The Biology of Malnutrition

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The Biology of Malnutrition Part 4

• Effects of Nutritional Insult at Different Points
  in the Lifecycle

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Key Indicator of Malnutrition

• Infant Mortality Rate
• Defined as number of children per 1,000 live
  births who die before their 1st birthday
• US infant mortality rate 8
• Italy 5
• Finland 4
• China 31
• India 70
• Nigeria 76
• Uganda 88

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Maternal Malnutrition

• Studies of famine situations
• Dutch famine of WWII
• Siege of St. Petersburg
• Warsaw ghetto
• Data showed effect of protein energy malnutrition
  on pregnancy
• PEM early in pregnancy resulted in increased rate
  of fetal loss and malformations
• PEM late in pregnancy resulted in low birth
  weight babies

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Maternal Malnutrition

• Effect of maternal malnutrition on breastfeeding
• Lower volume of milk produced with energy
  nutrients in the same concentration
• Quality stays the same but quantity diminished
• Nutrients such as calcium and iron are taken from
  the maternal stores

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Maternal Malnutrition

• Effect of anemia
• Increased blood volume in pregnancy results in
  increased iron needs
• Maternal anemia associated with low birth weight
  and then low/no stores for the infant
• Affect on infant cognition if born with low
  stores
• Anemia in mother also results in decreased work
  capacity
• Increased maternal mortality rate
• Severe anemia accounts for up to 20 of maternal
  deaths in developing countries

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Maternal Malnutrition

• Affect of maternal iodine deficiency
• Cretinism in infant
• Affect of maternal size
• Stunted women have smaller babies
• Smaller pelvic area also results in higher
  incidence of difficult births
• Results in infant and maternal mortality

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Effects of Malnutrition on the Infant

• Intra Uterine Growth Retardation (IUGR)
• Major determinants are
• Inadequate maternal nutritional status before
  conception
• Short maternal stature
• Principally due to undernutrition and infection
  during childhood
• Poor maternal nutrition during pregnancy

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Effects of Malnutrition on the Infant

• In industrialized countries, cigarette smoking is
  the most important determinant of IUGR
• Followed by low gestational weight gain and low
  pre-pregnancy body mass index

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Effects of IUGR

• IUGR newborns in industrialized countries
• Partially catch up to controls during the first 2
  years of life but usually about 5 cm shorter and
  5 kg lighter in adulthood
• Same was shown in Guatemala, but still shorter,
  lighter and weaker than controls as young adults
• Neurologic dysfunctions (ADD) and immune function
  impairment also occur

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Effects of IUGR

• Barkers fetal origins of disease hypothesis
• Nutritional insults during critical periods of
  gestation and early infancy, followed by relative
  affluence, increase the risks of chronic diseases
  in adulthood
• Baby programmed for a life of scarcity and then
  confronted with a world of plenty
• See increases in CVD, DM and HBP, esp. if insult
  is in the 3rd trimester

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Effects of IUGR

• Low birthweight (lt2500 gm) results in
• a higher mortality rate
• Impaired mental function
• Majority of brain growth occurs during fetal
  period and first 18 months of life
• Increased risk of adult disease

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IUGR

• Intrauterine growth retardation is a pivotal
  indicator of progress in breaking the
  intergenerational cycle of undernutrition, a
  prospective marker of a childs future nutrition
  and health status as well as a retrospective
  measure of the nutrition and health status of the
  mother. 4th Report

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Infant Nutritional Status

• Influenced by
• Inadequate feeding
• Frequent infections
• Inadequate food
• Health
• Care
• Defined as the behaviors and practices of
  caregivers to provide the food, health care,
  stimulation, and emotional support necessary for
  childrens health growth and development -4th
  Report

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Infant Nutritional Status

• Babies who breast feed usually have better
  nutritional status than those who do not
• Infant does not compete with food supply for
  family
• Breast milk is a clean food supply in a clean
  container
• Breast milk has immunologic benefits so decreases
  disease in this way, too

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Infant Nutritional Status

• BREAST IS BEST
• Breast feeding is considered the best method of
  feeding infants
• Exclusive breast feeding usually extends the time
  between children
• Length of the birth interval strongly related to
  infant and child survival
• NOT an effective method of birth control however

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Infant Nutritional Status

• Evidence linking breastfeeding to
• Stronger intellectual development of the child
• Reduced risk of cancer, obesity and several
  chronic diseases
• Women who were breastfed as infants have a
  reduced risk of breast cancer

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Infant Feeding Recommendations

• Exclusive breast feeding for 4 to 6 months
• Breastfeeding with complementary feedings
  starting at about 6 months of age
• Continued breastfeeding in the second year of
  life and beyond

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Infant Feeding Recommendations

• Field studies show no advantage in growth or
  development when complementary foods introduced
  between 4 and 6 months
• UNICEF and many ministries of health in general
  recommend exclusive breastfeeding for 6 months
• WHO recommends exclusive breast feeding for 4-6
  months, so some confusion on this issue

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Infant Feeding Recommendations

• Interventions to improve intake of complementary
  foods can result in improved infant and child
  growth among populations at risk of
  undernutrition
• Effects of improved nutritional intake on growth
  are greatest in the first year of life with
  significant effects into the second and third
  year
• Adequate nutrition mitigates the negative effect
  of diarrhea seen in these years on linear growth

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Infant Feeding Recommendations

• Complementary foods are required in the second 6
  months of life to provide adequate nutrition and
  stimulate development
• Delayed introduction of food is a serious problem
  in countries such as Bangladesh, India and
  Pakistan

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Infant Feeding Recommendations

• Complementary foods must be adequately dense in
  energy and micronutrients to meet the
  requirements of infants and young children.
• Must be prepared, stored and fed in hygienic
  conditions to prevent diarrhea
• Foods also must be easy to prepare and culturally
  appropriate.

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Breastfeeding and HIV/AIDS

• Breastfeeding is a significant and preventable
  mode of HIV transmission
• Observational data have shown that 3 month old
  infants of HIV-positive women who were
  exclusively breastfed have the same risk of
  contracting HIV as infants who were never
  breastfed
• Partially breastfed infants had a significantly
  higher risk

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Breastfeeding and HIV/AIDS

• New guidelines call for urgent action to educate,
  counsel, and support HIV-positive women in making
  decisions about how to feed their infants safely.
• In order for a mother to make a decision, she
  must have access to
• Voluntary and confidential testing and counseling
• Information about feeding options and risk
  associated with them

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Breastfeeding and HIV/AIDS

• Previous recommendations stated that infants of
  HIV-positive mothers in developing countries
  should be breastfed because mortality was still
  lower in the breastfed infants.
• Shorter duration of breastfeeding is one option
  suggested in the new UNAIDS/WHO/UNICEF guidelines
• Awaiting confirmation of protective effect of
  exclusive breastfeeding

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Role of National and International Initiative in
Support of Optimal Infant Feeding

• 3 particularly important national and
  international initiatives to promote
  breastfeeding
• The International Code of Marketing of Breastmilk
  Substitutes The Code
• The Innocenti Declaration
• The WHO/UNICEF Baby Friendly Hospital Initiative

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The Code

• Adopted by the World Health Assembly in 1981
• Provides guidelines for the marketing of breast
  milk substitutes, bottles and teats
• Aims to restrict practices that make infant
  feeding decisions responsive to market pressures
• Especially restricts direct promotion to the
  public

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The Code

• Resolutions also urge
• No donations of free or subsidized supplies of
  breastmilk substitutes to any part of the health
  care system
• Even with a mixed record of compliance, it has
  had a major impact on the way formula is
  advertised and marketed

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The Code

• Has been particularly effective in the virtual
  elimination of the direct marketing to women who
  receive services through the public sector and in
  the restriction of marketing to health providers.

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The Innocenti Declaration

• Focuses on the need to protect, promote, and
  support breastfeeding
• Was signed by more than 30 countries in 1989
• One operational target of this is the universal
  implementation of the Ten Steps to Successful
  Breastfeeding
• Forms the basis for the WHO/UNICEF Baby Friendly
  Hospital Initiative

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The WHO/UNICEF Baby Friendly Hospital Initiative

• Endorsed by the 45th World Health Assembly in
  1992
• Has influenced the routines and norms of
  hospitals around the world through the Baby
  Friendly certification process

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The WHO/UNICEF Baby Friendly Hospital Initiative

• A hospital is designated as Baby Friendly when it
  has agreed not to accept free or low-cost
  breastmilk substitutes, feeding bottle and teats
  and to implement the Ten Steps
• 14,500 hospitals in over 142 countries have been
  certified

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The Maternal Milk

• Protects the baby from
• Diarrhea
• The flu
• Infection
• allergies

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Mobile Restaurant

• Tax free
• All free
• Perfectly balanced
• No infections
• Natural nourishment
• Attractive
• Open 24 hours
• Service with love

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Maternal Lactation come in , the most
nutritious, exquisite, free food
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• MMM, its time to eat
• But what are they going to give me?
• Ahh! My mother chose the best
• Mothers milk

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Child

• Brain cells increase in number (hyperplasia)
  until about age 18 months
• Malnutrition results in fewer cells and decreased
  mental capacity
• Prenatal malnutrition combined with postnatal
  malnutrition leads to a larger deficit

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Child

• Chronic malnutrition also has an indirect effect
  on mental development because it makes children
  less active and therefore their brains are less
  stimulated
• Less exploratory behavior
• Iodine deficiency has been shown to lower IQ by
  13.5 points
• If average is 100, -13.5 86.5, a level that is
  only higher than about 20 of the population

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Child

• Measures of malnutrition
• Stunting
• Wasting
• Underweight

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Child

• Underweight
• Low weight-for-age at lt 2SD of the median value
  of the NCHS/WHO reference
• Weight for age is influenced by the height and
  weight of a child
• Therefore is a composite of stunting and wasting
• Makes interpretation of this indicator difficult
  since both weight for age and height for age
  reflect the long-term nutrition and heath
  experience of the individual or population

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Child

• Wasting
• lt 2SD of median weight for height
• Severe lt 3SD
• Usually due to acute food shortage and/or severe
  disease
• Chronic dietary deficit or disease can also lead
  to wasting
• This indicator is used extensively in emergency
  settings

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Child

• Chronic low intake leads to STUNTING
• Growth charts key indicators
• Linear growth
• lt2 SD from median value of international growth
  reference for height stunting
• lt3 SD severe stunting
• Poor diet and disease leads to shortness
• Know that nutrition, not heredity, is the cause
  because of studies of better fed children in the
  same culture and growth velocity when breastfed

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Child

• Incidence of stunting is estimated at 32.5 of
  children under age 5 in developing countries
• Potential for catch-up growth is limited amongst
  stunted children after the age of 2
• Especially kids in poor environments
• Some catch-up possible between 2 and 8 /12 if NOT
  born with LBW or severely stunted in infancy

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Child

• Stunting at age 2 is associated significantly
  with later deficits in cognitive ability
• Alleviating hunger improves learning
• School feeding, both breakfast and lunch
  programs, has been shown t improve school
  performance in both developing and industrialized
  countries

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Child

• Alleviating hunger helps children perform better
• Hungry children have more difficulty
  concentrating and performing complex tasks, even
  if they are otherwise well nourished
• Studies in Jamaica have shown that children who
  were wasted, stunted, or previously malnourished
  benefited the most from feeding programs

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Child

• Poor nutrition also increases nutrition-related
  illnesses, causing children to miss more days of
  school
• Text cites case of 4 Latin American countries
  where illness causes children to miss more than
  50 days of school a year
• This has a definite affect on learning as well

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Child Catch Up
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Child

• A higher proportion of boys than girls are
  stunted in all countries
• Probably due to the increased time boys spend
  outside the home
• Girls have better physical access to available
  food

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Child

• Ways to improve nutrition and health status of
  children
• Antihelminthics
• Given in conjunction with vitamin A or iron
  supplementation shows better outcomes
• Delivery of micronutrients
• Treatment of injuries and routine health problems

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Adolescents

• Adolescent hormonal changes accelerate growth
• Growth is faster than at any other postnatal time
  except the first year

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Adolescent Girls

• Better nourished girls
• Have higher premenarcheal growth velocity
• Reach menarche earlier
• Undernourished girls
• Grow longer before a later menarche
• Growth of better nourished and undernourished
  girls during this period balances out
• Growth difference due to pre-existing childhood
  stunting even when total growth during growth
  spurt ends up being the same

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Adolescent Girls

• Undernourished girls grow for a longer period of
  time, so may not be finished growing before the
  1st pregnancy
• Leads to smaller infants due to competition for
  nutrients and poorer placental function
• Calcium a special concern since bones of
  adolescents have not reached maximum density
• Higher maternal and infant mortality and pre-term
  delivery with adolescent pregnancies

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Adolescent Boys

• Growth occurs for a longer time before growth
  spurt
• Velocity of growth spurt higher and longer than
  for girls
• Requires significant calories, protein, iron and
  other nutrients to support

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Adolescents

• Some catch-up growth may be possible in
  adolescence but there is little evidence to
  support it
• Stunted children are more likely than
  non-stunted children to become stunted adults as
  long as they continue to reside in the same
  environment that gave rise to the stunting

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Child ? Adolescent ? Adult

• Stunted women also are more likely to have
  obstructed labor due to pelvic disproportion (too
  small)
• Stunted children lead to stunted adults, leading
  to LBW infants
• Smallness tends to be transmitted from one
  generation to the other

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Adults

• The economic livelihood of populations depends
  to a large extent on the health and nutrition of
  adults. 4th Report
• Adult malnutrition
• Underweight
• Decrease in food intake, often along with disease
• Overweight
• Fewer calories out than in
• Micronutrient

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Adults

• Appears to be a continuous gradient in work
  capacity and productivity that is linked to body
  weight
• Adults with low body weight allocate fewer days
  to heavy labor
• Are more likely to fail to appear for work
  because of illness or exhaustion

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Adults

• Study of women Chinese cotton-mill workers
• Work increased 14 for each one-gram increase in
  their hemoglobin
• Increase was obtained by giving supplements
• Malnutrition
• work capacity
• Income
• money for food
• malnutrition of the women and children

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Adults

• Mortality rates go up when BMI lt 18.5
• Nigerian study showed increased mortality rates
  for each level of underweight
• Mild ? 40
• Moderate ? 140
• Severe ? 150
• High BMIs are also associated with increased
  mortality rates
• Growing data that shows burden of obesity is
  becoming greater among the poor than others

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Elderly

• 1950 200 million people over the age of 60 years
• 2025 projected to be 1.2 billion gt 60 years
• 70 will live in developing countries

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4th Report Statement

• The majority of poor older people in developing
  countries enter old age after a lifetime of
  poverty and deprivation, poor access to health
  care, and a diet that is usually inadequate in
  quantity and quality. For most of these older
  people, retirement is not an option. Poverty,
  lack of pensions, death of younger people from
  AIDS, and rural to urban migration of younger
  people are among the factors that compel older
  people to continue working. Adequate nutrition,
  healthy ageing, and the ability to function
  independently are thus essential components of a
  good quality of life.

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Elderly

• Nutritional status is related to functional
  ability
• Undernutrition (even after controlling for age,
  sex, and disease) is associated with higher risk
  of impairments in
• psychomotor speed and coordination
• mobility
• the ability to carry out activities of daily
  living independently

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Elderly

• Sarcopenia (the gradual loss of muscle mass with
  age) linked to
• Age-related losses of strength
• Increased risks of morbidity
• Functional impairment
• Dependence
• Mortality
• Data shows that energy and protein intake can
  directly affect this condition

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Elderly

• Malnutrition leads to decreased functional
  capacity and need for more help
• Can contribute less to the family (i.e.
  childcare)
• Depression/malnutrition connection
• See downward spiral in elderly with depression
  and malnutrition
• Leads to frailness and lack of ability to care
  for self

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Elderly

• Very little experience with nutrition
  interventions for older adults at the global
  level
• Dont really know if nutritional status can be
  improved or if it would lead to better functional
  ability
• Research need on adequate nutrition for this age
  group
• US experience shows some possibilities

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Summary

• Focus should be on preventing fetal and early
  childhood malnutrition, but the life cycle
  dynamics of cause and consequence demand a
  holistic inclusive approach
• Intervening at each point in the life cycle will
  accelerate and consolidate positive change