Hi, Carlotta -- These are very much needed. Would it be possible to provide a poster template on which nationals could paste the info in their own language? Thank you. Taber Hand, Wetlands Work! - Cambodia

Here's the newest paper on the subject published last week. Unfortunately, the full paper isn't available without cost, but the abstract is useful:
An evolving perspective about the origins of childhood undernutrition and nutritional interventions that includes the gut microbiome
onlinelibrary.wiley.com/doi/10.1111/nyas.12487/abstract

The world is only beginning to understand the relationship between poor sanitation and malnutrition. This and previous papers by the same authors reveal gut dysbiosis/infection (using genetic tools such as PCR stool testing) as cause of malnutrition, not a simple matter of lack of food as we've wrongly believed for decades.

So, how is this relevant to sustainable sanitation (Rule 8 of the forum)? Open defecation and mixing our waste with drinking water is negatively affecting general health which begins in the intestines. This problem is associated with decline in cognitive health and diabetes, hardly a sustainable choice.

Carlotta, I stumbled on this drawing of leaky gut you may find useful; here it is attached.

carlottadenis wrote: I also quite like the two drawings in this article (health villi vs. atrophied villi), however I regret they only show the consequences of having atrophied villi for nutrients absorption and not for intestine permeability (allowing microbs to enter the body)
duncanmarasanitation.blogspot.fr/2009/09...l-enteropathy-3.html

Yes, Carlotta, those are great drawings, very simple. And, I agree, they don't convey microbial translocation or what is commonly known as "leaky gut" which includes toxins and undigested food particles slipping between what would otherwise be tight junctions into general circulation. There are many leaky gut diagrams available.

It may be good to convey how a healthy mix of microbes actually tend the gut lining to preserve tight junctions, i.e., bifidobacteria and lactobacillus. And also how certain nutrients, especially zinc and butyrate (product of flora, especially clostridium clusters IV and XIVa), enhance tight junctions.
www.zincsaveskids.org/

Hi everybody,

Thank you very much for your useful comments and suggestions.

Keith, I like the NIH article's illustration. I don't think the endoscopy images will be clear to people who don't have any WASH neither health background.

I also quite like the two drawings in this article (health villi vs. atrophied villi), however I regret they only show the consequences of having atrophied villi for nutrients absorption and not for intestine permeability (allowing microbs to enter the body)
duncanmarasanitation.blogspot.fr/2009/09...l-enteropathy-3.html

Arno, I think the F diagram is complementary to what we are trying to produce, but shows rather different things. It might be useful to include it in a corner of our poster then.

Best,
Carlotta

canaday wrote: Please check the link to this NIH article, as it did not open.

There is no text associated with the 4 photos you linked to from Nature. What does each one represent?

The link works here, thanks. The 4 Nature photos are Celiac images as example. But now I've found an "Endoscopic appearance of environmental enteropathy" in this paper. The image is from Zambia. Please click on the image for larger view.
Enteropathies in the Developing World: Neglected Effects on Global Health
www.ncbi.nlm.nih.gov/pmc/articles/PMC3335677/

Endoscopic appearance of environmental enteropathy. Endoscopic view of second part of the duodenum showing villi with characteristic changes of environmental enteropathy: fusion of villi so that instead of a finger-like appearance they take on a leaf-shaped appearance. Sometimes villous fusion goes further and takes on a cerebriform (sulcus and gyrus) appearance. Endoscopic image from Endoscopy Unit, University Teaching Hospital, Lusaka (P. Kelly).

Hi Carlotta
I think the three diagrams would be difficult to use for communication and learning among stakeholders. The first diagram is an excellent mapping of the ontogeny that lies behind the symptoms. And is very useful for practitioners and experts.

It is difficult to communicate the specific risk surrounding nutrition without also including some of the more better known vectors of disease related to faecal contamination. So it might be worthwhile to start with the well-used F diagram (siteresources.worldbank.org/INTTOPSANHYG...es/The_F_Diagram.jpg) and then add the nutrition impact thread to that. The F diagram can also be made much more living with addition of graphics as can be seen here:
www.infonet-biovision.org/res/res/files/3899.700x600.png

Regards
--Arno

Hi Keith,

Please check the link to this NIH article, as it did not open.

There is no text associated with the 4 photos you linked to from Nature. What does each one represent?

I agree that this is a big issue, but it is also cutting-edge science, so this is new to everyone. It is also a very uncomfortable and upsetting concept that many may not like to face up to, especially if they live in densely populated countries.

Best wishes,
Chris

carlottadenis wrote: If I understand your idea correctly, you would like a document illustrating the effect of environmental enteropathy on the intestine (healthy intestine vs. unhealthy intestine with atrophied villi). Would you see it on a different document or integrated to one of the posters I introduced here?

How about both? I think the more we focus on intestinal health as crucial to general health, the better (and that includes mental health). It seems especially true of the small intestine which is directly between the liver and pancreas. People may need to see what villous atrophy is to understand how poor sanitation leads to malnutrition. I'm not sure what type of image may best represent the issue, but I believe small intestinal microbial overgrowth to be the malady of our time.

This paper reveals the issue microscopically, but I think something in larger scale may be more effective:
www.ncbi.nlm.nih.gov/pmc/articles/PMC3372657/
www.ncbi.nlm.nih.gov/pmc/articles/PMC3372657/figure/F2/

Maybe endoscopy images such as these:
www.nature.com/ajg/journal/v107/n10/images/ajg2012199f1.jpg

Thanks for the Guardian article!

Dear Keith,

Thank you very much for your encouragement!

I was glad to see general public newspapers talking about the Wash/Nutrition links. Laurence Haddad also wrote an article published in the Guardian (on the links between sanitation and nutrition)
What do toilets have to do with nutrition? More than you might think

If I understand your idea correctly, you would like a document illustrating the effect of environmental enteropathy on the intestine (healthy intestine vs. unhealthy intestine with atrophied villi). Would you see it on a different document or integrated to one of the posters I introduced here?

Kind regards,
Carlotta

Very important subject matter and speaks toward the recent NYT article:
Poor Sanitation in India May Afflict Well-Fed Children With Malnutrition
www.nytimes.com/2014/07/15/world/asia/po...lnutrition.html?_r=0

I'd like to see an additional human anatomy graphic giving people a better idea of what causes malnutrition, actually malabsorption syndrome. In my understanding, the problem stems especially in the small intestine. Perhaps a "healthy vs. unhealthy" drawing of this part of the intestinal tract responsible for most of our nutrient/mineral absorption would really drive home the point that sanitation and nutrition are linked. It's not necessarily what we eat, but what we can absorb based on intestinal health.

Great project!

Dear Elisabeth,

Thank you for your interesting comments.

My work is evolving, and I am now focusing on a single poster, which combines the former N°2 and N°3.



The first poster is targeting people with a minimum technical background, like the SuSanA forum users. As you said, it is not easy to understand and look at, but making it visually pleasing without losing details seems rather impossible.

On the contrary, the new version I am working on is targeting ACF missions, people who do not necessarily have a technical background (would it be in Wash or in Nutrition). The purpose is to enable people to see at a glance the links between Wash and Nutrition, and the available evidence. We would like to see this poster on the walls of ACF missions' premises, easily accessible to everyone. For these reasons, a poster seems more relevant than a factsheet. Do you think a factsheet would be more useful?

From what I have found on the internet, I don't think something similar has been done already, however if you have something in mind please do not hesitate to share it.

Kind regards,
Carlotta

Dear Carlotta,

I took a look at the 3 posters that you shared with us. They are, as you said, still in an early stage of development. I quite like the first one, although I cannot imagine how you can make it visually pleasing as it looks quite complex (which is what makes it interesting).

So I am wondering: who is actually your target group for these posters? Would they perhaps not be better off as factsheets rather than as posters?
And have you scoured the internet for other people's posters and factsheets on the links between WASH and nutrition? I would assume that there is already some stuff out there? Did you find anything at all?

Kind regards,
Elisabeth