Underweight and Malnutrition

7/30/2019 Underweight and Malnutrition

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by

Thaddee Katembo, BSND,MPH, DrPHApril, 2012

Underweight and

Malnutrition


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Introduction Obesity is no more only a health problem in adult

people, but currentdatarevealthatchildrenarenotsaved.

WHO specifies that at least 20 million children underthe age of 5 years were overweight globally in2005(WHO, 2006).

In parallel to the development in adults, theprevalence of overweight children and adolescentsis also increasing worldwide, illustrating thatchildren and adolescents are part of the worldwide

epidemic of obesity. (McArdle, Katch&Katch,2007) In many countries, about 15 to 35% of the children

and adolescents are now classified as beingoverweight and about 5% are classified obese.


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A Double Burden

In developing countries, obesity coexists with

undernutrition, with prevalence rates higher in urbanthan in rural population. (McArdle, Katch and Katch,2007).

This double burden of malnutrition refers to the dual

burden of under- and overnutrition occurringsimultaneously within a population in the developingcountries (FAO, 2006).

According to WHO, globally, it is estimated that thereare nearly 20 million children who are severely andacutely malnourished.

Most of them live in South Asia and in Sub-Saharan

Africa.


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Mortality

Estimates suggest that about 1 million

children die every year from severe acute

malnutrition(WHO, 2007)

Malnutrition is directly responsible for

300,000 deaths per year in children younger

than 5 years in developing countries and

contributes indirectly to over half the deathsin childhood worldwide (Shashidhar et al.,

2011)


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Vulnerable People and Regions

Women and young

children are the most

adversely affected groups;

one quarter to one half of

women of child-bearingage in Sub-Saharan Africa

and South Asia are

underweight, whichcontributes to the

number of low birth

weight infants born

annually.


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Double Burden

WHO specifies that at least 20 million children

under the age of 5 years were overweight

globally in 2005(WHO, 2006).

Public health professionals should address

both undernutrition and overnutrition health

problems.


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Inpatient Health Problem

Malnutrition is globally the most important risk

factor for illness and death, contributing to more

than half of deaths in children worldwide; child

malnutrition was associated with 54% of deaths

in children in developing countries in 2001.[1, 2]

Protein-energy malnutrition (PEM), has been

described with increasing frequency inhospitalized and chronically ill children in the

United States.[3]


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Currently

More than halfof young children in South Asia have

PEM, which is 6.5 times the prevalence in the western

hemisphere.

In sub-Saharan Africa, 30% of children have PEM.

Despite marked improvements globally in theprevalence of malnutrition, rates of undernutrition and

stunting have continued to rise in Africa, where rates of

undernutrition and stunting have risen from 24% to

26.8% and 47.3% to 48%, respectively, since 1990, with

the worst increases occurring in the eastern region of

Africa.


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By 2015

The World Health Organization estimates that the

prevalence of malnutrition will have decreased to 17.6%

globally, with 113.4 million children younger than 5

years affected as measured by low weight for age.

The overwhelming majority of these children, 112.8million, will live in developing countries with 70% of

these children in Asia, particularly the south central

region, and 26% in Africa.

An additional 165 million (29.0%) children will have

stunted length/height secondary to poor nutrition.


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Thats why

This presentation will focus on strategies ofweight management for underweight childrenin terms of prevention and treatment

Many presentations have been focused onoverweight and obesity, ignoring the

malnutrition as an important public healthissue related undernutrition and infectiousdisease


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1.Definitions of cases

Child. The United Nations Convention on the

Rights of the Child defines a child as "a human

being below the age of 18 years. In thispresentation, the focus is on the under-five years

old who are at high risk.

Underweight. From age 2 to 20 years , it refers to aBMI that is less than the 5th percentile.


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Concepts

Underweight. For children aged 059 months,

using the standard of NCHS/WHO, moderate

underweight is the index weight/age below

- 2SD from median weight for age and severe

underweight is the index weight/age below

-3SD from median weight for age of theNCHS/WHO reference population.


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Malnutrition

The World Health Organization defines

malnutrition as "the cellular imbalance

between supply of nutrients and energy and

the body's demand for them to ensuregrowth, maintenance, and specific functions.


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2. Factors of Underweight among children

1. Low birth-weight(


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Factors

The effects of changing environmental

conditions in increasing malnutrition is

multifactorial. Poor environmental conditions

may increase insect and protozoal infectionsand also contribute to environmental

deficiencies in micronutrients.


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Factors

Overpopulation, more commonly seen in

developing countries, can reduce food

production, leading to inadequate food intake

or intake of foods of poor nutritional quality.Conversely, the effects of malnutrition on

individuals can create and maintain poverty,

which can further hamper economic andsocial development.


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Causal Framework as Developed by

UNICEF (1998)

This conceptual framework on the causes of

malnutrition was developed in 1990 as part

of the UNICEF Nutrition Strategy. The framework shows that causes

ofmalnutrition are multisectoral, embracing

food, health and caring practices.


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UNICEF conceptual framework

They are also classified as immediate (individual level),

underlying (household or family level) and basic(societal level)

The immediate causes are inadequate dietary intake

and infectious disease;

The underlying causes are household food insecurity,

inadequate maternal and child care and inadequate

health services and health environment;

The basic causes include formal and non-formalinstitutions, political and ideological superstructure,

economic structure and potential resources.


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Conceptual Framework

Although more refined versions of this

framework have since been developed, (e.g.,

adding female educationjust below the

underlying causes and distinguishing human,economic and organizational resources),


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3. Typology

Kwashiorkor and marasmus are 2

forms of PEM that have been

described. The distinction between

the 2 forms of PEM is based on the

presence of edema (kwashiorkor) orabsence of edema with

emaciation(marasmus).

Edema is significant in kwashiorkorbut can also be present in marasmus

or in the frequently encountered

mixedforms of PEM.


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Acute Malnutrition and Wasting

Acute malnutrition (defined as the

presence of bi-pedal edema or

weight for height


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Stunting as Chronic Malnutrition

Stunting, or low height for

age, is caused by long-term

insufficient nutrient intake

and frequent infections.Stunting generally occurs

before age two, and effects

are largely irreversible.

Malnutrition and Stunting in

Guatemala


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Origin of the concept Kwashiorkor

Following brief descriptions by Procter (1926) in

Kenya and Lieurade (1932) in the Cameroons,

Jamaican pediatrician Dr Cecily Williams (1933,

1935), working at Accra in the Gold Coast, first

adequately described the syndrome.

She noted the disease only among children and

she considered that it was a new clinical entity.

She suggested the term kwashiorkor, because

the Ga tribe around Accra called it thus: (kwashi

=the name of a boy born on Sunday - orkor

=red, that is a Red boy).


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4.Pathophysiology of Underweight

and Malnutrition

Although significant clinical differences

between kwashiorkor and marasmus are

noted, some studies suggest that marasmus

represents an adaptation to starvationwhereas kwashiorkor represents a

dysadaptation to starvation.

The presence of edema caused by poornutrition defines kwashiorkor.


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Proteins or Energy?

Kwashiorkor was thought to be primarily

caused by insufficient protein consumption

but with sufficient calorie intake,

distinguishing it from marasmus.

But know, it is believed that the fundamental

problem is related to both insufficient energy

and proteins, leading to the imbalanced use of

calories from the three energy-yieldingmacronutrients

That is why the name PEM (Protein-Energy

Malnutrition)


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From PEM to Pluricarential syndrome

More recently, micronutrient and antioxidant

deficiencies have come to be recognized as

contributory of malnutrition, thus the name of

Pluricarential syndrome


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Several structural and functional

side effects

Malnutrition affects virtually every organ

system. Dietary protein is needed to provide

amino acids for synthesis of body proteins and

other compounds that have various functionalroles. Energy is essential for all biochemical

and physiologic functions in the body.

Furthermore, micronutrients are essential inmany metabolic functions in the body as

components and cofactors in enzymatic

processes.

Digestive functions


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Digestive functions

Atrophy of the mucosa from the mouth to

intestine (small and colon)

Deficiency of enzyme secretion

Liver: hepatomegaly (enlargement of the liver)

due to fat accumulation (steatosis or fatty

degeneration )

Pancreas athrophy ( which may be related to

malnutrition diabetes)


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Immunity functions

Immune response changes occur early in the

course of significant malnutrition in a child. These

immune response changes correlate with poor

outcomes and mimic the changes observed in

children with acquired immune deficiencysyndrome (AIDS).

Loss of delayed hypersensitivity, fewer T

lymphocytes, impaired lymphocyte response,impaired phagocytosis secondary to decreased

complement and certain cytokines, and decreased

secretory immunoglobulin A (IgA)


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Immune functions

These immune changes predispose children to

severe and chronic infections, most

commonly, infectious diarrhea, which further

compromises nutrition causing anorexia,decreased nutrient absorption, increased

metabolic needs, and direct nutrient losses.


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Cerebral and Mental functions

Changes in the developing brain, including, a

slowed rate of growth of the brain, lower

brain weight, thinner cerebral cortex,

decreased number of neurons, insufficientmyelinization, etc. These changes are similar

to those described in patients with mental

retardation of different causes
http://emedicine.medscape.com/article/289117-overviewhttp://emedicine.medscape.com/article/289117-overviewhttp://emedicine.medscape.com/article/289117-overviewhttp://emedicine.medscape.com/article/289117-overview


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Why?

Edema? Due to the oncotic pressure, or

colloid osmotic pressure, a form of osmotic

pressure exerted by proteins in blood plasma

that usually tends to pull water into thecirculatory system

Depigmentation ? Lack of melanin, protein in

the skin and keratin, a protein of hairs

Diarrhea? Malabsorption syndrome due the

digestive mucosa atrophy


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Other Affected Functions

Renal functions

Cardiac functions

Pulmonary functions

Skeletomuscular functions


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5. Management of Malnutrition

a. Assessment of Nutritional Status

Table 1: Weight Status Categories for the Calculated BMI-for-

age PercentileWeight Status Category Percentile Range of BMIUnderweight Less than the 5th percentile (


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T bl 2 W i h f H i h I d i Z


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Table 2: Weight for Height Index in Z-scores

(Children aged 0-59 months)

Z-scores of the median Nutritional status


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The Mid-Upper Arm Circumference (MUAC)

In children aged 659 months

Green: >135mm (normal)

Yellow: 125-134mm (risk of

malnutrition)

Orange: 110-124mm(moderate malnutrition)

Red:


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The Kwashiorkor: Child presents oedema


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b. Dietary Assessment

Childs and familys eating habits should be

performed to identify food preferences and eating

patterns through an interview with the child or

teenager as well as the parent, and with food

records and a food frequency check list. The same process should be followed, in case of

undernutrition to identify the different factors

related to the child and/or to the family for asustainable intervention.


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c. Environmental Assessment

Factors to be assessed are such as family composition,

family income,

family schedules,

childcare arrangements,

food availability,

school environments,

community environments, etc. (Copperman &Jacobson, 2004)

d P h i l A t B h i


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d. Psychosocial Assessment or Behavior

Modification

An assessment of the childs/ adolescents and

parents readiness to make lifestyle changes

is an important measure of whether the

weight management program will besuccessful.


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Primordial and Primary Prevention of

Malnutrition

Primordial prevention is defined as prevention

of risk factors themselves, beginning with

change in social and environmental conditions

in which these factors are observed todevelop, and continuing for high risk

Primary prevention is the prevention of the

occurrence of the disease given the existingrisk factors

a- Breastfeeding Promotion


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a Breastfeeding Promotion

Promote breastfeeding(exclusive upto 6 months and with complementaryfood up to 2 years)

Adequate transition from exclusive

breastfeeding to family foods, referred to ascomplementary feeding, from 6 to 18-24months of age ( whole grains flour )

Adequate weaning The Baby-Friendly Hospital Initiative (BFHI) is

a global program sponsored by the WorldHealth Organization (WHO) and the UnitedNations Childrens Fund (UNICEF) toencourage and recognize hospitals andbirthing centers that offer an optimal level ofcare for infant feeding.

Mother Friendly Workplace


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Mother-Friendly Workplace

A workplace providing private lactation

designated areas for mothers to express and

store breast milk

A workplace offering flexible breaks for mothers

expressing milk throughout the work day

A workplace providing access to a lactation

consultant for mothers expressing milk at work

A workplace having a written policy supporting

breastfeeding women


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B-Medical checkups for preschool children

To prevent and detect certain diseases

Prevent malnutrition

Surveillance of diseases of children.

Screening of infections


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C-Prevention and control of infants

diseases

Expanded Program on Immunization (EPI)

Prevention of micronutrient deficiencies

(Vitamine A, Iron,)

Diarrheal diseases

Prevention of verminosis (parasitic worms)

Prevention of ARI


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E-Family planning

Important to increase food

availability

To improve health and

nutritional status for both

infants and mothers


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Secondary and Tertiary Prevention

Case-management : Applied for severe

malnutrition

Phase 1 - Recovering normal metabolic function and


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Phase 1 - Recovering normal metabolic function and

rehydration (Hospital level).

Patients without inadequateappetite and/or a major medicalcomplications are initiallyadmitted in the hospital for Phase1 treatment.

During this phase patients aregiven a Therapeutic milk formulacalled F-75(meaning 75kcal/100ml of solution ) and

energy intake is 100 kcal/Kg/day. ReSoMal(oral rehydration salts

solution for severely malnourishedchildren).

Infectious diseases treatment

Phase 2 - Gaining weight with the right kind of


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Phase Gaining weight with the right kind of

therapeutic food. (Community level)

Use of the Community-based

Management of Acute Malnutrition

strategy (CMAM)

The principle of treatment is the use of

the Ready-to-Use Therapeutic Food

(RUTF)

No use of milk like the formula F-100

because it needs to be prepared bytrained personnel and presents a risk of

contamination due to its high water

content.


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Background of CMAM

The Community Therapeutic Care (CTC)

approach to treating acute malnutrition

(defined as the presence of bi-pedal edema or

weight for height


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Background of CMAM

Prior to that, the standard response wasprovided through therapeutic feeding centers

(TFCs) or Nutrition Rehabilitation Units (RHUs);

in-patient facilities which treated all cases with

therapeutic milk-based formulas (F75 and F100)

administered by medical staff.

Disadvantages:

Facilities often overcrowded,

cross-infections,

lengthy stays that led to high default rates

mothers absence from her other children for extended

eriods at the TFC


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Three key innovations

Three key innovations allowed the evolution

from in-patient to community-based care:

1. The development of ready-to-use therapeutic

foods (RUTF or RUF) such as Plumpynut,

which are lipid-based and thus resistant to

contamination and which do not require

medical oversight;2. A new classification distinguishing between

severe cases with and without medical

complications; and


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Three key innovations

3. The use of simple, color-coded Mid-Upper Arm

Circumference (MUAC)

measuring tapes for diagnosisthat allow community

members to be trained to

identify acute malnutrition for

referral to treatment.

Plumpy Nut


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Plumpy Nut

Ingredients :

Plumpy Nut is composed of peanut

butter, vegetable fat, dry skimmed milk,lactoserum, maltodextrines, sugar,mineral and vitamin complex.

How to use it ?

1. Child of height >85cm: 5 sachets/day ( that is 2500 Kcal)

2. Child of height


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2 BP 100

Ingredients of BP100: It is a solid

F-100 with added iron, Wheatflour (backed)

Oat flour (backed), Vegetable oil,Sugar, Milk proteins, Skimmedmilk powder

Minerals, Milk calcium, Aminoacids, Vitamins

How to serve it?

Child of height >85cm: 9 bars /day( 2700 Kcal)

Child of height


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Correctly used

Mean weight gain is 10-

20g/Kg/day

Recovery intervenes

within 21-30 days.


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DOUBLE BURDEN

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