Nutritional Disorders in Turkey and in the World

Prof.Dr.Selma KARABEY

Nutritional Disorders Micronutrient malnutrition1. Iron deficiency2. Iodine deficiency3. Vitamin A deficiency4. Folate deficiency Protein energy malnutrition5. Kawashiorkor diseasese,6. Marasmus( or wasting)

Nutritional Disorders-2 Chronic non-communicable diseases associated with diet and nutrition:1. Coronary hearth disease2. Hypertansion and stroke3. Cancers4. Obesity5. Non-insulin dependent diabetes mellitus6. Dental caries

Terminology Stunting (inadequate length/height for

age) captures early chronic exposure to undernutrition;

Wasting (inadequate weight for height) captures acute undernutrition;

Underweight (inadequate weight for age) is a composite indicator that includes elements of stunting and wasting.

Terminology-2 Severe acute malnutrition :is defined as the percentage

of children aged 6 to 59 months whose weight for height is below minus three standard deviations from the median of the WHO Child Growth Standards, or by a mid-upper-arm circumference less than 115 mm, with or without nutritional oedema.

Overweight :is defined as the percentage of children aged 0 to 59 months whose weight for height is above two standard deviations (overweight and obese) or above three standard deviations (obese) from the median of the WHO Child Growth Standards.

Low birthweight :is defined as a weight of less than 2,500 grams at birth.

Contribution of Undernutrition to

death

Types of UndernutritionGrowth Failure

Acute Malnutrition-

Wasting

Chronic Malnutrition-

Stunting

Acute and/or chronic

malnutrition-Underweight

Micronutrient

Malnutrition

Vitamin A Deficiency

Iron Deficiency

Iodine Deficiency

Other Micronutrient Deficiencies

…

Chronic Malnutrition:Stunting

Chronic malnutrition, or stunting, is another form of growth failure. Chronic malnutrition occurs over time, unlike acute malnutrition.

A child who is stunted or chronically malnourished often appears to be normally proportioned but is actually shorter than normal for his/her age.

Stunting starts before birth and is caused by poor maternal nutrition, poor feeding practices, poor food quality as well as frequent infections which can slow down growth.

Chronic Malnutrition:Stunting

Stunting is estimated by the United Nations Children’s Fund (UNICEF) to affect 800 million people world wide.

195 million children under 5 years of ages are stunted. 85% of the worlds stunted children live in 20 countries.

But this burden is not evenly distributed around the world. Sub-Saharan Africa and South Asia are home to three fourths of the world’s stunted children.

In sub-Saharan Africa, 40 per cent of children under 5 years of age are stunted; in South Asia, 39 per cent are stunted.

The World Health Assembly has adopted a new target of reducing the number of stunted children under the age of 5 by 40 per cent by 2025.

Stunting in Turkey In Turkey, 1/10 of children under 5 years

old are stunted and more than 1/3 of them are severly stunted.(TNSA 2008)

% 12 of 24-59 months children are stunted. Severly stunting is more commen in the age

group of 24-35 months. % 3 of 48-59 months children are severly

stunted. In the 6-10 years old school age group, % 5

of them stunted and % 21.5 of them short.(TOÇBİ 2011)

Stunting in Turkey

Acute Malnutrition:Wasting

Globally in 2011, 52 million children under 5 years of age were moderately or severely wasted, an 11 per cent decrease from the estimated figure of 58 million in 1990. More than 29 million children under 5, an estimated 5 per cent, suffered from severe wasting.

In Turkey, 4 per cent of 24-35 months children and lower than 2 per cent of 48 and upper months children are underweight.

8 per cent (in urban areas) or 9 per cent (in rural) of 0-59 months children are wasted. (TNSA 2008)

Clinical Forms of Acut Malnutrition

There are 3 clinical forms of acute malnutrition:

Marasmus –  severe weight loss or wasting

Kwashiorkor – bloated appearance due to water retention (bi-lateral oedema).

Marasmic-kwashiorkor – a combination of both wasting and bi-lateral oedema.

Acute Malnutrition : Marasmus(Or Wasting)

A rapid deterioration in nutritional status in a short time can lead to marasmus,  one form of acute malnutrition.

Marasmus is the most common form of acute malnutrition in nutritional emergencies and, in its severe form, can very quickly lead to death if untreated.

It is characterised by severe wasting of fat and muscle which the body breaks down to make energy.

Wasting can affect both children and adults.

Acute Malnutrition : Marasmus(Or Wasting)

The body of a wasted child tries to conserve energy as much as possible by reducing physical activity and growth, reducing internal body processes and shutting down the body’s response to infection.

This reduced activity results in limited function of the liver, kidney, heart and gut putting the child at risk for:

Low blood sugar (hypoglisemia) Low body temparature (hypothermia) Fluid overlood/heart failure Infection

Acute Malnutrition : Marasmus(Or Wasting)

Typical characteristics of a wasted child include:

‘Skin and bones’ apperance A thin ‘old man’ face Ribs and shoulder bones easily seen, skin

of upper arms loose, skin of thighs loose,flesh missing from buttocks resulting in loose skin

Usually active and may appear to be alert

Acute Malnutrition : Marasmus(Or Wasting)

A wasted child can be classified as either moderately or severely acutely malnourished based on body measurements.

Mid-Upper Arm Circumference (MUAC) and Weight-for-Height Z-score (WHZ) are the indicators used to classify a child with wasting.

Acute Malnutrition:Kwashiorkor(or bi-lateral pitting oedema)

Kwashiorkor is characterised by bilateral pitting oedema (affecting both sides of the body) in the lower legs and feet which as it progresses becomes more generalised to the arms, hands and face.

Oedema is the excessive accumulation of  fluid in body tissues which results from severe nutritional deficiencies.

All cases of kwashiorkor are classified as severe acute malnutrition.

Acute Malnutrition:Kwashiorkor(or bi-lateral pitting oedema)

Kwashiorkor is classified by the severity of the oedema, as follows: + Mild: both feet ++ Moderate: both

feet, plus lower legs, hands or lower arms

+++ Severe: generalized oedema including both feet, legs, hands, arms and face.

Acute Malnutrition:Kwashiorkor(or bi-lateral pitting oedema)

Clinical signs of kwashiorkor include: Loss of appetite Apathy and irritability Changes in hair colour (yellow/orange) Dermatosis Dermatosis is common in children with oedema. Signs of dermatosis include: Patches of skin abnormally light or dark Shedding of skin, ulceration of skin and/or

weeping lesions

Acute Malnutrition:Marasmic-Kwashiorcor

(Combined wasting and bi-lateral pitting oedema)

Marasmic-kwashiorkor is a mixed form of both marasmus and kwashiorkor and is characterized by the presence of both wasting and bilateral pitting oedema.

Both Kwashiorkor and Marasmic-kwashiorkor are very serious conditions and are classified as forms of severe acute malnutrition.

Acute Malnutrition:Classificati

on Moderate Acute

Malnutrition (MAM)Severe Acute

Malnutrition (SAM)

Global Acute Malnutrition

(GAM)

• Weight-for-Height Z-score <-2 but >-3• MUAC<11.5cm,

• Weight-for-Height Z-score <-3

• Bilateral pitting oedema

• Marasmic-kwashiorkor (both wasting and oedema)• The sum of the prevalence of SAM plus MAM at a population level.

Adult Undernutrition Adults with a BMI ˂18.5 are considered to be

chronically undernourished while those with BMI˃25 and ˃30 are considered overweight and obese and the same cut offs apply both males and females.

The number of undernourished estimated is 854 million of which 820 million are in devoloping countries.(2006 FAO)

Adult Overweight and Obesity 1/3 Adults (%34 of men,%35 of women) owerweight― BMI ≥ 25 kg/m2

1/10 men (%10) and more than one in 10 women (%14) obese― BMI ≥ 30 kg/m2

In the Region of the Americas, followed by the European Region, more than 50% of the adult population were overweight and more than 20% were obese.

Adult overweight and obesity was much more prevalent in upper middle-income and high-income groups than in lower middle-income and low-income groups.

Obesity was more common in women than in men.

Nutrition-specific interventions

The 2009 Tracking Progress on Child and Maternal Nutrition report summarized the evidence base for nutrition-specific interventions. Taking a life-cycle approach, the activities fall broadly into the following categories:

Maternal nutrition and prevention of low birthweight Infant and young child feeding (IYCF) Breastfeeding, with early

initiation (within one hour of birth) and continued exclusive breastfeeding for the first six months followed by continued breastfeeding up to 2 years

Safe, timely, adequate and appropriate complementary feeding from 6 months onwards

Prevention and treatment of micronutrient deficiencies Prevention and treatment of severe acute malnutrition Promotion of good sanitation practices and access to clean

drinking water Promotion of healthy practices and appropriate use of health

services

Iron deficiency and anaemia

Iron deficiency is the most common nutritional deficiency, with more than 2 billion people affected worldwide (WHO, 2001).

Globally, anaemia affects 1.62 billion people, or 24.8% of the world’s population. Anaemia in preschool-age children and in women is a severe public health problem, with a prevalence of at least 40%, in most countries in the African Region and the South-East Asia Region, and in parts of Latin America (WHO & CDC, 2008)

Iron deficiency and anaemia

The highest prevalence of anaemia is found among preschool-age children (47.4%), and the lowest prevalence is among men (12.7%).

The population group in which the largest number of individuals affected is non-pregnant women (468.4 million). The African Region has the highest rates of all the regions, with anaemia affecting two out of three preschool-age children (67.6%), and about every second pregnant (57.1%) and nonpregnant (47.5%) woman.

The largest numbers are in the South-East Asia Region, where 315 million individuals in these three population groups are affected (WHO & CDC,2008).

WHO/FAO 2006

WHO/FAO 2006

Vitamin A deficiency

Globally, one in three preschool-aged children and one in six pregnant women are deficient in vitamin A due to inadequate dietary intake (1995–2005 data).

The highest prevalence remains in Africa and South- East Asia.

Vitamin A is necessary to support immune system response, and children who are deficient face a higher risk of dying from infectious diseases such as measles and diarrhoea

Vitamin A deficiency-2 Vitamin A deficiency (VAD) is the leading cause of

preventable blindness in children and increases the risk of disease and death from severe infections. In pregnant women VAD causes night blindness and may increase the risk of maternal mortality

An estimated 250 million preschool children are vitamin A deficient and it is likely that in vitamin A deficient areas a substantial proportion of pregnant women is vitamin A deficient._Globally, one in three preschool-aged children and one in six pregnant women are deficient in vitamin A due to inadequate dietary intake (1995–2005 data).

Iodine deficiency Iodine deficiency is the most common cause of

preventable mental impairment. Fortification of salt is widely used to avert consequences associated with this deficiency.

Significant progress has been made in reducing the number of countries whose populations suffer mild to severe iodine deficiency, from 54 countries in 2003 to 32 in 2011.

During this period the number of countries reaching adequate iodine intake increased by more than one third, from 43 to 69.

Folic Asid Deficiency Maternal health and nutrition conditions may

lead to a congenital condition called neural tube defects, which annually affect an estimated

320 000 newborns worldwide.

In Turkey, the prevelance of neural tube defect ( due to a lack of folic acid ) is ‰ 30.1 ( Boys ‰ 43.9, girls ‰ 56.1, Boys/girls: 1.27)

(Tunçbilek et al, 1999)

Folic Asid Deficiency-2 The two most common neural tube defects

are spina bifida, which causes paralysis of the legs, and anencephaly, in which most of the brain and skull do not develop. These disabilities may be prevented by maternal folic acid supplementation.

Folic acid supplementation of the mother enabling adequate folate levels at conception can not only improve the mother’s health and nutrition levels, but also prevent up to 70% of neural tube defects in the unborn child.

Diet, Nutrition and Cardiovascular Diseases

The commonest cardiovasculer diseases that are diet-related are coronary heart disease and hypertension.

Globally, one third of ischaemic heart disease is attributable to high cholesterol.

In 2008, the prevalence of raised total cholesterol among adults

– defined as total cholesterol ≥ 6.2 mmol/l (240 mg/dl) – was 9.7% (8.5% for males and 10.7% for females).

Diet, Nutrition and Coronary Heart Diseases

The risk of CHD( Coronary Heart Diseases) in individuals is dominated by three major factors:

1. High serum total cholestrol2. High blood pressure3. Cigarette smoking (WHO1982) There is also sinergism between risk factors.

Saturated fats raise total and low density lipoprotein (LDL) cholestrol, and of these fatty acids myristic and palmitic acids abundant in diets rich in diery and meat products have the greatest effects. (Seven Country Study 1980)

Both mono-unsaturated and n-3 and n-6 polyunsaturated fatty acids( PUFAs) lower plasma total and LDL cholestrol; PUFAs are more effective than mono-unsaturates.(Kris-Etherton 1999; Mori and Beilin 2001)

Diet, Nutrition and Hypertansion The dietary factors that are implicated are

alcohol and caffeine intake, excessive sodium and saturated fat intake and low potassium and calcium intake.

In most countries average per-person salt intake is too high and is between 9 grams (g) and 12 g/day .

WHO recommends that adults should consume less than 2000 milligrams of sodium, or 5 g of salt per day.

Finland initiated a systematic approach to reduce salt intake in the late 1970s through mass-media campaigns, cooperation with the food industry, and implementation of salt labeling legislation. The reduction in salt intake was accompanied by a decline in both systolic and diastolic blood pressure of 10 mm Hg or more.

Diet, Nutrition and Cancers It is now widely accepted that one-third of human

cancers could relate directly to some dietary component.

(Doll and Peto 1981) Thus up to 80 per cent of all cancers may have a

link with nutrition. The intake of alcohol appears to be an

independent risk factor for oral, laryngeal and pharyngeal cancers as well as oesophagus, liver and breast cancers.

Consumption of salted fish, preserved and fermented foods containing nitrosamins as weaning foods or from early childhood may introduce a substantial risk for nasopharyngeal cancer.

Diet, Nutrition and Cancer-2 Stomach cancer is also associated with

diets comprising large amounts of salted and salty foods and low levels of fresh fruit and vegetables.

International comparisons indicate that diets low in fibre or complex carbohidrates and high in animal fat and animal protein increase the risk of colon cancer.

Primary liver cancers have been correlated with mycotoxin (aflatoxin) contamination of foodstuffs.

In prospective studies, the frequency of the consumption of foods rich in β-carotene has been inversely associated with lung cancer risk.

Diet, Nutrition and Obesity Expert panels suggest a body mass index (BMI) above 25 is classified as overweight and above 30 as obese.

(Eckel-Krauss 1998) Changes in the environment that affect the levels of physical activity among to children and adults and changes both in the food consumed and in the paterns of eating behavior may contribute tom increase energy intakes beyond one’s requirement, thus causing obesity.

The main health risk of obesity is premature death due to heart disease and hypertansion and other chronic diseases.

Weight gain is strongly associated with increased blood pressure, elevated plasma cholestrol, and triglycerides and hyperglisemia (fasting and post-parandial).

Diet, Nutrition and Diabetes

Obesity is major risk factor for occurance of NIDDM; the risk being related both to the duration and degree of obesity.

Lifestyle strategies, weight loss and physical activity can be effective at reducing blood glucose and controlling the associated risk factors

Diets high in plant foods are associated with a lower incidence of NIDDM, and vegetarians have lower risk than non-vegetarians.

Physical activity improves glucose tolerance by weight reduction and by its beneficial effects on insulin resistance.

Anorexia nervosa Blumia nervosa

Psycho-spcial Problems effecting nutrition

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