Ramona Sunderwirth, MD MPHGlobal Health Fellowship, EM

St Lukes/Roosevelt HospitalNew York, NY

objectivesGeneral principlesSpecific nutrientsLife cycle approach to nutritionMeasures of malnutritionSevere malnutrition

Hunger is a term which has three meanings Uneasy or painful sensation caused by want of food; craving

appetite, the exhausted condition caused by want of foodWant or scarcity of food in a countryA strong desire or craving

World hunger refers to the second definitionThe related technical term is malnutrition.1 

Malnutrition is a general term that indicates a lack of some or all nutritional elements necessary for human health Underweight, Stunting, WastingObesity

Number of People Hungry in the world 2010

925M

Major Causes of Death in Children Under Five in Developing Countries and the Contribution of

Malnutrition

Causes of HungerPoverty – principle cause

Lack of resources, unequal distribution resources (Amartya Sen)

Harmful economic systems → poverty & hungercontrol over resources & income based on military,

political & economic power that typically ends up in the hands of a minority, who live well, while those at the bottom barely survive, or don’t

Conflict → poverty & hungerDisplaced: refugees & IDP

Hunger → poverty → hungerpoor health, ↓ levels of energy, mental impairment, ↓

ability to work & learn → greater hunger

Causes of Hunger, cont.Dietary practices

BreastfeedingSingle source diets (corn, rice, cassava)Lack of education/knowledge or access

Agricultural productivitylack of farming skills , technology or resources

(nitrogen, fertilizers, pesticides , irrigation)Climate change

current & future cause of hunger & poverty↑drought, flooding, changing climatic patterns

requiring a shift in crops / farming practices not easily accomplished

Nutritional determinants of healthamong the most powerful environmental factors influencing health & disease

Recommended nutrient intakes RDA now DRV (dietary reference values) Food based dietary guidelines Food pyramid

Malnutrition modulates other diseases Infection Major contributor to death

Immunity and malnutrition Immunity greatly compromised Barrier defenses breached, cell-mediated immunity depressed Lymph glands/thymus atrophic IgA, complement components , phagoycytic activity depressed Effects of less extreme malnutrition/nutrient deficiencies

Essential NutrientsEnergy

Drives consumption of all other nutrientsIntake balanced w/ expendituresDeficit must be met by body stores

Short term: muscles/liver glycogen/ short term fat stores Medium term: adipose tissue Long term: protein

Wasting: sustained energy deficits Adults: Chronic Energy Deficiency CED (BMI < 18.5) Famines/poverty Incorrect child feeding practices Anorexia of infection & illness

Essential nutrientsCarbohydrates

Most energy in most diets (17.6kJ/g)

Amylase, sucrase, maltase, lactase → glucoseGlucose: used by tissues, stored in liver/muscle (glycogen)Insulin vs Cortisol/GHBrain consumes 60% of total circulating glucose

Ketones used during starvation (B-hydroxybutyric acid from fats)

Clinically significant disturbances in carbohydrate metabolism

Malabsorption Lactase deficiency, gut

infections, Kwashiorkor, persistent gastroenteropathy

Disturbed Metabolism: hypoGlycemia Inadequate stores

Marasmus, Kwashiorkor Liver damage, hepatitis Sepsis

Toxins/drugs Alcohol, insulin

Cerebral malaria

Disturbed Metabolism: hyperGlycemia Hormonal

DM (insulin resistance) Excess corticosteroids

Essential nutrientsFats (TG) (39 kJ/g)

Saturated (animal) vs Unsaturated (plants)Long chain PUFAs (breast milk) & EFAs (found only

in food)In Times of Plenty: TG stored in adipose tissue (insulin)

In Times of Negative Energy Balance: Noradrenaline & GH stimulate Lipase in adipocytesFat deposits depletedEFA & TG oxidized in liver to acetoacetic acid (used for

energy)EFA used directly by skeletal & heart muscle

Disturbances in Fat metabolismInadequate stores

Dietary Starvation, Marasmus

Malabsorption Infections in Gut

(giardia, strongyloides) Bile salt deficiency

Obstructive Jaundice, Gall bladder disease,

Bacterial overgrowth Pancreatic damage

Kwashiorkor Pancreatitis

Disturbed metabolismFatty Liver

Kwashiorkor Alcoholism

Essential nutrientsProteins (17kJ/g)

Provides AA for synthesis: enzymes, plasma proteins, milk, tissue cells

Starvation: AA → glucose (gluconeogenesis)>→decrease muscle mass/ damage to vital organs (Marasmus)

Essential AA found in diet onlyQuality of dietary protein measured by animal

growthAnimal protein: first class protein, similar AA composition to

humansMilk: high net protein utilization index (NPU=biological value

(quality + digestibility)Plant protein: variable digestibility + quality

plant mixtures can supplement each other (high quality proteins)

Protein concentration in diets5-6% energy6-8%: infants, malnourished children, lactating women

Clinically important disturbances in protein metabolism

Inadequate storesStarvationMarasmus, Kwashiorkor

MalabsorptionPancreatic diseaseKwashiorkor

Increased catabolismInfectionsTumours

Inadequate synthesisCirrhosis of liverDiabetes

Increased lossNephrotic syndromeSevere gut infections

Measles, amoebiasis Bacillary dysentery

Burns & exudates

Food component

Energy Density

kJ/g kcal/g

Fat 37 9

Ethanol (alcohol) 29 7

Proteins 17 4

Carbohydrates 17 4

Organic acids 13 3

Polyols (sugar alcohols, sweeteners)

10 2.4

Fiber 8 2

Essential NutrientsMinerals

Contained in all tissues/fluids, mainly in bone

Functions in co enzymes, hormones, vitamins

Balanced diet provides adequate amounts Calcium/Iron: meat/fish/eggs/diary products Iodide, fluoride, selenium: uptake by plants from soil/rocks Potassium/magnesium: cardiac/renal diseases &

Kwashiorkor/ chronic diarrhea

Micronutrient Initiative (2002): eliminate “hidden hunger” – most damaging worldwide Iron, iodine deficiency , Vit A

Essential NutrientsVitamins

Minute amounts vital for life Not synthesized in body (except Vit D): obtained in diet

Regulators of metabolic reactions Fat soluble: Vit A,D,E, K Water soluble: Vit C, B complex

Deficiencies : Together in people on poor, monotonous diets

Lack of dairy products (riboflavin); Vit A, Vit C (seasonal) Emergencies (famines), prisons Illness w/ suppressed food intake Cultural: women/infants kept indoors

Life cycle approach to nutritionSpecial needs at special times

Phases are linked, and each affect next stage of development: continuous loop Cause & Effect

“Fetal & infant origins of diseases” & “Thrifty phenotype”

Inter generational cycle of malnutrition

Fetal Growth & nutritional needs of pregnant women

Low birth weightNutritional effects on fetal growthNutritional needs of pregnancyDietary supplements in pregnancyLactation

Fetal growth & nutritional needs of pregnant women

Low birth weight predictor of NN & post NN mortality Interventions that raise BW by 100 g have major impact on mortality

Fetal growth influenced by many factorsWoman’s size predictor of BW (S. Asia vs African SGA rates)Maternal wt gain in pregnancy : 1.5 kg/mo↑normal energy intake by 10% (remarkable maternal energy sparing

mechanisms)

Nutritional needs of pregnancy & dietary supplementsCommunity-wide dietary supplementation of poor rural women can

enhance BW (Gambia)HIV + women given micronutrient supplementation : ↓ SGA Interventions to prevent fetal growth retardation targeted at specific

pop.

LactationNutritional requirements of infant > fetusEnergy requirements lactation > pregnancy

Highly “robust” processNeeds to increase energy intake by 20-25%If balanced diet, other nutrient needs met

Water soluble vitamins, minerals (calcium)Maternal deficiencies reflected as low concentrations in milk

Fat soluble vitaminsBetter bufferedProtein, fat, carbohydrate composition very constant

Supplementation: in extreme situations

Infant NutritionGrowthCauses of growth failureSevere forms of PEM

Classifications: Gomez vs WellcomeMarasmusKwashiorkor

Breast-feedingOptimal duration of exclusive breast feedingWeaning foods

Infant Growth where food supplies insecure, diet low quality, infections frequent

Breast-fed infants (3-4 mos)Ideal food, adequate amount, protection from infectionWHO recommends exclusive BF till 6 mos age

Growth falteringBegins w/ weaning: low nutrient density, contaminatedBy 1yr average WFA -2Z score in many areas AfricaIf stunted as well as wasted, look better nourished

Strongly associated w/ developmental deficits

“Road to Health” chartsWasting: acute malnutritionStunting: longer term deficit

Malnutrition

WHO defines malnutrition as the cellular imbalance between the supply of nutrients & energy & the body’s demand for them to ensure growth, maintenance, & specific functions.

Protein energy malnutritionPediatrics

Wasting : acute malnutritionRapid weight loss or failure to gain weight normally

Stunting: chronic malnutritionFailure of linear growth

Underweight: acute & chronic malnutrition occurs as a result of wasting, stunting, or both

Nutrition & MalnutritionChild

•

Malnutrition ClassificationsChronic Malnutrition → Stunting

Eventually affects child’s body proportions → Wasting

Gomez Classification:  The child's wt compared to that of a nl child of the same age Useful for population screening & public health evaluations% of reference wt for age = [(patient wt) / (wt of nl child of

same age)]

Waterlow Classification: % wt for ht = [(wt of patient) / (wt of a nl child of the same ht)] % ht for age = [(ht of patient) / (ht of a nl child of the same

age)]

 

Wellcome Classificationevaluates the child for edema & with the Gomez Classification system

Wt for Age (Gomez) w/ Edema w/ out Edema

60-80% Kwashiorkor Under nutrition

<60% Marasmic- Marasmus

Kwashiorkor

 Classification  Definition  Grading

 GomezWeight below %median WFA

Mild (grade 1)Moderate (grade 2)Severe (grade 3)

75%–90% WFA60%–74% WFA<60% WFA

 Waterlowz-scores (SD) belowmedian WFH

MildModerateSevere

80%–90% WFH70%–80% WFH<70% WFH

 WHO (wasting)z-scores (SD) belowmedian WFH

ModerateSevere

-3%</= z-score < -2z-score < -3

 WHO (stunting)z-scores (SD) belowmedian HFA

ModerateSevere

-3%</= z-score < -2z-score < -3

 Kanawati

MUAC divided byoccipitofrontal headcircumference

MildModerateSevere

<0.31<0.28<0.25

 Colez-scores of BMI for age

Grade 1Grade 2Grade 3

BMI for age z-score < -1BMI for age z-score < -2BMI for age z-score < -3

Definitions of malnutrition .

   Mild Malnutrition Moderate

Malnutrition Severe

Malnutrition

 Percent Ideal Body Weight  80-90%  70-79%  < 70%

 Percent of Usual Body Weight

 90-95%  80-89% < 80%

 Albumin (g/dL)  2.8-3.4  2.1-2.7  < 2.1

 Transferrin (mg/dL)

 150 - 200  100 - 149  < 100

 Total Lymphocyte Count (per µL)

 1200 - 2000  800 - 1199  < 800

Classification of Malnutrition in Children 

Malnutrition Classifications

Gomez- Public Health screenings & EmergenciesWFA% (reference) Classification

90-110 Normal 75-89 Grade I – Mild 60-74 Grade II – Moderate <60 Grade III - Severe

Wellcome – Clinical SettingsWFA% (NCHS median) No edema With edema

60-80 Undernutrition Kwashiorkor < 60 Marasmus Marasmic/

Kwashiorkor

Methods of assessing growth failure & pediatric malnutrition

Reference growth curves for Wt & Ht Road to Health: %WFA %HFA %WFH ( if age unknown) Expected wt/ht for age WHO curves in Africa

Centile curves Same reference curves, 50% is line up center distribution Nl

population

Z-scores 1 SD from mean of Nl population (average WFH O Z-score) Applied to WFH, HFA, WFA

MUAC: constant from 1-5 yrs ag >140: Normal , 115-140 mild/moderate, <115 severe Red-severe acute Orange -moderate acute Yellow refer Green- Nl

HC, Skinfold thickness (triceps & supra-scapular)

Road to Health Chart

MUAC

Skin fold thickness

Causes of growth failureInfections

Primary nutrient shortages-seasonal, famine, cultural, conflict

Tropical gastroenteropathyVillous atrophy: degree predicts growth

Affects nutrient absorption (lactose) Loss of plasma proteins: protein enteropathy (measles)

Increased permeabilityOver active inflammatory response

Malnutrition in Children25% world’s pediatric pop undernourished

Contributes to > 50% U5 Mortality in RPC

Children very vulnerable to malnutritionHigh nutritional requirements for growthReliance on others for food access

Two classic phenotypic presentationsPEM + micronutrient deficienciesMarasmus: decreased WFH + severe wastingKwashiorkor: distinguished by edemaMarasmic/Kwashiorkor : elements of both

PathophysiologyTissue starvation influences physiology at every level

Native & acquired immunity weakened

Antioxidant deficiencies → unchecked free radicals to inflict direct cellular damage

Injury to cell wall Na-K pumps → Na retention & K wasting

HypoGlu: exhaustion of muscle glycogen stores & impaired gluconeogenesis

Atrophy & oxidant induced damage of myocardial tissues → cardiac dysfunction +

Fluid shifts from leaky membranes + large Na loads during recovery → CHF

Severe forms of MalnutritionMarasmus

“adapted state”: prolonged underfeeding forces child to consume own fat/protein stores to maintain function vital organs

1st yr of life, WFA & HFA diminished Thin, severe muscle wasting, weak Sunken eyes, dry mucous membranes, skin tenting,

decreased tears : not to be confused w/ dehydrationBradycardia, hypo TA & hypothermiaThin, dry skin, redundant skin fold. Thin, sparse

hair, easily plucked

Severe Forms of MalnutritionKwashiorkor

“Disadapted state”, imbalance in protein supply limits hepatic production albumin & plasma proteins → edema

2nd year of life. Acute illnessMarked muscle atrophy, w/ nl body fat. Anorexia.

Apathetic, irritable Pitting edema, anasarca, “Moon Face”Dry, atrophic, peeling skin, confluent areas of

hyperkeratosis & hyper pigmentation: Flaky paint dermatosis

Dry, dull, hypopigmented hair, orange, falls out/easily plucked

Hepatomegaly (fatty liver infiltrates)+ dilated/hypomotile intestinal loops + bacterial overgrowth/gas production, weak abd muscles → distended abdomen

Kwashiorkor & Marasmus

Kwashiorkor & Marasmus

Childhood & adolescence

Higher metabolism rate /energy/nutrient requirements than adults

Adolescent growth spurt energy, protein, Ca & Iron requirements raise

Same diet as Adults

Often fed last, after Men, Women & younger children

Treatment of Malnutrition

For another Thursday