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National Monitoring in Public Health Nutrition

Please feel free to spread the word about The Code of Life to anyone you know who is currently afflicted with disease or interested in disease prevention. Want to read The Code of Life on an eReader? How much is truly known about longevity? Does our government really want all of us to live one hundred healthy years and beyond? Has the anti-aging secret been uncovered and then concealed in the name of power, profit, and control?

Human-kind already possesses the knowledge to live a long, healthy, disease-free existence. The answer has been withheld from us.

The preventions and cures for the majority of diseases are known, and the astounding fact is, they are not complex, as we have been led to believe.

It is an undisputed scientific fact that disease prevention, health, healing, beauty, and anti-aging all begin at the cellular level. The health of your cells dictates the health of your body, and your mind.

Trillions of cells make up our bodies. Every tissue, organ, gland, cartilage, bone, muscle, and nerve, which amounts to every single part of our bodies, are made up of cells. The fact is, the cure for most diseases, and the perfect solution to prevention, health, healing, beauty, and anti-aging is already known and available. The Fountain of Youth, and Health, is not located on some far away island.

It is located within each and every one of our cells. Against the will of the pharmaceutical drug establishment, it is all about to be revealed to you! What is going on in our healthcare industry today? Are the large pharmaceutical corporations truly interested in finding cures for disease?

Is the pharmaceutical industry, whose profits are based on large segments of the population suffering from major illnesses, interested in eliminating their customer base? I can tell you from over thirty-five years experience in healthcare, including ten years of hospital, clinical laboratory, and medical research projects, that the answer is a resounding.

As a physician using natural means to treat my patients, I have been able to focus my attention on natural and safe alternatives to drugs. The economically lucrative drugs that are approved by the FDA Food and Drug Administration at enormous expense, and many of which are eventually pulled off the market due to adverse reactions, are designed to alleviate symptoms, but rarely, if ever, address the cause of the disease.

This comprehensive care would begin in our very early years, conceivably from conception, involving a system focused on the healthy maintenance of the cells and thus, the non-interference of cellular function, and subsequently unaltered DNA replication.

This effective healthcare system would begin before we were born with our pregnant mothers commencing a comprehensive regimen of specific nutrient-targeting to ensure the perfect cellular development of a healthy newborn infant. What has just been described in the last paragraph could be summed up with the term prevention. Real healthcare implies prevention. As we know, there is no such mainstream medicine system regimen focused from conception, or at anytime for that matter, specifically on the health of our cells.

Therefore, there is no specific system of. So what is the system currently in use designed to accomplish? Fifty percent of the time it will be the drug approved for the condition. In the overwhelming majority of cases, only the symptoms will be addressed, not the underlying condition or its cause , and in doing so, the symptoms of the disease will be managed at best, while the disease itself progresses.

If this correct and accurate term were used to describe this system, no one would partake in the system. In order to market a system to the public whose underlying motivation is the sale of economically lucrative drugs and medical procedures, one must create false atmospheres via the use of soft terms. The problem with the current system is that caring for disease is very profitable, while preventing disease is not.

The structure of the entire system is a financial conflict-of-interest in which the patient most often pays with his money, health, time, and eventually his life. The medical and pharmaceutical industries are the benefactors of illness in America. These are the industries that thrive on the economics of disease. This is the modern day Cartel. The simplicity of optimal health and disease prevention through the specific support of cellular requirements is the hidden truth which their curtain conceals from public understanding.

In order to effectively market their myriad of harmful concoctions, they must continue to convince us that the problems are complex. They have spent billions in their attempt to convince us of this complexity and for many decades they have been successful.

They believe that the masses are ignorant and their smoke and mirror marketing tactics designed to lead the public away from the effective natural solution will be permitted to continue without exposure. They have suppressed the basic truths of health. The Basic Health Facts. Having a life-long interest and passion for healing, and after dedicating my life to the study and practice of the healing arts, I have written this book on the single most significant discovery relating to health; the understanding of the function and effect of specific nutritional components in relation to cellular support and communication, disease prevention, disease recovery, and effective anti-aging.

First and foremost, and against the will of The Cartel, the reader will be widely introduced to the phytonutrients, and in particular, natural Aloe polymannan molecules and their diverse healing effects on the human body. Secondly, and equally as important, the reader will be widely informed of the fact that these molecules and healing components, along with specific nutrients all taken in adequate quantities are indeed the prevention and cure for most diseases known to man.

They are also the most efficient and effective general health, weight control, beauty, and anti-aging solution due to the proven fact that they promote the proper functioning of the human cell, as designed! I want to emphasize the importance of reading the findings and health benefits listed in this book. In order to form a solid habit in regard to ingesting the vital nutrients daily, we must be consciously aware of. This awareness provides strong motivation to form the needed habit, and thus reap the health and longevity rewards.

The most important thing to remember about fighting and preventing aging and disease through nutritional cellular support is that it should be done consistently, every day. Obviously, eating good quality food, swallowing a few capsules, or taking some nutrient powder with juice is a small price to pay for quality-of-life and longevity.

More good news, depending on your present and ongoing level of health, is that over time, you may be able to taper off the quantity ingested and still receive adequate cellular support. We all understand what would happen if we put gasoline into the fuel tank of a car with a diesel engine, or vice versa. Needless to say, damage would occur to the engines of both vehicles because we attempted to use a source of energy for which the engines were not designed.

The damage would occur quickly and be immediately apparent. Two damaging processes would take place. In both cases, the engines would be starved for the components they need to operate smoothly, while being damaged by components they are not designed for.

Another example would be if we were to attempt to run a high performance engine on 87 octane gasoline, which demands 94 octane by design. In this case the damage would be less noticeable, but would occur over time until the engine was prematurely destroyed. Although many of us are not familiar with the internal workings of a combustion engine and may think of it as complex, in reality, it is a crude and simplistic invention in comparison to the intricate design of the human body, and in particular, the human cell.

The answer is premeditated ill-design , in the form of clever, misleading, and deceptive marketing more on this to follow. The human cell, the very foundation of human life, possesses an intricate and highly sophisticated design.

Individual cells are invisible to the naked eye, and yet a multitude of processes occur within them dictating our health, appearance, quality of life, and ultimately our lifespan. The cell contains many components which perform an entire array of vital functions for the body. Within the nucleus of the. The cell is the foundation of health and life, and it has specific requirements that must be constantly met in order to avoid cellular starvation, deterioration, pre-mature aging, and ultimately disease.

Most scientists and engineers agree that the human being is the most intricate and amazing design known to the planet. Man did not design or create man. Man did not design or create the earth or the universe.

Man, regardless of desire or ego, does not possess the knowledge to fully comprehend the complexity of nature or the human blueprint. With each new scientific discovery concerning the human body, we are yet further amazed by the majesty and intricacy of this grand design, obviously conceived by an intelligence far superior to our own.

All the necessary components and nutrients for the sustenance of human life, as well as all living creatures on the planet, were also designed by this Superior Intelligence , not by man.

Many things are marketed to us to ensure profits. Products for internal consumption such as foods, pharmaceuticals, and even some nutritional supplements are made to appear attractive or beneficial, but in many instances, they are not what the human body is designed to receive.

Humans are not designed for synthetics. They are no t what we are designed for. Synthetics are the wrong fuel or energy source for the human body design. Damage inevitably occurs, short and long term, when we attempt to replace natural with most synthetics. The wrench would fall into a running engine, getting caught in moving parts, causing damage. The cliché infers that if you throw something into a system that does not belong there, you may cause damage or destroy the entire system.

The cellular damage caused by unnatural, against-the-design substances varies widely from reversible to lethal, and all levels of damage in between. Many drugs manufactured are originally derived from a natural compound found in nature. Through synthetic molecular alteration, the patentable drug is created.

Natural substances cannot be patented. In a sublime manner, they attempt to convince us that The Superior Intelligence does not know what is best for us. Common sense tells us that in order for a treatment to be superior, or even compatible with the human body, it would need to benefit all areas, or specific areas of the body without causing harm to any other area or areas.

The presence of these direct unwanted or harmful effects is proof positive that man has failed to accomplish this task. It is rather some men, who do not know what is best for us, or who are simply unwilling to acknowledge fact for reasons of financial gain. When given some serious thought, is it not amazing that Big Pharma would have the audacity to attempt to frighten the public away from many of the side-effect-free healing compounds found in nature, some of the very compounds used as the basis of their synthetic drugs and products prior to molecular alteration?

The perfect human fuels and medicines come from plant-derived foods and are referred to as Phytonutrients. The term phytonutrient , plant nutrient , is derived from the Greek word phyto, meaning plant, and nutrient , a constituent of food, vital for physiological function. A phytonutrient is a plant-derived natural nutrient.

Phytonutrients are biologically active compounds in plant-derived foods that elicit biological activity throughout the body. There are numerous classes of phytonutrients, many of which can contain scores of different phytonutrients. Many overlap and complement one another, working synergistically to boost total health benefits. I estimate that upwards of phytonutrients have been identified to date, and many more of these remain yet undiscovered. Some of the more vital forms, many not seen listed on government websites or literature, or classified as phytonutrients are; ajoenes, allylic sulfides, amino acids, anthocyanins, anti-oxidants, betaines, bioflavinoids, capsaicin, carotenoids, catechins, chelating agents, chlorophyll , complex carbohydrates, coumarins, cyclic compounds, enzymes, essential fatty acids, flavonoids, flavonols, flavones, flavanones, gamma-oryzanol glucomannans, glucopolymannans, hydroxycinnamic acids, isoflavones, isothiocyanates, indoles, lignans, limonoids, mannans, methionine reductase, mucopolysaccharides, organic minerals, organic trace minerals, organic vitamins, phenols, phospholipids, phytosterols, polymannans, polyphenols, polysaccharides, plant proteins, resveratrol, saponins, sulfides, thiols, terpenes, and tocopherols to name just a few.

Some of those mentioned above are classes, others are subclasses. Researchers are finding that the same phytonutrients that keep plants free from disease also perform the very same function within our bodies. The list of health benefits is virtually endless and includes cellular fueling and repair, increasing cell life anti-aging , the inhibition of cancer-producing substances, and the prevention of degenerative diseases, to name just a few. In short, specific phytonutrients found in certain fruits, vegetables, and the plants themselves, work synergistically to protect our health.

Science has proven the effectiveness of this perfect natural human fuel and medicine through countless studies to date. So what would we expect to find concerning the fuel and medicine designed for the human, by the creator of the human? Misinformation is generated in multiple forms in the attempt to. If millions of people were not dying, made and kept ill, due to The Pharmaceutical Cartel generated confusion, their attempts of disguising the obvious would almost be amusing.

Despite political and financial pressures placed upon the various government agencies to down-play and disguise these facts, due to the magnitude of the subject public health, life, and death , they must publish them somewhere so they themselves are covered. Let us examine the way it is done. Phytonutrients are certain organic components of plants, and these components are thought to promote human health. Fruits, vegetables, grains, legumes, nuts and teas are rich sources of phytonutrients.

Unlike the traditional nutrients protein, fat, vitamins, minerals , phytonutrients are not "essential" for life, so some people prefer the term "phytochemical". One could have a field-day with this paragraph alone. Compare it to the first paragraph in this section. Notice that in defining the word phytonutrient for the suffering public, somehow they failed to define the word nutrient. Here are three common definitions of the word nutrient: Obviously, each definition of the word nutrient indicates that it is a substance vital for physiological function , or Life.

The pharmaceutical industry is also responsible for the manufacturing of many of these synthetics as well. For now, let us have a look at the various statements below.

Centers for Disease Control and Prevention: Food and drug Administration FDA: And a wide array of compounds in fruits and vegetables may protect cell components against oxidative damage as well as vitamins C or E. Research supports that some of these foods, as part of an overall healthful diet, have the potential to delay the onset of many age-related diseases. Because oxidation is a naturally occurring process within the body, a balance with antioxidants must exist to maintain health.

They are involved in many processes including ones that help prevent cell damage, prevent cancer cell replication, and decrease cholesterol levels. The published statements in regard to the benefits of phytonutrients could fill this book, therefore, we will stop here. For the benefit of our health, let us now intelligently define the term phytonutrients: A phytonutrient is a plant-derived, biologically active natural nutrient, essential and vital for optimum health, longevity, physiological function, and the prevention of diseases.

They include all those mentioned in the second paragraph of this section, and so many more. Additionally, since plant derived natural vitamins, minerals, amino acids, complex carbohydrates, enzymes, co-factors, etc. A synthetic of any kind is not a phytonutrient. Should this be widely understood, it would End The Manufactured Confusion. They are plant-derived nutrients phytonutrients. In other words, they originate from a natural plant source. This is the form of food and medicine that we have been designed to utilize.

Why is the plant designed to extract inorganic earth minerals and nutrients from the soil and convert them to organically bound phytonutrients? The plant is preparing the nutrient in an absorbable form for consumption by another life form, such as humans or animals. Amazing, is it not? Has a plant ever been described to you in this manner? This is one function of a food bearing plant.

Providing oxygen for us to breath is yet another. Herein lies the modern-age dilemma; if the mineral or nutrient is no longer in the soil, it cannot be in the plant, and those plant constituents or phytonutrients normally made from the inorganic soil matter, such as vitamins, enzymes, and co-factors, subsequently cannot be produced within the plant either.

The difference between the two numbers, 87 and 94, in our simple analogy does not seem vast; however, the difference between a nutrient poor food supply and adequate nutrition is the difference between prolonged cellular life and pre-mature cellular death. Currently within the U. However, history has shown us that millions die while waiting for official recognition, often of the scientifically obvious.

Aside from man-made synthetic, radioactive, and inert elements, the universe is composed of approximately 77 naturally occurring atomic elements found within the Periodic Table of Elements used in chemistry. All of these elements are naturally present within the human body, and utilized if made available.

They exist within all plant and animal life. They are found in the waters of the oceans, the soils of the land, and within the atmosphere we breathe. They are the components of life on this planet. There are quite possibly thousands of naturally occurring phytonutrients found within an organic natural food supply, many yet to be discovered.

These miraculous compounds include complex carbohydrates, amino acids, fatty acids, enzymes, vitamins, minerals, and an entire array of co-factors. Co-factors are substances that need to be present in addition to an enzyme for a certain physiologic reaction to take place. Our choices boil down to a stark simplicity. As you will learn, there exists an entire multitude of nutrients scientifically shown to be beneficial to health and longevity.

Therefore, the term essential should not be the guideline or goal, but rather the provision of an optimum supply of nutrients. The intelligent course of action to obtain optimum health, is clearly the consumption of the widest possible spectrum of naturally occurring, side-effect-free nutrients and phytonutrients available, in their purest bio-available form.

This is the mentality which infers that drugs are more beneficial than consistent, diverse, and quality nutrition. There exist many other damaging terms as well, curiously inserted within the common health vocabulary which are clearly counter productive to public well being.

This is true, yet government agencies currently list approximately forty, while scientists have discovered and continue to discover hundreds, if not thousands of natural occurring life enhancing nutrients. They persist to perpetuate arbitrary, inadequate, misleading, and damaging concepts. The fact is, we are not receiving them in significant quantities. The current Plague of degenerative disease is firm confirmation of this. Without adequate amounts of proline and vitamin C, the production of collagen from pro-collagen is inhibited.

Proline, lysine, green tea extract, and vitamin C inhibited the spread of cancer cells in an experimental study. All nutrients required by the human cell are essential, and we can no longer afford to rely on the body to synthesize nutrients where co-factor components may no longer exist. Missing nutrients during childhood development potentially provide an open door for the manifestation of diseases in childhood and the later appearance in adulthood.

It is all economics. The term semi-essential should be eliminated as well in regard to nutrients. Under optimum conditions, your body can manufacture the other fatty acids required for health if you have adequate amounts present of these two essential fatty acids. The reality is that most Americans consume a dietary ratio estimated to be 1: We are falling considerably short on Omega III.

Furthermore, due to the nutrient and trace nutrient poor diet that is consumed by most, it is highly likely that the conversion of the inadequate levels of essential fatty acids will not likely be converted to the other necessary fatty acids, and therefore, we are deficient in them as well!

We would all prefer optimum health and a disease-free existence. Interestingly, this surviving but suffering public certainly creates an endless demand for expensive pharmaceuticals and medical procedures.

Perfect nutritional cellular support, over time, also minimizes or prevents the need for expensive drugs and invasive surgical procedures. Thus, Prevention eliminates the need for the bulk of pharmaceuticals. Would Big Pharma like to hinder or even eliminate Prevention? I will leave this question open for you. Should we attend a magic show at the local fair, a magician may entertain us with illusions. Illusions are tricks designed to cause us to believe something is, or has occurred, that in reality is not or has not.

The basis of a good trick or illusion is to distract the viewer while the reality of the situation goes unnoticed. Humans are designed with two eyes situated in the front of their skulls. We look forward when we think and focus. We usually focus on what is being presented directly in front of us. We are easily distracted, sometimes with the use of props. We cannot focus clearly on any subject using our peripheral vision.

When something is off to the side and not emphasized, we tend to miss it. Things we miss or do not see clearly, we cannot focus on.

Sometimes, things we do not see, we may not believe really exist. Way back when aspiring masters of illusion, the pharmaceutical marketeers , first realized their products carried harmful and sometimes lethal effects, they were presented with a daunting dilemma. As they do today, they desired desperately to peddle their synthetic concoctions in the largest possible volume, regardless of consequence to the public. Their self-serving, profit-driven desire was to minimize the focus on the harmful properties within their synthetic products.

Certainly, they must have initially wished they could just push these marketing dilemmas off the table, or at least, off to the side. Resorting to psychology, they soon discovered that inference is often a master of problem solving. The power of suggestion! The stark reality is ; the biological monkey wrench is causing damage to the pristine cellular machine from the moment we swallow the synthetic substance. Ninety-nine percent of all drugs marketed only mask cover-up symptoms of underlying problems.

These are The Masters of Distraction. Diverting public attention away from the reality of prevention and healing is the crux of their illusion. Obviously, prevention and healing should be intelligently addressed through cellular support by the natural means for which we are designed. Apparently, we are not supposed to be paying close attention.

Ironically, the vast majority of medications treat only symptoms and possess no curative powers. This is one important fact the pharmaceutical industry does not want emphasized; namely that given the proper natural resources, barring overwhelming trauma, intoxification, or infection, the body can and will heal itself!

Many volumes could be written on this subject and the financial conflicts of interest existing within a bureaucracy intended to protect the public. The result of decades of manufactured public blind faith in this approval system, in addition to the blind faith in practitioners who have forcibly become little more than Cartel sales persons, has rendered the masses perfect clients of Mr.

Then he dramatically raised the price! The television ads at present are no less than hilarious. Currently, they are telling us to take a pill rather than be annoyed with the prospect of having to urinate between baseball innings.

Unfortunately, this pill may at the very least induce uncontrollable gambling urges, in conjunction with extremely vivid, horrifically violent and brutal nightmares all documented side-effects. If you suffer from osteoporosis low bone mineral density , do not concern yourself with calcium and mineral supplementation - certainly not.

Just pop the latest synthetic masterpiece, linked to osteonecrosis of the jaw, causing bone tissue to die and never regenerate, and be done with it! If you would like to quit smoking, never mind will-power, your flavor-of-the-month awaits in a doosie that is likely, according to their winking tortoise, to send you into fits of chronic vomiting. Take all five together and you could sit in your chair for hours, feeling no tingles, passing no fluids, unable to rise, unable to speak, and vomiting on yourself in the name of modern medicine.

Maybe it is among those that do not reveal themselves right away. Could it be one of those the FDA does not require announcing to the silly unassuming consumer? Losing this dangerous game of health roulette is not always immediately apparent.

Many times, the cellular damage caused by these synthetic concoctions may not surface for months or even years. Our health care system, if properly restructured, would profit enormously, not by being a self-preserving drain on the patient, but by providing true heath care with the main focus on prevention. The Tricks of the Trade. How do they frighten us away from what is good for us — what was designed for us, and lure us towards harmful synthetic products-for-profit?

The key tool used is misinformation. The tactics are profitable and the result over time on public perception, and consequently public health, is a manufactured disaster. Organic aluminum is present in many common fruits and vegetables such as bananas, cucumbers, and tomatoes. Inorganic aluminum is a toxic and potentially harmful metal. The plant has processed the inorganic mineral because we need the organic mineral. You can not die eating organically grown bananas, cucumbers, and tomatoes.

You can only become healthier! Another classic example is the attack on natural Vitamin E and other naturally derived vitamins. None of the other seven naturally occurring components of vitamin E were added. They conveniently failed to inform the public that they were using synthetically produced vitamin E. They did not go as far as to warn against almonds, avocado, olives, and spinach - all wonderful sources of natural Vitamin E.

These types of covert and diabolical side shows are a flagrant abuse of the public trust and inevitably culminate in the deterioration of public health!

Nowhere was it mentioned that dehydrated powered eggs contain oxidized cholesterol, which was the cause of the elevation in abnormal lipids. Who would eat rotten eggs containing rancid fat, except unsuspecting pawns in a misguided experiment designed to perpetuate misinformation to confuse and frighten the public? Typically, eggs do not raise cholesterol levels. They are a wonderful source of protein and other beneficial nutrients. They are indirectly one of the leading causes of the rising rates of degenerative diseases.

The wonderful and positive news which I am about to share with you can and will change your life. In all probability it will also extend your life if you take it to heart and take simple action. According to the U. Iatrogenic death is a term defining patient death as a direct result of treatments by a physician, whether from misdiagnosis of the ailment, or adverse drug reactions used to treat the illness.

Drug reactions are the most common cause of iatrogenic death. Although an argument seems to exist as to who rightfully receives credit for the show position, 3 , concerning hundreds of thousands of needless deaths, the diseases or the doctors , one thing is curious for certain: As of the printing of this publication, the public is unable to access this information on the American Medical Association web-site.

For this reason, they argue, The Establishment is responsible, directly or indirectly, for every death involving disease which may have been prevented or cured, had the patient been properly informed. Most doctors are not aware of, or perpetrating any conspiracy, they are simply being misled. As you read the information to follow, it may become more than apparent that if the American Medical Association AMA would allow doctors to PROPERLY instruct patients in regard to health, over time we would see no diseases outranking accidents, drastic reductions in all disease figures across the board, and very little deaths if any caused by doctors.

To give credit where credit is due, probably the greatest technological advance in modern medicine is the treatment for crisis situations. Surgical procedures have been developed that accomplish miraculous results. Where would we be, for example, without the skilled emergency room doctor, surgeon, and staff when we are burned, poisoned, or injured by accident?

Emergency surgery can be life saving in the case of heart attack, stroke, or the removal of a tumor to name just a few. Unfortunately, we have been conditioned to rely on drugs and surgery to correct the majority of our ills. The need for most surgeries could certainly be avoided in the first place if the patient was not permitted to deteriorate for decades due to misinformation and a complete lack of prevention. Most doctors practicing today, regardless of their specific field, are wonderful caring individuals.

It is the entrenched profit-based policies of The Establishment system which are to blame for the miserable track record of modern medicine … not the doctors. The word standard no longer refers to the qualities of high or low, excellent or poor. It now means that you do what everybody else is doing; even though no vote on the matter has been taken. The neuroses of arrogance and dogma have made medicine self-destructive and severely impaired its capacity for creative or dissident thinking.

It has always been the dissident thinker which has caused the art and the science of medicine to advance and flourish. The pharmaceutical complex provides research grants, contracts and advertising support responsible for the existence for the many thousands of journals published each year.

This guarantees virtual control over scientific and medical direction and thought. The result has been highly profitable. The great majority of physicians are honest, dedicated, and sincere scientists. Such treatment destroys the sound sentiments, the sincerity and the self-confidence of pupils and produces a subservient subject. The doctors today are working with the tools they are permitted to utilize by establishment policy , primarily drugs.

The majority of these brilliant, well-intentioned practitioners have become the subservient subjects. This will be further discussed, but for now it is most important to understand the current epidemic of disease upon our society and the solution.

Currently, one in three Americans are expected to contract some type of cancer in their lifetime. Over million Americans suffer from some form of digestive disease, 80 million Americans suffer from arthritis, 61 million Americans almost one-fourth of the adult population live with active cardiovascular disease, 21 million suffer from diabetes, 18 million from obstructive sleep apnea OSA , and 50 million Americans are afflicted with tinnitus, to mention the tip of the iceberg.

The young are developing diseases which will be diagnosed in their later years. Diseases are out of control in America and they are fueled by the allopathic philosophy of the main-stream medical establishment, which focuses on symptoms rather than prevention and the causes of disease. This philosophy is the imposed will of Big Pharma. If ganglion cells are absent, the next step depends on the clinical picture and setting.

If the pathologist is experienced and confident of the interpretation, the diagnosis of Hirschsprung's disease can be made with confidence. If there is any doubt about the absence of ganglion cells in the suction biopsy, a full thickness biopsy of the rectum a difficult technical procedure requiring a general anesthetic can be done to settle the issue.

If Hirschsprung's disease is believed to be the problem, it must be diagnosed histologically before the infant is operated upon because at the time of surgery the site of obstruction may not be apparent and the abdomen may be closed because no obvious site of obstruction is found. Hypothyroidism in the first two to three months of life can mimic Hirschsprung's disease in all aspects except for a normal rectal biopsy.

Another important point to remember is that duodenal atresia is a different disease from jejunal or ileal atresia in terms of their cause.

Jejunal and ileal atresia occur as a result of a vascular accident in the small bowel mesentery during fetal life. Consequently, there is a relatively low incidence of other congenital anomalies except for cystic fibrosis.

Duodenal atresia is a different disease in that there is a very high incidence of associated anomalies-- Down's syndrome, imperforate anus, renal anomalies, congenital heart disease, etc.

It can be unsafe to rely on parents to observe their infant for problems resulting from the above conditions. Incidence is one in every live births. The trachea and esophagus initially begin as a ventral diverticulum of the foregut during the third intrauterine week of life. A proliferation of endodermal cells appears on the lateral aspect of this growing diverticulum. These cell masses will divide the foregut into trachea and esophageal tubes.

Whether interruption of this normal event leads to tracheo-esophageal anomalies, or during tracheal growth atresia of the esophagus results because of fistulous fixation of the esophagus to the trachea remians to be proven. Polyhydramnios is most commonly seen in pure EA. EA causes excessive salivation, choking, coughing, regurgitation with first feed and inability to pass a feeding tube into the stomach. Contrast studies are rarely needed and of potential disaster aspiration.

Correct dehydration, acid-base disturbances, respiratory distress and decompress proximal esophageal pouch Reploge tube. Delayed repair gastrostomy first for all other patients. Repair consists of muscle-sparing thoracotomy, closure of TEF and primary anastomosis. Esophagogram is done days after repair. Most important predictors of outcome: Increase survival is associated with improvements in perioperative care, meticulous surgical technique and aggressive treatment of associated anomalies.

More than H-type is N-type, due to the obliquity of the fistula from trachea carina or main bronchi to esophageal side see the figure anatomically at the level of the neck root C7-T1. Pressure changes between both structure can cause entrance of air into the esophagus, or esophageal content into the trachea. Thus, the clinical manifestation that we must be aware for early diagnosis are: Diagnosis is confirmed with a well-done esophagogram, or video-esophagogram high success rates, establish level of the TEF.

Barium in the trachea could be caused by aspiration during the procedure. Upon radiologic doubt bronchoscopy should be the next diagnostic step.

Any delay in surgery is generally due to delay in diagnosis rather than delay in presentation. Management consists of surgical closure of the TEF through a right cervical approach. Working in the tracheo-esophageal groove can cause injury to the recurrent laryngeal nerve with vocal cord paralysis.

Recurrence after closure is rare. The three most common anastomotic complications are in order of frequency: Tension on the anastomoses followed by leakage may lead to local inflammation with breakage of both suture lines enhancing the chance of recurrent TEF.

Once established, the fistula allows saliva and food into the trachea, hence clinical suspicion of this diagnosis arises with recurrent respiratory symptoms associated with feedings after repair of esophageal atresia. Diagnosis is confirmed with cineradiography of the esophagus or bronchoscopy. A second thoracotomy is very hazardous, but has proved to be the most effective method to close the recurrent TEF.

Either a pleural or pericardial flap will effectively isolate the suture line. Pericardial flap is easier to mobilize, provides sufficient tissue to use and serves as template for ingrowth of new mucosa should leakage occur. Other alternatives are endoscopic diathermy obliteration, laser coagulation, or fibrin glue deposition.

Congenital gastric outlet obstruction is extremely rare. It occurs either in the pyloric or antral region. They probably represent the developmental product of excess local endodermal proliferation and redundancy. The diagnosis should rely on history, contrast roentgenology studies and endoscopic findings.

Symptoms are those of recurrent non-bilious vomiting and vary according to the diameter of aperture of the membrane. There is a slight male predominance with fair distribution between age groups in children. History of polyhydramnios in the mother. Demonstration of a radioluscent line perpendicular to the long axis of the antrum is diagnostic of a web.

Endoscopy corroborates the diagnosis. Management can be either surgical or non-surgical. Surgical Tx is successful in symptomatic pt. Other alternative is endoscopic balloon dilatation or transection of the web. Non-obtructive webs found incidentally can be managed medically with small curd formula and antispasmodics. The presence of an abnormally dilated gastric bubble in prenatal sonography should alert the physician toward the diagnosis of congenital antro-pyloric obstruction.

Is an abnormality of the pyloric musculature hypertrophy causing gastric outlet obstruction in early infancy. The incidence is 3 per live births. The etiology is unknown, but pylorospasm to formula protein cause a work hypertrophy of the muscle.

The treatment consist in correction of hypochloremic alkalosis and state of dehydration and performing a Fredet-Ramstedt modified pyloromyotomy. Post-operative management consist of: Occur distal or proximal to the ampulla of Vater. Most commonly distal to ampulla and therefore bilious vomiting is present. Bilious vomiting is surgical until proven otherwise in a baby.

The first major event in the differentiation of the duodenum, hepatobiliary tree, and pancreas occurs at about the third week in gestation, when the biliary and pancreatic buds form at the junction of the foregut and the midgut. The duodenum at this time is a solid cord of epithelium, which undergoes vacuolization followed by recanalization and restitution of the intestinal lumen over weeks of normal development. Failure of recanalization of the second part of the duodenum results in congenital obstruction of the lumen, often in conjunction with developmental malformation of the pancreatic anlagen and the terminal part of the biliary tree.

In support of this concept is the high incidence of annular pancreas observed, believed to represent a persistence of the ventral pancreatic anlage in association with intrinsic duodenal obstruction. Congenital partial obstruction of the duodenum can be either intrinsic membrane, web or pure or extrinsic Ladd's bands, annular pancreas.

This does not entail a higher risk of early mortality unless associated with cardiac malformations. Other associated conditions are malrotation midgut volvulus is rare due to absent bowel distension and peristalsis , biliary tract anomalies and Meckel's diverticulum.

The diagnosis is suggested in utero by the double-bubble image on ultrasound. Vomiting is the most frequent presenting symptom.

UGIS is diagnostic, showing a dilated stomach and first duodenal portion with scanty passage of contrast material distally. Management varies accordingly to the type of stenosis: Ladd's bands are lysed. Pure stenosis is opened longitudinally and closed transversely Heineke-Mickulicz. Membranous stenosis is resected. Successful endoscopic membranectomy of duodenal stenosis has been reported. Duodeno-duodenostomy is the procedure of choice for annular pancreas.

Diaphragms can rarely be double. Anastomotic malfunction requiring prolonged intravenous nutrition and hospitalization has prompted development of a diamond shape larger stoma. Tapering or plication of the dilated duodenum is another effective method of improving disturbed transit.

Other complications after surgery are megaduodenum with blind loop syndrome, biliary reflux, cholestatic jaundice, delayed transit and bowel obstruction. Early mortality is associated to prematurity and associated malformations. Long-term follow-up is warranted to identify late problems.

The diagnostic characteristics are: The rotation and normal fixation of the intestinal tract takes place within the first three months of fetal life. In the earliest stages when the intestinal tract is recognizable as a continuous tube, the stomach, small intestine, and colon constitute a single tube with its blood supply arising posteriorly. The midgut portion of this tube, from the second portion of the duodenum to the mid-transverse colon, lengthens and migrates out into an extension of the abdomen, which lies at the base of the umbilical cord.

Here this loop of bowel undergoes a degree counterclockwise twist at its neck. In the center of the twisted loop lie the blood vessels that will become the superior mesenteric artery and vein.

After rotation, the small intestine quite rapidly withdraws into the abdominal cavity, with the duodenum and the proximal jejunum going first. During this process the duodenojejunal junction goes beneath and to the left of the base of the superior mesenteric vessels. This leaves the upper intestine, including the stomach and the duodenum, encircling the superior mesenteric vessels like a horseshoe with its opening on the left side of the embryo.

The small intestine then follows into the abdomen, and withdrawal of the right half of the colon takes place so that it lies to the left. At the next step, the cecum and the right colon begin to travel across the top of the superior mesenteric vessels and then down to the right lower quadrant. The colon now lies draped across the top of the superior mesenteric vessels, again like a horseshoe, with its opening placed inferiorly.

The duodenojejunal loop is said to attach to the posterior abdominal wall soon after its turn, whereas the mesenteric attachments of the entire colon and of the remaining small bowel gradually adhere after they arrive in their normal positions.

In malrotation the right colon can create peritoneal attachments that include and obstruct the third portion of the duodenum Ladd's bands. The diagnostic hallmarks are: A UGIS is more reliable than barium enema, most patients present in first month of life neonatal , but may present at any time. The treatment is immediate operation; volvulus often means strangulation. Needs fluid and electrolyte replacement. Ladd's procedure consist of: In cases of questionable non-viable bowel a second look procedure is required.

Meconium ileus is a neonatal intraluminal intestinal obstruction caused by inspissated meconium blocking the distal ileum. The meconium has a reduced water, abnormal high protein and mucoproteint content, the result of decreased pancreatic enzyme activity and prolonged small bowel intestinal transit time.

Meconium Ileus is classified into two types: The distal small bowel cm of distal ileum is relatively small, measuring less than 2 cm in diameter and contains concretions of gray, inspissated meconium with the consistency of thick glue or putty. It is often beaklike in appearance, conforming to the shape of the contained pellets.

Proximally, the mid-ileum is large, measuring up to 7 cm in diameter. It is greatly distended by a mass of extremely thick, tenacious, dark green or tarry meconium. The unused small colon microcolon contains a small amount of inspissated mucus or grayish meconium. A cystic mass or atresia of the bowel may occur. The degree of obstruction varies, may be cured in mild cases by rectal irrigations. Failure to pass meconium, abdominal distension and vomiting are seen in more severe cases.

The diagnosis is suspected with findings of: Some cases may show calcifications in the peritoneum Meconium peritonitis. This test is not useful in infant during first weeks of life. It consist of a careful gastrograffin enema after the baby is well-hydrated. Gastrograffin is a hyperosmolar aqueous solution of meglumine diatrizoate containing 0. Long-term prognosis depends on the degree of severity and progression of cystic fibrosis pulmonary disease.

Total colonic aganglionosis TCA is found in approx. There are three critical phases for patients with TCA The first period comprises the time from birth until correct diagnosis. Patients with TCA present with a large variety of symptoms. Several authors have outlined the diagnostic problems in patients with TCA 2,4, Atypical symptoms may lead to excessively delayed diagnosis.

Patients present with either ileus or symptoms as in typical Hirschsprung's disease but additionally with recurrent vomiting. In patients presenting with ileus, diagnosis may be delayed for several weeks because causative factors like volvulus or meconium ileus do not primarily warrant investigations for aganglionosis. Furthermore, TCA may be associated with other anomalies of the gastrointestinal tract. Only a few reports of TCA associated with small bowel atresia and volvulus can be found 3, 7.

In cases of midgut volvulus without malrotation, aganglionosis has to be ruled out. Neonatal appendicitis, a very rare disease, may be the leading symptom of TCA.

Therefore, rectal biopsies are mandatory in those cases. Additional to the diagnostic problems due to atypical and heterogenic symptoms, histochemical examination of rectal biopsies may prove negative or equivocal because increased acetylcholinesterase activity may not be present in TCA 5,10, Furthermore, there is no typical radiographic pattern 13, Plain abdominal radiographs usually suggests low bowel obstruction whereas barium enema usually does not show pathognomonic features.

If no mechanical obstruction is found at laparotomy in neonates presenting with ileus, it is suggested to resect the appendix to rule out TCA.

If rectal mucosal biopsies are negative or equivocal, biopsies should be repeated or a formal sphincterectomy for thorough analysis is done. The second period lasts from the raising of stoma to its closure, including the definite surgical procedure. Failure to thrive and excessive fluid losses have been reported in patients with ileostomies 2. Post-ileostomy complications, however, have been eliminated after the importance of oral sodium supplementation to maintain the enteral co-transport system has been realized Interestingly, right transversostomies may show a good function even in cases of TCA.

Therefore, frozen section biopsies are mandatory when raising a stoma. The definitive surgical procedure has been debated 2,5,8,9, Colonic patch graft procedures were the first proposals for surgical management of TCA The rational behind were to use the distinctive resorptive function of part of the aganglionic colon 6.

Use of the right colon has the theoretical advantage of improved water resorption. However the colon patch procedures have significant complications, e. Actually, a modified Duhamel's pull-through procedure seems favorable in the treatment of TCA 2, The third critical phase begins with closure of the stoma. Complications in this period are predominantly recurrent episodes of sub-ileus and diarrhea or nocturnal incontinence. The cause for sub-ileus is a raised tone in the residual sphincter.

Repeated manual anal dilatations may be mandatory. Side effects of large doses of Loperamide are mental irritability and dyskinesia. Significantly better survival of the patients with TCA nowadays is mainly attributed to more accurate diagnosis and improved management of infants with ileostomies. A new approach to total aganglionosis of the colon.

Surg Gynecol Obstet Cass DT, Myers N: Pediatr Surg Int 2: Total colonic aganglionosis with or without ileal involvement: A review of 27 cases. J Pediatr Surg Festen C, Severijner R, v. The absorptive function of colonic aganglionoic intestine: Are the Duhamel and Martin procedures rational?

Ikeada K, Goto S: Total colonic aganglionosis with or without small bowel involvement: An analysis of patients. A new surgical approach to extensive aganglionosis. Further experience with the colonic patch graft procedure and long-term results. Suction biopsy in Hirschsprung's disease. Arch Dis Child A possible cause of anastomotic failure following repair of intestinal atresia.

Can J Surg Surgical management of Hirschsprung's disease involving the small intestine. Improvements in the management of total colonic aganglionosis. Pediatr Surg Int 5: The importance of oral sodium replacement in ileostomy patients. Progr Pediatr Surg Diagnosis of congenital megacolon: J Pediatr Surg 7: Imperforate anus IA is a congenital anomaly in which the natural anal opening is absent. Diagnosis of IA is usually made shortly after birth on routine physical examination.

The incidence of IA is approximately 1 in live births and it is more common in males. Its etiology is unknown and it runs equally through all racial, cultural and socio-economic groups. IA is classified as either "high" or "low" depending on the termination of the distal rectum. When the rectum ends above the levator muscles the malformations are classified as high, and when the rectum ends below the levator muscles the malformations are classified as low.

High lesions are more frequent in males, low ones in females. Determination of the level of the lesion by abdominal x-ray or perineal ultrasound is critical for appropriate management. Children who have IA may also have other congenital anomalies.

Vertebral defects, Anal atresia, Cardiac anomalies, Tracheoesophageal fistula, Esophageal atresia, Renal anomalies, and Limb anomalies. Repair of low IA is relatively simple and is usually treated with perineal anoplasty; however, repair of high IA is more complex. Patients are initially given a temporary colostomy and time is given to allow the child to grow.

A pull-through operation is completed at a later date. Independent of the level of the lesion, the goal of the surgery is the creation of adequate nerve and muscle structures around the rectum and anus to provide the child with the capacity for bowel control. Male patients will benefit from perineal inspection to check for the presence of a fistula wait hours of life before deciding.

During this time start antibiotherapy, decompress the GI tract, do a urinalysis to check for meconium cells, and an ultrasound of abdomen to identify urological associated anomalies. Perineal signs in low malformations that will NOT need a colostomy are: These infants can be managed with a perineal anoplasty during the neonatal period with an excellent prognosis.

Meconium in urine shows the pt has a fistula between the rectum and the urinary tract. Flat "bottom" or perineum lack of intergluteal fold , and absence of anal dimple indicates poor muscles and a rather high malformation needing a colostomy. Patients with no clinical signs at 24 hours of birth will need a invertogram or cross-table lateral film in prone position to decide rectal pouch position.

Those cases with high defect are initially managed with a totally diverting colostomy. Diverting the fecal stream reduces the chances of genito-urinary tract contamination and future damage. These infants require a colostomy before final corrective surgery.

The colostomy can be done electively before discharge from the nursery while the GI tract is decompressed by dilatation of the fistulous tract. A single orifice is diagnostic of a persistent cloacal defect usually accompany with a small-looking genitalia.

Cloacas are associated to distended vaginas hydrocolpos and urologic malformations. This makes a sonogram of abdomen very important in the initial management of these babies for screening of obstructive uropathy hydronephrosis and hydroureter. Hydrocolpos can cause compressive obstruction of the bladder trigone and interfere with ureteral drainage.

Failure to gain weight and frequents episodes of urinary tract infections shows a poorly drained urologic system. A colostomy in cloacas is indicated. Radiological evaluation will be of help along with a diverting colostomy in this cases.

Perineal fistulas can be managed with cutback without colostomy during the neonatal period. The most important prognostic characteristic is the severity of the IA. Patients with low IA have a good probability of having normal stool patterns. Patients with high IA report more problems such as fecal incontinence and constipation. For patients who cannot maintain normal bowel function, the use of a special diet, underpants liners, enemas and drugs have ameliorated their lives.

Long-term follow up with both qualitative and quantitative quality of life considerations of these patients is very important. References 1- Chen CJ: The treatment of imperforate anus: J Pediatr Surg 34 Inheritance of familial congenital isolated anorectal malformations: Am J Med Genetics Do children with repaired low anorectal malformations have normal bowel function? J Pediatr Surg 32 6: Semin Pediatr Surg 4 1: Management of anorectal malformations during the newborn period.

World J Surg 17 3: Posterior sagittal approach for the correction of anorectal malformations. Surgical treatment of high imperforate anus.

World J Surg 9 2: J Pediatr Surg 17 5: Although intussusception can occur at any age, the greatest incidence occurs in infants between months of age. Over half of the cases are in the first year of life. Frequently occurs after a recent upper respiratory infection, by Adenovirus type 3 that causes a reactive lymphoid hyperplasia that act as lead point of Peyer's patch. Meckel's diverticulum, polyps, Henoch's Schonlein purpura, hematoma, lymphoma, foreign bodies, and duplications.

Most children have no lead point and it is felt that enlarged mesenteric nodes or swollen Peyer's patches may be the cause. The baby has intermittent periods of severe discomfort with screaming, stiffening and drawing up of the legs, followed by periods of rest.

Vomiting may occur and bloody, mucoid currant jelly stool may be passed. The baby may become dehydrated and appear acutely ill. Frequently, lethargy may be an early sign. To be successful, the barium must reflux into the terminal ileum. The surgeon should be notified before an attempt at barium reduction, and should be present at the time of study. Recently the use of gas enema reduction has been successful in patients with: Ultrasonography can be used as a rapid sensitive screening procedure in the initial diagnosis of intussusception.

Previous adverse clinical features that precluded barium reduction can be replaced during gas reduction. Predictors of failure of reduction are: Air reduction pneumocolon is a very effective alternative method since it brings less radiation shorter flouroscopy time , less costs and less morbidity in cases of perforations. Failure of hydrostatic reduction requires urgent operation through a right lower quadrant horizontal incision. The intussusception is reduced by pushing on the distal bowel like a tube of toothpaste rather than pulling the proximal bowel.

Most cases are ileo-colic intussusception, and a few are jejuno-jejunal or ileo-ileal intussusception. The traditional method of diagnosing and managing ileo-colic intussusception is barium enema contrast reduction. In China where this is the most common surgical emergency in childhood, pneumatic reduction has been used for more than 25 years.

A recent tendency toward this approach is seen in recent years in Occident. Small bowel aeration is a sign of complete reduction. Gas enema reduction is very successful in patients with: The condition can occur in an isolated form either localized to colon or disseminated throughout the bowel , or associated to other diseases such as Hirschsprung's HD , neurofibromatosis, MEN type IIB, and anorectal malformations. Clinically two different types of isolated IND have been described: This causes an increase in variance and implies that larger samples will be needed in order to assess correctly the level of the indicator and its variations over time.

Subjectivity bias is a frequent risk with indicators deriving from qualitative surveys, as they describe behaviours or opinions of households, for example, since the personality or technique of the person conducting the survey may influence the nature of responses.

Moreover, respondents to a questionnaire or subjects under observation can modify their responses or behaviour in a normative way. People who are overweight, for example, often minimise their actual food intake when interviewed for a food consumption survey. Reproducibility guarantees that an indicator can be measured at repeated intervals in a comparable manner - a quality which is crucial when using the indicator to assess and monitor the situation.

A complementary characteristic is specificity, which refers to the ability to identify those not affected by the risk or characteristic. Sensitivity is measured in practice by the ratio of the number of individuals identified by the indicator as being at risk or as having the characteristic to the number of individuals who are actually at risk or have the characteristic. Specificity is the ratio of the number of individuals not identified by the indicator to the number of individuals who are actually not at risk or do not possess the characteristic.

Sensitivity thus gives an idea of the degree of correct or misclassification linked to the use of an indicator. Not all indicators lend themselves to an assessment of sensitivity.

Sensitivity applies essentially to indicators with cut-off values. Moreover, sensitivity is measured with respect to a given goal; sensitivity of an indicator such as weight-for-height at a given cut-off value will not be the same, depending on whether the goal is to identify children who are wasted or those who are at risk of dying in coming months. Data for quick computation of these parameters sensitivity, specificity are not always available, so in practice, reference is made to existing data from the literature to find those closest to the chosen cut-off values and expected prevalences.

One particular aspect of sensitivity is the ability of an indicator to measure change, not in order to identify or target a particular category of individuals as previously but to detect the smallest possible change in the phenomenon described, in a significant way.

While sensitivity, in general, is important when establishing a baseline, and for defining the target groups to which the activities will be directed, this ability for measuring change is crucial for assessing or monitoring trends, in particular to detect changes in the situation during implementation of the programme. However, it is relatively inert when assessing small progressive changes in nutritional status over time, and the weight-for-height indicator will be preferred in this case, since it is more sensitive to change.

Also, urinary iodine will respond to introduction of salt iodization in a region quicker than prevalence of goitre, which will decline only slowly. In addition to these inherent characteristics of indicators, their operational value should be examined; it will be essential when the choice of indicators is made, especially in terms of speed and cost of collecting data for producing these indicators. It represents the practical possibility of making available the indicator in question.

It implies the feasibility of collecting the corresponding data by whatever means. There are indicators described as "ideal" which nobody is in practice able to collect. As a result of major international conferences and of programmes that have followed them during the last two decades, many of the required indicators are already systematically and regularly collected within the framework of such programmes and are thus very easily available.

It affects use of the indicator not only at the descriptive stage, but also when monitoring the situation. An indication of the quality of the measurements, of sampling and of the confidence interval of the result is essential here to assess dependability.

Occasionally, it has been observed that the number of malnourished children estimated by nutritional surveys carried out by various organizations on identical populations and during the same periods, differed substantially; using the results for targeting purposes or for monitoring the situation is ruled out in this case.

The reason was usually the lack of precision of the anthropometric measurements or of the definition of age, and occasionally a sampling problem. Data on food consumption obtained by weighing food are more precise than those obtained with the "recall" technique, although the former implies technical constraints and can therefore only apply to small samples, so that there is a broad confidence interval in the results.

Recall techniques, on the contrary, can easily be applied to a large sample, obviously with a smaller confidence interval. The various available data must therefore be carefully examined before using them for monitoring purposes, and a choice will sometimes be made between data collected with a higher level of accuracy but lower power at the level of the target population, or the opposite. On this depends, in part, the speed and frequency with which the indicator can be regularly measured.

When the data necessary for the construction of the indicator need to be collected specifically for evaluation or monitoring, cost should be considered; it depends on the difficulty and sophistication of the measurements, the accessibility of the objects or people to be measured, the frequency of collection and the complexity of the analysis subsequently. The cost of non-collection may be measured, in the case of a food subsidy programme, for example, by the difference between the cost of the programme if it is carried out without particular targeting, in the absence of any indicator allowing targeting, and the cost of the programme for the target population, plus the cost of targeting, if the programme is to be directed at a high risk group only.

Nevertheless, information on the cost of collecting an indicator for each situation is seldom available. It is difficult to measure, and estimates are generally based on the cost of different types of survey within the country, taking account of the fact that several indicators are collected at the same time. Indicators can be categorized schematically in the following way according to the level at which they are produced or made available:. They include both indicators regarding the implementation of services as well as indicators regarding the situation or the impact of actions under way.

It is generally easy to obtain them from the departments concerned, which usually have time series that are very useful in distinguishing medium- and long-term trends. Even so, it is not always possible to cross-tabulate these indicators, since they do not necessarily come from the same databases and are accessible only in a relatively aggregated form.

It is also difficult to verify the quality of the original data. Lastly, even if the data are collected on a frequent basis monthly reports, for example , recovery and analysis may take too long. Such data tend not to be immediately accessible except in summary form, although it is easy to organize new analyses with the departments in charge of them.

These data allow statistical cross-tabulation to be made between the many variables collected simultaneously on the sample. Although carried out at best at very long intervals, they can be updated with reasonable projections, especially if information on trends in the fields of interest, based on routinely collected data, are also available.

These data are often kept together in national statistical offices. They consist of a regular collection of information based on a small number of selected indicators. The system varies by country, those that perform best are based on an explicit conceptual framework and are linked to a clear decision-making mechanism.

They can represent a sound basis for central monitoring. A particular category is derived from surveys conducted by international bodies for various purposes: These cross-sectional surveys are conducted directly at household level on samples which are representative at national level but of variable size; they include a wide variety of indicators in number, goals and qualities and are now frequently repeated.

Although conducted peripherally, they are generally available and used centrally. These sources, which are in principle fairly reliable, benefit from an advanced level of analysis allowing causal inference to be derived of relationships among various household indicators, and with individual indicators, such as nutritional status. They represent a precious source when establishing a baseline and when analysing causes prior to launching an intervention. These are constructed primarily on the basis of routinely collected data from local government offices, community-based authorities.

They are usually passed on as indicators or raw data to the central level, and then sent back to the decentralized levels, with varying degree of regularity, after analysis.

They are often disaggregated by district or locality, but are not always representative, since they often refer only to users of the services under consideration. They are generally grouped together at the central administrations of regions or administrative centres. The indicators relate primarily to activities that lend themselves to regular observation, either because they record activities indicators of operation or delivery of services or because they are necessary for decision-making crop forecasts, unemployment rates or for monitoring purposes market prices of staples, number of cases of diseases, etc.

They do not necessarily include indicators of the causes of the phenomena recorded and are not in principle qualitative indicators. Indicators collected at decentralized levels should meet both the needs of users on these levels and also those of users on the central level for the implementation and monitoring of programmes.

If these regularly compiled indicators do not have any real use at the local level and are intended only for the national central level, there is a danger that their quality will drop over time, for lack of sufficient motivation of those responsible for collection and transmission - and gaps are therefore often found in available data sets.

Nevertheless, they are invaluable in giving a clear picture of the situation on the regional or district level, together with medium-term trends.

Generally speaking, their limitation is the low level of integration of data from different sectors. A certain number of indicators, particularly those concerning the life of communities or households and not touching on the activities of the various government departments, are not routinely collected by such departments and are in any case not handed on to the regional or central offices.

They are sometimes collected at irregular intervals by local authorities, but most often by non-governmental organizations for specific purposes connected with their spheres of activity - health, hygiene, welfare, agricultural extension, etc. Analytical capabilities are often lacking at this level, and the available raw data may not have led to the production of useful indicators. Action therefore should be taken to enhance analytical capacities or else sample surveys will have to be carried out periodically on these data in order to produce indicators.

A sound knowledge of local records and their quality is needed to avoid wasting time. New collection procedures often have to be introduced for use by local units, while being careful not to overload them or divert them from their own work.

Otherwise a specific collection has to be carried out by surveying village communities targeted for analysis or intervention. These surveys are vital for a knowledge of the situation and behaviours of individuals and households and an evaluation of their relationship with the policies introduced. In general, they offer an integrated view of the issues concerned.

They may have the aim of supplying elements concerning the local situation and local analysis, in order to confirm the consensus of the population and of those in charge as to the situation and interventions to be carried out, and also to allow an evaluation of the impact of such interventions.

The participatory aspect should be emphasized rather than the precision or sophistication of data. An FAO work on participatory projects illustrates issues of evaluation, and especially the choice of indicators in the context of such projects FAO If data already collected are used or if a new survey is carried out for use on a higher level, the size and representativeness of the sample must be checked, and it must be ensured that the data can be linked to a more general set on the basis of common indicators collected under the same conditions method, period, etc.

Verification of the quality of the data is crucial. Before undertaking a specific data collection, a list of indicators and of corresponding raw data should be developed which can be used by services at all levels; it is not unusual to find that surveys could have been avoided by a better knowledge of the data available from different sources.

To track down these useful sources and judge the quality of the data available and their level of aggregation, a good understanding is needed of the goals and procedures of the underlying information system. The country had set up a monthly national information system on production estimates for 35 crops, covering information on crop intentions, areas actually planted, crop yields and quantities harvested in each state.

The information was obtained during monthly meetings of experts at various levels - local, regional and national. The information was then put together at the state level, and then at the national level, reviewed by a national committee of experts, and sent on to the central statistics office.

The different levels thus had some rich information at their disposal, coming from a range of local-level sources. Although it was certainly fairly reliable, being confirmed by a large number of stakeholders and experts, its precision could not be defined, in view of its diversity.

The usefulness of such data varies depending on information needs and thus on the quality of the data required. Data concentrated at the central level are probably useful primarily for analysing trends. On the other hand, apart from the figures, more general information on production systems exists at local level, and this can be useful for identifying relevant indicators of causes, or for simplifying monitoring of the situation.

We have seen that there is a great number of indicators which differ widely in quality; the availability of corresponding data is variable, and any active collection will be subject to constraints.

Therefore the choice of indicators must be restricted to the real needs of decision makers or programme planners. This implies that a method is needed for guiding the choice. The main elements that will guide choice are: Any intervention is based on an analysis of the situation, an understanding of the factors that determine this situation, and the formulation of hypotheses regarding programmes able to improve the situation.

A general framework was presented earlier see Figure , representing a holistic model of causes of malnutrition and mortality, which was endorsed by most international organizations and nutrition planners. However, the convenient classification that it implies, for instance into levels of immediate, underlying or basic causes needs to be operationalized through further elaboration in context.

The benefit of constructing such a framework, over and above the complete review of the chain of events which determine the nutritional situation, is to allow the expression, in measurable terms, of general concepts which, because of their complexity, are not always well defined. For example, it is not enough to refer to "food security"; one should state which of the existing definitions is to be used, on which dimensions of food security the focus is placed and the corresponding indicators.

The use of conceptual frameworks when implementing programmes or planning food and nutrition is not new. Many examples have been developed, focusing on different aspects. The concept of food security is generally perceived as that of sufficient availability of food for all. However, several dozen different definitions have been proposed over these last 15 years!

This concept may, for example, comprise different aspects depending on the level being related to: In the first case, analysis will focus on agricultural production, and in the second the emphasis will be on improving the resources of those who lack access to a correct diet. This preliminary brainstorming exercise will allow a better definition of the perceived chain of causes production shortfall, excessive market prices, defective marketing infrastructures, low minimum wage, low level of education, etc.

It will then be easier to consider potential indicators of the situation and its causes, or potential indicators of programme impact. Obviously it is not so much the final diagram which is of importance as the process through which it was developed.

Insofar as the relations between all the links of the chain of events or flow data, depending on the type of representation have been discussed step by step and argued with supporting facts, the framework will be adapted to the local situation and will become operational.

Methodologies have been developed for making this process effective in the context of planning, for example with the method of "planning by objectives" see ZOPP , which comprises several phases: During this planning process, all programme activities, corresponding partners, necessary inputs and resulting outputs as well as indicators for both monitoring implementation and evaluating impact of the programme will be successively identified.

The method acts as a guide for team work, encouraging intersectoral analysis and offering a simplified picture of the situation, so that the results of discussions are clear to all in the team. Let us again take the example of a problem of food security. It can be broken down into three determining sectors: A series of structural elements can be defined for each sector: These elements affect both production levels and operation of markets. A certain number of macro-economic or specific policies will affect one or all the elements in this block.

Each block can be considered in a similar way, and this will provide the groundwork for a theoretical model of how the system works see C. The final steps in order to operationalize the model are i that of defining indicators that will, in the specific context of the country, reflect the key elements of the system, and ii , once policies and programmes have been chosen, that of identifying which of these indicators are useful for monitoring trends and evaluating programme impact.

This will be the basis for an information system reflecting the overall framework of the programme and how it should work. Another method has been proposed by researchers from the Institute of Tropical Medicine in Antwerp based on their field experience in collaboration with different partners Lefèvre et al.

Basically, it stresses the participatory aspect, with the aim of obtaining a true consensus on the local situation, the rationality of interventions in view of the situation, and the choice of indicators. It includes first a phase in which a causal framework is developed with the aim of providing an understanding of the mechanisms leading to undernutrition in the context under consideration.

The framework is constructed in the form of a schematic, hierarchized diagram of causal hypotheses formulated after discussions among all stakeholders.

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