Days Record: 5-2-1 » All Time Record: 263-287-7 0 0 Post Comment Advanced Mode Post Comment
chau1027 Posts:7 Followers:0 11/29/2011 07:45 PM start bet against the colts will get a nice profit at the end of the season 0 0 Post Comment Advanced Mode Post Comment


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We came, we saw, we enjoyed. Run by a friendly couple with just the right tips for us to enjoy our short stay - four ageing schoolmates we are. If you want quality accommodation at a reasonable price, you could hardly do better.
- Also Known As:
- Bowden Lodge Hotel Southport, England
- Official Description (provided by the hotel):
- Detached Victorian ... more less


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Last Updated: Friday - 09/24/2010Week of September 10, 2007Artists interpret Christ on the crossNew Mexico sanctuary offers a spiritual journey set in the biblical pastExaltation of the Cross – September 14
By TED FITZGERALD
Santa Cruz de la Cañada owes its name to the holy cross on which Christ was crucified, |
Santa Cruz Church, which has provided more than 250 years of uninterrupted service to the people of the area, is two miles east of the larger Rio Grande centre of Espanola in New Mexico highway 76 northwest of the state capital of Santa Fe.
The second Spanish town established in New Mexico - Santa Cruz - began in 1695 and for more than 100 years was the government administrative centre for the area north of Santa Fe. The second church built here was dedicated in 1776 and has been served for the last 87 years by priests of the Congregation of Sons of the Holy Family.
Santa Cruz was the temporary repository of the statue of Our Lord of Esquipulas discovered at nearby Chimayo in 1814.
Today, it's still an active community centre with all attendant religious and lay organizations. Mass is celebrated twice daily and six times on weekends. Since recent restoration, it's been placed on the National Register of Historic Places.
- WCR photo by Ted FitzgeraldEl Santo Entierro (Christ in the tomb) in Santa Cruz Church dates from 1776. |
The entrance to the church compound is by way of a broad, arched opening in the traditional low adobe wall that surrounds the landscaped churchyard. One large doorway gives access to the building's interior.
Inside, the church is the repository of dozens of old examples of the santeros' (wood carvers and painters of religious subjects) art, mainly relating to Christ's death on the cross. Dominating the nave is a large retablo behind the main altar that includes a priceless crucifixion by a noted area carver and several oil paintings, gifts of the Spanish king when the church opened.
A life-size, glass enclosed entombment dates from 1776. Christ in the tomb (El Santo Entierro) is a familiar adjunct to many southwestern churches. To its right stands another example of early santero art, a statue of Nuestro Padre Jesus Nazareno. This is a traditional image of Jesus the Nazarene being abused by the Roman soldiers.
In Mark 15:16-20 it is recorded how his tormentors placed a royal purple robe on Jesus, crowned him with thorns, proceeded to mock him as King of the Jews and strike him on the head with a reed.
They then led the suffering Christ out to carry his cross to his death on Calvary. The image of the Nazarene is another popular item in many southwestern and Mexican churches as a brutal reminder of the passion.
Many will find a visit to his New Mexico sanctuary a contemplative and restorative experience, an immersion in the very old, both biblically and historically.
Our mission: To serve our readers by bringing the Gospel to bear on current issues in the Church and in secular culture through accurate news coverage and reflective commentary.


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Great Holiday GivingGreat Western Bank |
Black Friday and Thanksgiving weekend is a time for shopping and giving and opening up a new bank account. While it might seem a little out of the ordinary, Strategic America collaborated with Great Western to leverage its in-store locations, conveniently located within retail stores like Walmart. The 15 in-store locations offered a promotion to drive in-store traffic to open up a free checking account and savings account.
SA quickly rolled out a creative strategy, "Great Holiday Giving" using geo-demographically targeted direct mail, e-mail blasts, flyers, lapel badges and POS signage to capture the attention of bargain hunters. By recommending a lead generation promotion (that produced several hundred leads) to go along with opening a checking account, consumers were instructed to bring in the direct mail piece for the opportunity to win an iPad™, Nook™ or cash.


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Musicologist, Anna Harwell Calenza tells young readers how it was that Duke Ellington and his collaborator, Billy Strayhorn, came to transform Tchaikovsky's classic Nutcracker Suite into a collection of jumpin' jazz melodies. Based on historic fact, this is a terrific way to introduce young audiences to jazz, using familiar music that they recognize as they hear the new variations. The story reflects how reluctant some of the band members were to playing ballet music and how the work of two masters opened their ears and minds. Vivid colors dance through the pages of the handsome book that comes with an orchestral CD of the composition played by Duke Ellington himself and members of his orchestra.
Age: Early School Years, Later School Years. Award Year: 2011.
Marjorie W. Sharmat's series has long been a staple for young chapter book readers. This 4-disk set includes The Lost List, The Sticky Case, The Fishy Prize, The Boring Beach Bag, The Mushy Valentine, Talks Turkey, and the Hungry Book Club. These are good for car pool quiet time or afternoon rest time. Bringing home some of the recordings give young readers a way into a series that they may then go on to enjoy on their own. 9 and up.
Age: Early School Years, Later School Years. Award Year: 2011. Click here to purchase the product on Amazon.com.
In this most recent recording of a Magic Tree House adventure, Jack and Annie are off to ancient India where they must find a magical emerald in order to rescue Penny, a penguin that has been put under a spell and turned to stone. Read by the author, Mary Pope Osborne, this is one of a series that 9-12 year olds love. Bringing home a 2 CD set may be a great way to whet their appetite to both hear and read more of the dozens of Magic Tee House stories. We like that it combines some fantasy with history and adventure that is right on the mark for this age group. They like having some familiar characters that ease them into each new story. Also new this season, Dogs in the Dead of Winter, a Swiss adventure.
Age: Early School Years, Later School Years. Award Year: 2011. Click here to purchase the product on Amazon.com.
Oppenheim Toy Portfolio - All Rights Reserved. Oppenheim Toy Portfolio, Oppenheim Toy Portfolio Platinum Award, and Oppenheim Toy Portfolio Blue Chip Award are Registered Trademarks of the Oppenheim Toy Portfolio. |
Instructions for submitting product to the Oppenheim Toy Portfolio for review. |
Contact the Toyportfolio by phone at (212) 598-0502 or by email at email@example.com. Copyright 1995-2013 Products reviewed by the Oppenheim Toy Portfolio are provided by the manufacturer at their cost. The Oppenheim Toy Portfolio does not require or accept fees for reviewing products. |


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To access other email accounts (also known as generic email accounts), that you have permissions to, please read the information below:
How do I access my generic email account?
- You can access your generic email account by going tohttps://email@example.com. (Replace genericaccountemailaddress with the email address of the generic email account you either own or are a member of.)
- You will now be prompted to login
- Once login is successful you may now access the account in OWA
How can I get access to my Generic Email Account in myNova?
- To access your generic email account in myNova, please click on the following link and go to "How do I customize myNova?" for instructions:http://www.villanova.edu/unit/support/luminis/external_faq.htm
How do I add or remove owners & members?
- Only owners can add additional owners or members to a generic email account.
- To add or remove members or owners of the generic email account, please click on the instructions on the right hand side called "Generic Account Maintenance".
Can I access my generic email account another way?
- You can also access a generic email account (that you own or are a member of) within your own OWA account. Please click on the instructions on the right hand side called "User's OWA Account"
Looking ahead….
In the future, we will implement a new process for maintaining the generic email accounts. For example, we will require a designation of an account owner, who will administer the addition, deletion, or modification of names within the account, as well as manage the account as per these guidelines.
- These accounts will be created with an expiration date of 1 year, at which time the owner can request a renewal, which will be granted pending verification of ownership and the member list.
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If you have any questions, please contact the Helpdesk @ 97777 or email@example.com.


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text: What's In It For Me? – The Key Question Companies Ask of Cloud Computing "What's in it for me? I've got to ask, If it's only more tears Then I'll have to pass. If you'll open up Then I can see, Deep in your heart What's in it for me?" – John Berry, American country singer and songwriter. The key to selling anything – a product, a service, an idea – is the ability to convincingly answer the one question every customer has on his or her or its (if you are selling to an organization or company) mind –


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Protein-Energy Malnutrition (Encyclopedia of Medicine)
Protein-energy malnutrition (PEM) is a potentially fatal body-depletion disorder. It is the leading cause of death in children in developing countries.
PEM is also referred to as protein-calorie malnutrition. It develops in children and adults whose consumption of protein and energy (measured by calories) is insufficient to satisfy the body's nutritional needs. While pure protein deficiency can occur when a person's diet provides enough energy but lacks the protein minimum, in most cases the deficiency will be dual. PEM may also occur in persons who are unable to absorb vital nutrients or convert them to energy essential for healthy tissue formation and organ function.
Although PEM is not prevalent among the general population of the United States, it is often seen in elderly people who live in nursing homes and in children whose parents are poor. PEM occurs in one of every two surgical patients and in 48% of all other hospital patients.
Types of PEM
Primary PEM results from a diet that lacks sufficient sources of protein and/or energy. Secondary PEM is more common in the United States, where it usually occurs as a complication of AIDS, cancer, chronic kidney failure, inflammatory bowel...
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Protein-Energy Malnutrition (Encyclopedia of Children's Health)
Protein-energy malnutrition (PEM) is a potentially fatal body-depletion disorder. It is the leading cause of death in children in developing countries.
PEM is also referred to as protein-calorie malnutrition. It develops in children whose consumption of protein and energy (measured by calories) is insufficient to satisfy their nutritional needs. While pure protein deficiency can occur when a person's diet provides enough energy but lacks an adequate amount of protein, in most cases deficiency will exist in both total calorie and protein intake. PEM may also occur in children with illnesses that leave them unable to absorb vital nutrients or convert them to the energy essential for healthy tissue formation and organ function.
Types of PEM
Primary PEM results from a diet that lacks sufficient sources of protein. Secondary PEM is more common in the United States, where it usually occurs as a complication of AIDS, cancer, chronic kidney failure, inflammatory bowel disease, and other illnesses that impair the body's ability to absorb or use nutrients or to compensate for nutrient losses. PEM can develop gradually in a child...
(The entire section is 1533 words.)
Malnutrition: Protein-Energy Malnutrition (Encyclopedia of Food & Culture)
MALNUTRITION: PROTEIN-ENERGY MALNUTRITION. Protein-energy malnutrition (PEM) may be present at any time during the life cycle, but it is more common in the extreme ages, that is, during infancy/childhood and in the elderly. The present review will be restricted mostly to the condition present during infancy and childhood.
Protein-energy malnutrition is a syndrome characterized by its progressive onset and a series of symptoms and signs that encompass a continuum, ranging from clinically undetected manifestations to the full-blown clinical picture of marasmus or kwashiorkor. A syndrome is defined in clinical practice as a set of symptoms and signs that may be caused by different etiologies.
In the case of PEM, the earliest symptoms include subtle changes in the mood of the child, which may be described by the mother as saying that the child is not as playful as he/she used to be. Further changes include a loss of appetite and a loss of interest in the surroundings, which lead to decreased social interaction with peers or siblings and adults (parents or other caregivers). When PEM becomes more severe, there are adverse effects on the child's cognitive and behavioral development, evident in both the short and the long term.
In relation to signs, the earliest clinical sign of PEM is the lack of adequate weight gain. Also common in the early stages are mild episodes of common acute infectious diseases, such as acute diarrhea or acute respiratory infections. As the condition advances, the child will show signs of body wasting, progressing to an extreme thinness. If the syndrome becomes chronic, there are small or no increases in length. When the condition becomes more severe, the child may show the clinical pictures of marasmus or kwashiorkor, which will be defined later in this article.
The etiology of protein-energy malnutrition as a syndrome may be classified as primary or secondary. Although in practice most cases of PEM are caused by a combination of both, the concept may be useful for targeting interventions. Primary PEM refers to a deficit of available food. This, in turn, may be because of biological conditions, such as maternal malnutrition prior to or during pregnancy and lactation, or to social conditions, such as poverty; to a limited or selective unavailability of food; to war; to ecological disasters leading to famine, or, more often, as a result of profound social inequalities, either at the individual level (discrimination, refugees, prisoners) or at the community or country level. The largest prevalences of protein-energy malnutrition are found in socioeconomically deprived areas of the world, as will be reviewed further on in this article. Secondary causes of PEM include several conditions that impair food intake, absorption, or utilization, or that increase energy and/or protein requirements or losses. Secondary causes of PEM may be biological or social conditions.
Biological conditions may interfere with food intake, such as congenital anomalies (for example, harelip); with absorption, such as any of several malabsorption syndromes (for example, tropical sprue); or with utilization, such as inherited metabolic diseases (for example, phenylketonuria). Biological conditions that increase the need for energy include all infectious diseases accompanied by fever, and other diseases that increase catabolism, such as tuberculosis, or that are accompanied by an increased nutrient loss, such as intestinal parasitism.
On the other hand, social causes that affect food intake, whether it be in quantity or quality (protein-energy or micronutrient content), include several conditions associated with poverty, such as ignorance, inadequate weaning practices, child abuse, alcoholism or other drug addictions, and others.
Different conceptual frameworks for the study of malnutrition have been proposed and adopted throughout the years; one of the most widely accepted ones was developed during the WHO/UNICEF Joint Nutrition Programme in Iringe, Tanzania (B. Jonsson et al., 1993) (UNICEF 1990), from where it has been extended to many parts of the world. An appealing feature of this conceptual framework is that it may be adapted to describe causes of the major nutritional deficiencies present in the world, including vitamin A, iron, and iodine deficiency.
Clinical Picture of Marasmus and Kwashiorkor
Marasmus is characterized by a chronic and severe restriction of both energy and protein to the body. Marasmus is more frequently found at a younger age than kwashiorkor, usually in children under one year of age. A marasmic child presents severe wasting, with a very low weight-for-age and reduced length-for-age, often below -3 standard deviation of the reference population values. The clinical history of a marasmic child may reveal poverty or famine affecting the family; inadequate child-rearing practices, like starvation wrongly prescribed as part of the management of diarrhea; an early stopping of breast-feeding; over-dilution of formula; a history of repeated and/or chronic infections, such as diarrhea or tuberculosis; or some physical condition that affected the child's growth and development, such as prematurity, mental defects, or a malabsorption syndrome. The mother or caregiver will often report that the child is hungry. On a first appreciation, the child may be interested in the environment, with an active cry and reaching for food if offered, or else he/she may be depressed to the point of coma. The typical clinical picture is that of a striking loss of subcutaneous fat and muscle wasting, observed as markedly thin limbs, an evident rib cage, sunken cheeks and eyes that give the child a "monkey-like" or gaunt appearance, a prominent abdomen (although with no evidence of an enlarged liver), and a relatively big head. The hair is often thin and dry, and comes off easily. However, skin rashes or dermatosis are not usually present. Common micronutrient deficiencies include vitamins A and D, zinc, and iron, although anemia is less common in marasmus than in kwashiorkor.
The clinical picture of kwashiorkor is not as striking in appearance, as this syndrome often affects slightly older children, i.e., between one and three years of age. The clinical onset of kwashiorkor usually takes place in a shorter period of time as compared to marasmus, and is characterized by a relative, though severe, limitation in protein intake, with a lesser involvement of energy deficit. A child affected with kwashiorkor is often apathetic to external stimuli, is irritable, and gives the impression of misery, rejecting or crying when cared for. The most salient clinical characteristic of this syndrome is the presence of edema, which may mask the evidence of body weight loss and reduced length in relation to age. It is also common to find skin lesions that range from a flaky, pink dermatosis with skin dryness and depigmentation to deep ulcerations. Also common are petechiae and ecchymoses, as well as clinical signs of anemia. The hair presents discoloration with bands of dark and light hair (described by clinicians as the "flag sign"). An enlarged, fatty liver is also characteristic of kwashiorkor, palpable as a soft mass under the right rib cage. Co-occurring micronutrient deficiencies are common, so clinical signs of deficiencies of specific vitamins, including A, B, C, D, iron, or others, also may be present.
Classification of Protein-Energy Malnutrition
The clinical signs of severe PEM are so impressive that, for several years, they drew the attention of pediatricians and other physicians interested in furthering the understanding of the clinical syndromes and their treatment. Therefore, the study of PEM was long confined to the hospital setting. Actually, the first classification of PEM came from Mexican observers, who ranked the severity of malnutrition based on the risk of death for children with a clinical diagnosis of PEM. This group, led by Gomez, proposed that children with a weight-for-age deficit greater than 40 percent in relation to a reference population were in the greatest risk of dying, and thus labeled them as having third-degree malnutrition. Further, children with 250 percent weight-for-age deficit were labeled as having second degree malnutrition, and children with 105 percent weight-for-age deficit were classified as having first degree malnutrition (Gómez-Santos, 1946).
This classification had a high predictive value for the risk of death, and therefore had important implications for clinical practice. It was further abused, however, when its use was extended to the classification of malnutrition at a population level. In other words, children with no evidence of clinical malnutrition who have low weight-for-age should not be classified as malnourished; doing so may not only misdiagnose an individual, but may over-estimate the prevalence of malnutrition in a population. Also, the Gomez classification has been criticized because a single measure of a child's weight referred to age gives no idea about the nutritional history of the child. That is, an underweight child may be growing according to his/her normal growth channel, may be recovering from a recent episode of weight loss ("catch-up growth"), or may be deteriorating in relation to the recent past.
In order to overcome these caveats, Waterlow proposed combining weight-for-height, as an indicator of an acute episode of malnutrition, with height-for-age, as an indicator of chronic nutritional deficits that would be reflected in growth stunting (Waterlow, 1972).
Although these classifications have been used for several years, they have two important disadvantages that often are overlooked. To illustrate the first disadvantage, it is important to highlight the concept of Z-scores as a means of describing an individual child's anthropometric indicators in a normal distribution. The normal distribution of a reference population has been published by the World Health Organization (WHO) and is most often accepted worldwide as the standard for comparison. Eighty percent of the median weight-for-age might be above or below -2 Z-scores, depending on the child's age. The second disadvantage is that, to approximate a fixed point in the normal distribution, say, -2 Z-score, different percents of median have to be used depending on the anthropometric index usedor example, 90 percent for low height-for-age, or 80 percent of low weight-for-height.
In consequence, the World Health Organization Expert Committee on Physical Status has recommended the use of Z-scores to express weight-for-age, weight-for-height, or height-for-age relative to values reported in a reference population (WHO Expert Committee on Physical Status, 1995). The use of this system has several advantages; i.e., when applied at a population level, it allows the mean and standard deviation to be calculated for a group of Z-scores, and it allows the use of fixed cut-off points (i.e., -1, -2, or -3 Z-scores) to classify mild, moderate, or severe deficits for any anthropometric indicator. Although the use of Z-scores may be difficult to grasp for those who have been accustomed to classifying nutritional deficits based on the percent of median, the advantages of Z-scores outweigh their disadvantages.
Global Prevalence of Protein-Energy Malnutrition
The most recent estimates about the distribution of PEM at a worldwide level were compiled by the World Health Organization (WHO) Programme of Nutrition, available in its Global Database on Child Growth and Malnutrition (de Onis and Blössner, 1997). This database covered 95 percent of the total population of children under 5 years of age who lived in 103 developing nations in 1995, as was reported in nationally representative surveys available at the time. According to these data, an estimated 206.2 million children, who represent 38 percent of all children under 5 years old, were stunted (low height-forage); 167.3 million children (31 percent) were underweight (low weight-for-age), and 48.8 million children (9 percent) were wasted (low weight-for-height). PEM is most often found in the poor regions known as the "developing world." The largest number of affected children were found in Asia, where 41 percent of all under 5 years old were stunted, 35 percent were underweight, and 10.3 percent were wasted. Africa had 38.6 percent stunted, 28.4 percent underweight, and 8 percent wasted children of all those under 5 years old; Latin America and the Caribbean showed 17.9 percent stunted, 9.5 percent underweight, and 3 percent wasted children of all those under 5 years old. The proportion of children under 5 years of age affected in Oceania was 31.4 percent, 22.8 percent, and 5 percent, respectively, but the total number of children living in this region is much lower, so in reality, these percentages translate into many fewer children affected than in the other regions.
Since the mid-1980s, the Administrative Committee on Coordination/Sub-Committee on Nutrition (ACC/ SCN) of the United Nations periodically has examined the trends of malnutrition in the world's children. In its Third Report on the World Nutrition Situation (ACC/ SCN, 1997), this Committee (from data from 61 countries) estimated the trends in stunting with two or more nationally representative surveys. In the period from 1980 to 1995, stunting declined globally at a rate of 0.54 percentage points per year. Sub-Saharan Africa had an increase of 0.130 percentage points per year in the average prevalence of stunting; the remaining regions of the world showed statistically significant decreases that ranged from -0.26 in Middle-America and the Caribbean to -0.90 in Southeast Asia (Table 1).
The same Committee was able to use data from 95 countries that had data from at least one national survey to estimate the prevalence of undernutrition; underweight and stunting showed a consistent 11.5 percentage point difference. The higher prevalence was for the underweight classification. During the 1980995 period studied, only sub-Saharan Africa had an increase in the prevalences of both stunting and underweight; all the other regions showed decreasing trends in these two indicators (Table 1).
Acute and Long-Term Consequences of Protein-Energy Malnutrition
PEM results from a relative deficiency of protein (essential amino acids and/or total nitrogen) and energy substrates (carbohydrates, fats, or proteins). However, these deficiencies are almost always accompanied by micronutrient (minerals and vitamins) deficits. Manifestations of PEM differ depending on the duration, the severity, and the combination of these deficiencies. In the early stages,
Estimated prevalence of stunting (%) and numbers of children affected for 1980, 1985, 1990, and 1995 and by region | |||||||||
Prevalence stunting | Numbers stunted (in millions) | ||||||||
Region | 1980 | 1985 | 1990 | 1995 | 1980 | 1985 | 1990 | 1995 | % Increase/decrease in numbers from 1980 to 1985 |
Sub-Saharan Africa | 37.4 | 38.1 | 38.7 | 39.4 | 26.255 | 30.832 | 36.248 | 42.590 | +62 |
Near East/North Africa | 30.8 | 25.9 | 23.0 | 22.2 | 11.397 | 10.991 | 10.865 | 10.913 | -4 |
South Asia | 66.1 | 61.9 | 57.7 | 53.5 | 88.873 | 93.237 | 91.520 | 89.877 | +1 |
South East Asia | 51.9 | 47.3 | 42.8 | 38.3 | 35.581 | 32.862 | 30.119 | 30.206 | -15 |
Middle America/Caribbean | 31.6 | 30.4 | 29.1 | 27.8 | 5.398 | 5.467 | 5.631 | 5.626 | +4 |
South America | 25.0 | 21.0 | 16.9 | 12.9 | 8.285 | 7.309 | 5.965 | 4.644 | -44 |
China(1982) | 31.4 | 36.068 | |||||||
Across all regions (excluding China) | 48.8 | 45.6 | 42.5 | 39.9 | 175.789 | 180.698 | 180.348 | 183.856 | +5 |
Note: These estimates were derived assuming a linear relationship between stunting and year. The only region for which there was evidence of a nonlinear relationship was Near East/North Africa. For this region, a quadratic model was used to approximate the nonlinear relationship. The estimated prevalence values for this region were from this model. |
there are functional impairments, which are later followed by biochemical and physical damage.
The identification, understanding, and treatment of the full-blown clinical syndromes characteristic of severe PEM began in the mid-1930s with the description of kwashiorkor (Williams, 1933). On the other hand, the identification and understanding of the functional manifestations of malnutrition have only come about during the last three decades of the twentieth century, with the launching of two large-scale, community-based research projects: the first one, known as the INCAP Longitudinal Study, was based in Guatemala (Habicht and Martorell, 1992). The second took place simultaneously in three countriesgypt, Kenya, and Mexicond was known as the CRSP study (Calloway, Murphy, et al., 1988).
Functional consequences of protein-energy malnutrition. As described earlier, the functional consequences of PEM were recognized and studied only relatively recently (Allen, 1993). Among the most well documented functional consequences of PEM are growth impairment, a reduced immune response, and a disruption in cognitive ability.
Growth impairment. Growth failure because of PEM usually starts to manifest very early in life. Information from the INCAP longitudinal study, as well as from the CRSP studies, coincides in showing that growth stunting begins at about 3 to 4 months of age and is complete before 18 months (Allen, 1995). A further contribution from the INCAP study was provided by a long-term follow-up of the same populations that showed not only that growth stunting present during infancy carried on until adolescence, but also that length at 3 years of age was a strong predictor of adolescent size (Martorell, Schroeder, et al., 1995). It also seems as if stunting in early life is correlated significantly with reduced physical performance (Haas, Martinez, et al., 1995) and reduced psychomotor and mental performance, both during late childhood (Mendez and Adair, 1999) and even until adolescence (Grantham-McGregor, 1995; Pollit, Gorman, et al., 1995).
Two more relevant issues related to growth failure are that there is a window of opportunity for intervention from the ages of 3 to 6 months, when response to the intervention may be greatest (Lutter, Mora, et al., 1990), and that most of the growth deficit found at later ages accumulated during the first months of life (Rivera, Cortes, et al., 1998).
Immune response. It has been recognized that malnutrition is the most common cause of immunodeficiency worldwide (Chandra, 1991). Actually, malnutrition and infection interact in a vicious cycle: the presence of one more easily leads to the development of the other (Scrimshaw, Taylor, et al., 1968). There are several mechanisms involved in this relationship. PEM impairs cell-mediated immunity, phagocitic function, and the complement system. It also diminishes immunoglobulin (IgA, IgM, and IgG) concentrations, and cytokine production (Chandra, 1991). Micronutrient deficiencies associated with PEM also adversely effect the immune response. For example, iron plays an important role in several metabolic functions, including both the host and invasive bacteria. Several microorganisms that infect the human body only achieve their full infectious activity in the presence of iron. Such is the case of bacteria that cause diarrheal disease, such as Escherichia coli, Yersinia septica, Salmonella sp., and Vibrio cholerae; and others responsible for lower respiratory infections, such as Mycobacterium tuberculosis, Klebsiella pneumoniae, Pseudomona aeruginosa, and Listeria monocytogenes. These microorganisms actively seek iron in their host during infection, uptaking it from destroyed red cells (erythrocytes) and body stores (liver). On the other hand, the host tries to make iron less available to invasive microorganisms, sequestering it through different mechanismseferred to as nutritional immunityhat include the binding of iron to transferrin and lactoferrin, and the increase in ferritin saturation in the liver (Kochan, 1976). Other micronutrients that play active roles in modulating immunity include zinc, selenium, copper, vitamins A, C, E, B 6, and folic acid (Nezu and Nakahara, 1994).
Conversely, infectious diseases lead to malnutrition by several mechanisms that often interact with each other. Almost every malnourished child will sooner or later present with diarrhea. Many of the interactions between malnutrition and infection are understood because of studies of diarrheal disease (Chen, 1983); hence the illustration of the mechanisms by which these two morbid conditions interact is particularly useful. One of the first symptoms of diarrheal disease is anorexia, as a result of vomiting and abdominal discomfort. Also, fever, dehydration, and electrolyte imbalances contribute to it (Martorell, Yarbrough, et al., 1980). Anorexia leads to a restricted intake, which is often reinforced by erroneous caregiver practices. In part, it is culturally engrained in different societies to withhold food from a diarrheaaffected child (Bentley, 1988), and it is also quite common to find physicians who still think that it is necessary to "put the bowel to rest" during the acute stage of the illness (Brown and MacLean, 1984). The deleterious effect of decreased food intake is worsened by increased catabolic losses of nitrogen that occur as a result of increased metabolic rates and structural damage to the intestine (Powanda, 1977). Another consequence of intestinal damage is the transient loss of absorptive surface and absorptive function as a result of villous atrophy (Davidson and Barnes, 1979). This condition leads to a decreased absorption of macronutrients (fat and carbohydrates) and micronutrients (particularly fat-soluble vitamins). The presence of unabsorbed carbohydrates in the intestinal lumen increases the osmolarity of the intestinal content, thus causing an hyperosmolar diarrhea (Wapnir, 1982). It also subjects these substrates to bacterial fermentation, which produces gas and intestinal bloating, worsening gastrointestinal symptoms. Catabolic losses also are increased by the presence of fever. In cases of parasitic infestations, the child's nutritional status is impaired by blood losses that are secondary to colitis or direct intestinal mucosal damage (common in cases of roundworm [Ascaris lulmbricoides], hookworm [Ancylostoma duodenale and Necator americanus], or whipworm [Trichuris trichiura]). Parasitic infestations also are associated with respiratory symptoms (particularly in case of Ascaris infestations) and anorexia (Lunn and Northrop-Clewes, 1993).
Disrupted cognition. PEM can disrupt cognition in several ways. Following the lessons learned from the effect of PEM on the body during infections, the classic explanation was that malnutrition caused physical damage to the brain, particularly during sensitive periods of development, namely, during the first two years of life, when about 80 percent of the brain's growth is achieved (Guilarte, 1993; Levitsky and Strupp, 1995). At present, however, it is clear that there are several other mechanisms, aside from organic damage, by which malnutrition can impair intellectual development. There is also evidence that at least part of this damage may be reversible, even in the presence of structural damage to the brain (Levitsky and Strupp, 1995).
Malnutrition may affect brain growth and development, which will be reflected in cognitive disabilities, motor impairment, or lower intelligent quotient (IQ), by means of micronutrient deficiencies such as vitamin B 6 or iron, both of which are vital for normal brain function (Guilarte, 1993; Pollitt, 1997). Malnutrition also may affect these functions because of energy deficiency, which limits activity and social interaction with peers and caregivers. This mechanism was explored first in the early 1970s by Levitsky and coworkers in a rat model. They showed that energy-deprived rats scored lower on such tests as maze running proxy for mental abilityecause they were so feeble that they withdrew from contact with their peers and the objects in their surroundings (Levitsky and Strupp, 1995). Similar findings were shown to be present in children living in deprived third-world communities (Chávez and Martínez, 1982).
The extent to which PEM affects intellectual potential has been explored by studying the effect of protein-energy supplementation on behavioral development. In spite of different study designs that focused on prenatal supplementation (Rush, Stein, et al., 1980), on postnatal supplementation (Grantham-McGregor, Meeks Gardner, et al., 1990; Husaini, Karyadi, et al., 1991), or in both (Waber, Vuori-Chirstiansen, et al., 1981; Chávez and Martínez, 1982), results from these studies are consistent in showing that a significant proportion of the variability in mental and motor developmental scales during the first two years of life may be accounted for by nutritional supplementation.
The extent to which the differences in intellectual performance found at early ages in children affected by PEM carries on to later stages in life has been addressed by Pollitt et al. in a long-term follow-up study of Guatemalan children, who received supplements during the prenatal period and the first 2 years of life and were later followed up between the ages of 13 and 19 years old (Pollitt, Gorman, et al., 1995). This study found that children who had received a protein-energy supplement had significantly higher scores on tests of knowledge, numeracy, reading, and vocabulary, as well as a faster reaction time in information-processing tasks compared with children who had received only an energy supplement. This effect was particularly strong for protein-energy supplemented children at the lowest end of the socioeconomic distribution, an interesting finding when compared to only energy supplemented children, in whom the higher cognition test scores varied as a positive function of socioeconomic status, as expected. The authors interpretation is that the protein-energy supplement acted as a social equalizer in relation to the differences in performance usually found in populations as a function of differences in socioeconomic status.
Another long-term supplementation study was carried out in a Mexican village, where women received nutritional supplements during pregnancy and their offspring continued to receive micronutrient supplements from 12 weeks until 10 years of age. Compared to a control group (mothers and children from the same village, recruited two years before supplementation began), children who received supplements showed significantly better IQs, school performance, and behavior (Chávez, Martínez, et al., 1995).
The studies of the effects of iron deficiency on intellectual and motor abilities were addressed specifically during the 1980s and 1990s. Several well-designed intervention-control studies have shown that, before treatment, average mental scores on the Bayley Scales of Infant Development of infants with anemia were 6 to 14 points lower than the scores of non-anemic controls (Lozoff, Brittenham, et al., 1982; Grindulis, Scott, et al., 1986; Lozoff, Brittenham, et al., 1988; Walter, De Andraca, et al., 1989), and average motor development scores were 9 to 11 points lower, differences of statistical and clinical significance. No significant improvement on the test scores of initially iron-deficient children were noted following iron supplements for two to three months (Aukett, Parks, et al., 1986; Lozoff, Brittenham, et al., 1988; Walter, De Andraca, et al., 1989). Fewer studies have addressed whether these deficits prevail in later ages. In a long-term follow-up study of Costa Rican children at age 5 years whose iron status had been documented and consequently treated in infancy under careful supervision, Lozoff et al. found that at five years of age, all children had excellent iron status. However, those children who had been severely iron deficient during infancy (hemoglobin 00 g per liter) showed lower mental and motor functioning scores at school entry than did the rest of the children, even after controlling for background factors that were potential confounders (Lozoff, Jimenez, et al., 1991). Further, even anemic children with hemoglobin levels < 100 g per liter before and after treatment also had poorer outcomes at five years of age, compared to non-anemic children. Strong as this evidence may be, it is relevant to point out that, to date, there is no definite proof that iron deficiency is the cause of children's lower test scores. For obvious ethical reasons, the gold standard of experimental designs, the double-blind placebo-control study, has not been carried out.
Protein-energy malnutrition also may affect children's performance on cognitive tests by other, indirect mechanisms (often conceptualized as confounding variables in studies that attempt to establish links between PEM and impaired cognition).These include social and economical disadvantages (Johnston, Low, et al., 1987), differences in parental education (LeVine, LeVine, et al., 1991), years of schooling (Ceci, 1991), inadequate attention or affection from caregivers (Engle and Ricciuti, 1995), and other environmental factors, which may include peer interaction, parental presence in the home, etc. (Engle and Lhotska, 1999).
Recent research has addressed the role of breastfeeding (the gold-standard of good nutrition during the first months of life) on cognitive development, adjusting for the aforementioned variables. The results of a meta-analysis that included 11 studies that controlled for 5 covariates on the effect of breast-feeding on cognitive function, a statistically significant increment in cognitive function of 3.16 points was seen in breast-fed infants, consistent through all the studies, at 6 to 23 months of age. This study found a greater benefit of breast-feeding for cognitive development of premature babies (an adjusted benefit of 5.18 points), and a larger benefit in relation to duration of breast-feeding (an increase of the weighted mean benefit of 1.68 points with 81 weeks of breast-feeding to 2.91 points with 8 weeks) (Anderson, Johnstone, et al., 1999).
Concluding Remarks
Over the years, much has been learned about protein-energy malnutrition, its causes, and its effects. Without pretending that all is known, available knowledge can alleviate this burden on human development and social inequalities. Although the treatment of malnourished children all over the world is a clear imperative, the key to solving the problem is to focus on prevention. Preventive actions should be interdisciplinary. These actions should encompass a broad focus on education, particularly directed to women; they should include actions to improve sanitary conditions, schooling opportunities, employment, agricultural produce, and access to diverse food sources, particularly those rich in micronutrients. All sectors of society, including government and nongovernment organizations, should work together toward a common end. The opportunities to make a substantial improvement in the nutritional status of children all over the world are here, as never before in history. We have studied the causes of malnutrition, its mechanisms, and its consequences. It is now time to study the impact of specific interventions tailored to solve persistent problems.
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Homero Martínez
Source: Encyclopedia of Food & Culture, ©2003 Gale Cengage. All Rights Reserved. Full copyright.
Source: Encyclopedia of Medicine, ©2002 Gale Cengage. All Rights Reserved. Full copyright.
Source: Encyclopedia of Children's Health, ©2005 Gale Cengage. All Rights Reserved. Full copyright.


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Greetings from Matt Monarch
If you missed yesterday's video of me interviewing my mom, which everyone is going nutzo over, you can access it now by clicking the link here below: http://www.youtube.com/watch?v=G8JNgSNrGvY
Today, I want to let you in on an outrageous injustice that is taking place, if you haven't heard about this already. As you know, I strongly believe that Colon Hydrotherapy, coupled with a whole foods or raw food diet is the most powerful healing combination in the world.
In my experience, the things that have the most controversy around them, such as natural healing, avoiding vaccinations, avoiding hospital births, etc., ring to actually be the most beneficial choices. That is why there is so much controversy around cleansing the colon with water. Although there is documentation that before the pharmaceutical industry took over, every single hospital room had enema/colonic equipment available and this was used as the first method to help heal people in the past from any illness, today you will likely not meet a single doctor who would recommend for someone to cleanse their colon with water regularly. In fact, they would be much more likely to say that it is "dangerous" and advise you to not even go near it.
Many of you have probably been fed many reasons and excuses to avoid cleansing your colon with water, including that "it will wipe out your good bacteria for good", "puncture your colon" and so on. All of this is false. Whether you believe in the power of cleansing your colon with water or not, does not change the fact that it works more effectively in detoxing the body than anything else available to man today.
The controversy (aka: proof of truth) around colon cleansing continues. A dear friend of mine, Shea Lynn Baird, is one of the best colon therapists in the world and has been serving over 2000 clients in Santa Rosa, California. Just recently, medical board investigators came banging on Shea's door, bullied her around, lied to her, and threatened her with felony charges if she didn't sign a "cease and desist" paper right on the spot.
It seems that the medical board is trying to set a new precedent with Shea's case, because they can use this case and start knocking on many other colon hydrotherpists' doors all across the US. Shea won't stand for this and she and her husband are doing their best to stand up and fight back against the medical board. This is truly a "David and Goliath' situation here with the potential to have a huge impact on the availability of colon cleansing options in the future in the US; Shea is asking for your help. I urge you to click the link below so that you can get the entire download on what is happening and also learn how you can help keep colon cleansing legal in the US:
Angela and I made a donation and we urge you to do the same
In this newsletter you can also enjoy:
June 'At-Cost' Spec!als:
June's 'At-Cost' specials line-up is truly one of the best we've ever had. Check these all out below!
The other 'butter' product that we are offering is Artisana's Coconut Butter. This is not Coconut Oil. This Coconut BUTTER is a liquified version of whole coconut meat, not just the oil pressed out of that meat, and people go insane when they find out how decadent this Butter truly is. Last time we sold out of this Coconut Butter too, so this time we ordered up big time again.
Next are the Himalayan figs. These figs are so amazing. When I first tried them many years ago, they looked just like little miniature hard figs. It wasn't until I put one in my mouth and chewed on it, that I realized how amazing they are. I feel that these represent the way figs originally were. They are wild, small and full of seeds. I believe this is how figs started and have changed over time. Lastly, we have our organic Aronia berries. The Aronia berry is packed with antioxidants, polyphenols, minerals and vitamins.
This month, we wanted to offer whole food vitamins to help nourish you and your children or babies. We have Megafood's One Daily Multi-Vitamin for adults and also their Kid's One Daily, for your children. For those of you who are pregnant or have a younger child, we also wanted to offer the supplement which Angela took during pregn@ncy and continues to take on a daily basis while breastfeeding… Megafood's Baby & Me.
This Kamut is grown with Oceangrown's Ocean Minerals, which makes it even more mineral-rich. There is no Kamut product on the market that compares to this quality. Taking this Kamut grass powder is a great way to cover your grounds, to make sure you are getting the nutrition the body requires.
I have personally seen p!ctures of auras taken with a spec!al camera before and after putting one of these pendants on. The difference in the p!ctures was miraculous!
We actually did a video on this and you can check out these p!ctures in this video by clicking here.
The following spec!als are available until June 30th!
Remember that you can also now always get 13% or 14.5% Off the 'At-Cost' spec!als by joining 'The Raw Food World Benefits Program' – just click HERE.
Click Here For "At Cost" speci@ls
To get 13% – 14.5% Off all of your orders, you can sign up for TRFW Benefits Program by clicking HERE!
~ Many Blessings to you from The Raw Food World~ Thank you for continuing to let us serve you. We wish you and those you love, the very best of everything!
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I loved my stay here at the Schonbuhl! The owner really makes the experience at the hotel worth it! Such a character, I really enjoyed his rule of no cellphones at the dinner table as it encouraged the room to interact with each other… plus there is a nice sitting lounge right outside the dining room to be on your... More
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