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The Biology of Malnutrition – Part 4 . Effects of Nutritional Insult at Different Points in the Lifecycle. Key Indicator of Malnutrition. Infant Mortality Rate Defined as number of children per 1,000 live births who die before their 1 st birthday US infant mortality rate: 8 Italy 5

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The Biology of Malnutrition – Part 4

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the biology of malnutrition part 4

The Biology of Malnutrition – Part 4

Effects of Nutritional Insult at Different Points in the Lifecycle

key indicator of malnutrition
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
maternal malnutrition
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
maternal malnutrition5
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
maternal malnutrition6
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
maternal malnutrition7
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
effects of malnutrition on the infant
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
effects of malnutrition on the infant9
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
effects of iugr
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
effects of iugr11
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
effects of iugr12
Effects of IUGR
  • Low birthweight (<2500 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
  • “Intrauterine growth retardation is a pivotal indicator of progress in breaking the intergenerational cycle of undernutrition, a prospective marker of a child’s future nutrition and health status as well as a retrospective measure of the nutrition and health status of the mother.” 4th Report
infant nutritional status
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 children’s health growth and development” -4th Report
infant nutritional status15
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
infant nutritional status16
Infant Nutritional Status
    • 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
infant nutritional status17
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
infant feeding recommendations
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
infant feeding recommendations19
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
infant feeding recommendations20
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
infant feeding recommendations21
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
infant feeding recommendations22
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.
breastfeeding and hiv aids
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
breastfeeding and hiv aids24
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
breastfeeding and hiv aids25
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
role of national and international initiative in support of optimal infant feeding
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
the code
“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
the code28
“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
the code29
“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.
the innocenti declaration
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
the who unicef baby friendly hospital initiative
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
the who unicef baby friendly hospital initiative32
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
the maternal milk
The Maternal Milk
  • Protects the baby from
    • Diarrhea
    • The flu
    • Infection
    • allergies
mobile restaurant
Mobile Restaurant
  • Tax free
  • All free
  • Perfectly balanced
  • No infections
  • Natural nourishment
  • Attractive
  • Open 24 hours
  • Service with love
MMM, it’s time to eat
  • But what are they going to give me?
  • Ahh! My mother chose the best
  • Mother’s milk
  • 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
  • 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
  • Measures of malnutrition
    • Stunting
    • Wasting
    • Underweight
  • Underweight
    • Low weight-for-age at < 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
  • Wasting
    • < 2SD of median weight for height
      • Severe < 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
  • Chronic low intake leads to STUNTING
    • Growth charts key indicators
    • Linear growth
      • <2 SD from median value of international growth reference for height = stunting
      • <3 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Adolescent hormonal changes accelerate growth
    • Growth is faster than at any other postnatal time except the first year
adolescent girls
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
adolescent girls52
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
adolescent boys
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
  • 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”
child adolescent adult
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
  • “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
  • 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
  • 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
  • Mortality rates go up when BMI < 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
  • 1950: 200 million people over the age of 60 years
  • 2025: projected to be 1.2 billion > 60 years
    • 70% will live in developing countries
4 th report statement
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.”
  • 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
  • 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
  • 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
  • Very little experience with nutrition interventions for older adults at the global level
  • Don’t 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
  • 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