AAE 350

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

Recommendations for Use of Antibiotics in Acute Malnutrition

Children admitted with severe acute malnutrition and complications such as septic shock, hypoglycaemia, hypothermia, skin infections, or respiratory or urinary tract infections, or who appear lethargic or sickly, should be given parenteral (IM or intravenous [IV]) antibiotics; Children admitted with severe acute malnutrition and with no apparent signs of infection and no complications should be given an oral antibiotic Children with uncomplicated severe acute malnutrition, not requiring to be admitted and who are managed as outpatients, should be given a course of oral antibiotic such as amoxicillin. Children who are undernourished but who do not have severe acute malnutrition should not routinely receive antibiotics unless they show signs of clinical infection.

Determine nutritional status via..?

Clinical: physical signs; nails, hair, body fat (individual) Biochem: blood iron levels (individuals) Dietary recall records (individual) Food balance sheets (population) BMI Body composition (waist circumference, mid-upper arm circumference

Food sources of Vitamin A

Cooked carrots, mustard greens, total cereal, beef liver (too much)

How/where to break the cycle of malnutrition

Current emphasis on fetal nutrition & first 2 years of life -interventions at other times are important too

Zinc Supplements

Current evidence shows zinc supplementation reduces the length of time that diarrhea by 25% Reduces stool volume by 30% 20 mg dispersible zinc tablets used for 10 days Age-appropriate formulas and production currently limiting use WHO is continuing to work on this issue

Good diet determined by..?

DRI (Dietary reference intakes) --> recommended dietary allowance, estimated avg requirement, tolerable upper level (UL)

Recommendations for Redfeeding

Adults Provide calories at estimated basal energy expenditure based on actual body weight No more than 1.2XBEE No more than 150 to 200 gm of glucose 1.2-1.5 gm of protein per kg actual bodyweight 20-30% of calories from fat Begin feedings slowly and increase gradually over 5 to 7 days Effects most significant in first few days of refeeding and it may take 1 week to adapt to the increase oxygen demand Weight gain is not a goal in the first week of refeeding

Infant Nutritional Status --> (blank) is best

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

Babies who breast feed usually have..?

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

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

Child 1st Thousand Days

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

Malnutrition

Broad term for range of conditions that hinder good health caused by inadequate/unbalanced intake/absorption of food --> refers to both under & over nutrition

Congestive Heart Failure is a common complication of refeeding

Cardiac output can't increase enough to meet the needs from the increased plasma volume, increased oxygen consumption and increases in blood pressure and heart rate

Refeeding formulas

Catch up formula can be made using fresh cow's milk 880 ml milk 75 gm sugar 20 ml oil 20 ml electrolyte/mineral solution Water to make 1,000 ml

Thiamin Deficiency and Refeeding

Deficiency may contribute to refeeding syndrome Functions as a cofactor in intermediary carbohydrate metabolism Amount needed depends on carbohydrate ingested, so feeding carb without adequate thiamin supplementation can lead to deficiency symptoms Mental confusion, ataxia, muscle weakness, edema, muscle wasting, tachycardia and cardiomegaly Wernicke's encephalopathy can be brought on by carbohydrate feeding in thiamine-deficient patients

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

Keys Experiment at the University of Minnesota (Summary)

During WWII, 36 conscientious objectors volunteer to be part of a research program focused on malnutrition and starvation to mimic conditions happening in Europe at the time. 36 participants, 32 of which successfully completed the experiment. When the war ends there's going to be a need for food relief so they needed data to understand this. 11/19/44-10/20/45.

Maternal Malnutrition- Effect of maternal malnutrition on breastfeeding

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

Recent downward trend in % malnourished in some places/overall --> slight (blank) in some areas

Increase *Compare to obesity map --> higher % in more developed countries rates of childhood and adult obesity on rise

Effects of Refeeding on the Cardiovascular System

Increases in heart rate, blood pressure, oxygen consumption, cardiac output and an expansion of plasma volume are seen Response is dependent on amount of calories, protein and sodium given The malnourished heart can easily be given a metabolic demand that is too high for it to supply

Metabolic Response to Refeeding

Insulin release is stimulated by the presence of carbohydrate and protein in the gut Plays a key role in the switch from using up body stores to using food Stops the release of fat from stores and production of glucose from protein Stops sodium excretion Causes fluid retention in the first few days of refeeding and when the caloric intake is increased

Increase each feed by 10 ml until some remains uneaten

Likely to occur when intakes reach about 200ml/kg/day After a gradual transition, give Frequent feeds, unlimited amounts 150-220 kcal/kg/day 4-6 g/kg/day of protein

Issues with Adolescent Pregnancy

Linear growth of adolescent girls has been shown to stop when they get pregnant -An extra 1 cm of adult height will be added for each year that median age of first pregnancy can be delayed beyond age 15 -Taller women have bigger babies -Food supplementation of the adolescent pregnant for the first time does not improve BW -Growth hormones favor growth of mother instead -Control of anemia can improve birth weight -Best way to improve BW is to delay pregnancy until at least age 18

Mother's Milk

MMM, it's time to eat -But what are they going to give me? -Ahh! My mother chose the best -Mother's milk

MUAC Tape

Mid-Upper Arm Circumference Easy to be trained on how to use Can use on most individuals with out much effort Fast/quick indicator of nourishment -green= nourished vs. red= severe

Prevalence of Anaemia

More prevalent in Canada and other parts of the world other than the U.S.

Mortality rates go up when BMI < 18.5 what did the Nigerian study show?

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

Studies of children and health risk found that in the thinnest children, the more obese they became as adults, the greater was their risk of developing chronic diseases

No excess adult health risk was found from childhood or adolescent overweight

Secondary malnutrition

Not directly caused by diet, results from condition that prevents proper ingestion/digestion/absorption/metabolism *causes: loss of appetite, illness, parasite, etc.

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

Oral Rehydration Salts Solution

ORS is responsible for saving the lives of millions of children worldwide Inexpensive solution of sodium and glucose used to treat acute diarrhea Since WHO adopted ORS in 1978 as its primary tool to treat diarrhea, the mortality rate for children with this disease has gone from 5 million to 1.3 annually

Metabolic Consequences of Refeeding

Overfeeding carbohydrate can result in high blood sugars and dehydration Expansion of the extracellular fluid may lead to edema (swelling) Phosphorous Blood levels may decrease in the first few days Moves into cells from blood because of need in making phosphorylated compounds in the cell Insulin promotes uptake in liver and muscles Very low levels can lead to respiratory, cardiac, nervous system, and red and white blood cell dysfunction

Metabolic Consequences of Refeeding-Potassium

Potassium --> big in re-building muscles!! Refeeding causes a shift of potassium into the cells from the blood and the rebuilding of proteins also incorporates potassium into the cell protoplasm Low blood potassium levels may results Can cause irregular heart rhythm

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

In developing countries, the overfeeding of stunted populations should be avoided b/c..?

Programs need to consider appropriate energy for children who are low weight-forage but normal weight-for-height Education needs to be provided that stresses that overweight and obesity do not represent good health

The Maternal Milk

Protects the baby from: -Diarrhea -The flu -Infection -allergies

Fluid in Refeeding

Refeeding results in expansion of the extracellular space and fluid must be given carefully during the first few days to weeks of refeeding Weight gain greater than 1 kg the first week is due to fluid retention Fluid may need to be restricted to 800 to 1000cc/day Increases in blood pressure, heart rate and respiratory rate may be early signs of fluid excess

Child --> Chronic low intake leads to ..?

STUNTING --> Growth charts key indicators: -Linear growth: height for age -<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

Alleviating hunger improves learning

School feeding, both breakfast and lunch programs, has been shown to improve school performance in both developing and industrialized countries

Depression/malnutrition connection (In the Elderly)

See downward spiral in elderly with depression and malnutrition -Leads to frailness and lack of ability to care for self

What happens to people with not enough food or nutrients? (metabolic changes)

Shift in metabolic fuels: ▪ 1. glucose is produced from protein to make energy ▪ 2. fat breakdown provides ketones for all tissues except CNS RBC and WBC ▪ Serum fatty acid levels increase ▪ Serum albumin is normal until late in starvation o Negative nitrogen balance in the first 5-7 days o 12-15 grams of nitrogen per day exits in urine o Skeletal muscle is broken down to produce glucose using about 75 grams ▪ This causes weight loss o Gradually this slows down a month in, 2-4 grams lost per fat o Glucose only given to the cells that need it most ▪ Central nervous system ▪ Red blood cells ▪ White blood cells

Electrolytes in Refeeding

Sodium must be given carefully to prevent overexpansion of the extracellular fluid Additional phosphorus is required when refeeding 250-500 mg/day up to 5 to 7 days may be needed to replenish Potassium serum levels should be in the high normal range with 80 to 120 mEq/day needed Magnesium and thiamin also should be given

Refeeding formulas - WHO

Starter formula may be made with fresh cow's milk 300 ml milk 100 g sugar 20 ml oil 20 ml electrolyte/mineral solution Water to make 1,000 ml

A Negative Iron Balance Leads to Progressively More Severe Conditions

Storage gets used up first, then iron in plasma, then iron in RBCs (Red Blood Cells) Normal --> Depletion (Stage 1, 2, 3)--> Deficiency (Stage 4) (no iron except for in Red Blood Cells) **You may be deficit but just not showing it

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 **Stunted is a more lifelong condition (chronic condition) compared to wasting

Mobile Restuarant

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

Sensory stimulation and emotional support also a part of the therapy, so need to provide:

Tender loving care A cheerful stimulating environment Structured play therapy for 15-30 minutes a day Physical activity as soon as the child is well enough Maternal involvement (or primary caregiver) as much as possible (e.g. comforting, feeding, bathing, play)

Adults

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

Indicators of Hunger & Undernourishment

The prevalence of undernourishment and the proportion of underweight children under the age of 5

Other Issues Regarding Malnutrition and Catch up Growth

There is an association between low growth in the first year and an increased risk of CHD Blood pressure has been found to be highest in those with retarded fetal growth and greater weight gain in infancy Short stature is associated with an increased risk of CHD and stroke and to some extent diabetes The risk of stroke and cancer mortality at several sites is increased if shorter children show an accelerated growth in height An association of low growth in childhood and an increased risk of CHD has also been described, irrespective of size at birth In most studies the association between LBW and HBP is particularly strong if adjusted to current body size, suggesting importance of weight gain after birth

Food Sources of Iron

Total Cereal is the only one that meets the required amounts of iron --> in lots of foods iron gets added ** Having a little bit of meat in a meal can help iron get more absorbed by the meat itself or by other sources (such as spinach)

Hunger

Uneasy/painful sensation caused by lack of food

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

PEM develops gradually in weeks or months →

allows a series of metabolic and behavioral adjustments to occur as the body gets smaller -These adaptations result in decreased nutrient demands and a nutrition equilibrium compatible with the lower amounts of nutrients that are available -If nutrients remain persistently low, adaptation can no longer occur and death results i.e. only so much adaptation can occur

Protein calorie malnutrition/protein energy malnutrition

don't have enough energy -rare to have protein deficiency without calorie deficiency -exception: high starch foods

Dietary guidelines

evidence-based --> association vs. causality, dietary pattern

What happened after 3 months of starvation in study?

fatigue, soreness, irritability, hunger pains, moody, depressed, less able to tolerate heat, cough/sneeze, heart rate & muscle tone decreases **Recovery--> overeating, still tired, full recovery after 33 weeks (needed 33 weeks to recover)

Some catch-up growth may be possible in ..?

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"

Stunting at age 2 is associated significantly with ..?

later deficits in cognitive ability -Birth weight contributes to about half of the growth failure at age 2 -Prevention of this was shown in to be possible in the 46% reduction of stunting in the 1980s in children of Asian immigrants to the US -Birth weight also influences mental development -Studies of twins show differences in IQ later in childhood are determined by uterine growth and BW -Accentuated in lower socioeconomic groups4344454647

Undernourished girls grow for a..?

longer period of time, so may not be finished growing before the 1stpregnancy -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

Malnutrition leads to decreased functional capacity and need for ..? (In the Elderly)

more help -Can contribute less to the family (i.e. childcare)

What happens to people with not enough food or nutrients? (physiological changes)

o Hunger subsides after 2-3 days o Defecation ceases after 3-4 days o Urine drops after one week o Blood sugar levels drop to 35 to 65 without clinical signs of low blood sugar (no shaking or queasy symptoms) o Nausea occurs in 1/3 of people who are starving because of ketones (fat breaking down) o Decrease in size of body compartments=body starts to shrink (organs, muscles, etc) to conserve energy o Serum electrolytes do not change ▪ Kidnesy conservation occurs promptly ▪ Rarely see low potassium in prolonged fast

What is the role of calories?

o Involuntary actions ▪ Breathing, blood circulation, digestion, muscle, body tone, growth

Links between WASH and under nutrition

o Life cycle ▪ Most crucial development for child nutrition starts the first 1000 days after conception ▪ See graph on page 6 for root causes and effects

Weight loss as a response to metabolic changes?

o Salt and water loss of .7 to 1.3 kg per day which slows after the first week to .3 to .5 a day o BMR and TEE decreases o Decreased activity o Increased sleep

Types of malnutrition

overnutrition, secondary malnutrition, micronutrient malnutrition, protein colorie malnutrition/protein energy malnutrition

Hormonal changes to starvation

plasma insulin decreases, plasma cortisol stay, growth stay, glucagon increases --> mobilize fat stores *metabolic rate decreases

Undernutrition

result of prolonged low levels of food intake and/or low absorption of food consumed

Protein Energy Malnutrition (PEM)

the term malnutrition is usually used in lay language for protein energy malnutrition (PEM)

Overnutrition

too many calories, not enough exercise *2.1 billion people worldwide *overnutrition following fetal malnutrition --> chronic disease risk

Food insecurity

when people lack access to sufficient amounts of safe food and therefore don't consume enough for active healthy lifestyle

Metabolism

• ATP produced using amino acids • Uses oxygen to make more ATP • Citric acid cycle makes this work

Prevention of Nutrient Diversion

• Cleanliness in cooking and hand washing with soap • Toilets • Education of women especially important in this regard ▪ Doing most household tasks ▪ Responsible for teaching children

Ways to Reduce Hunger & Undernourishment

• Economic growth: Must be Inclusive * Opportunity for the poor ▪ Need more sustainable options for economic opportunity for low skilled workers and communities

Secondary Malnutrition: Causative conditions

• Environmental enteropathy --> Small intestinal disorder triggered by constant feces intake

Childhood under nutrition, the gut microbiota, and microbiota-directed therapeutics

• Under nutrition cases make up 40% of all childhood deaths under the age of 5 • Although current therapeutic approaches have reduced mortality in individuals with severe disease, they have had limited efficacy in ameliorating long-term sequelae, notably stunting, immune dysfunction, and neurocognitive deficits. • Environmental element contributors: ex is effect this has on breastmilk

Vitamin A

•"Vitamin A deficiency (VAD) is the leading cause of preventable blindness in children and increases the risk of disease and death from severe infections." -WHO 18' ▫ 250 million preschool children are vitamin A deficient ▫ 250,000-500,00 vitamin-A deficient children become blind every year, half of them dying within 12 months of losing their sight ▫ VAD is a public health problem in more than half of all countries, especially in Africa and SE Asia

Treating Vitamin A Deficiency

•15,000 to 60,000 micrograms of Vitamin A every 6 months can prevent deficiency in children ▫ Common dose is 200,000 IUs periodically •Improving the vitamin A status of young children reduces mortality rates by about 23% in populations where there is vitamin A deficiency

Iodine

•A major global problem with 700 million people with goiter BUT •"Progress towards the elimination of IDD (iodine deficiency disorders) through universal salt iodization appears to be one of the most significant successes in the field of noncommunicable disease." ▫ 4th Report of The World Nutrition Situation -Where iodization is >75% the mean goiter rate is now 10.5%

Vitamin A serves varied functions in the human body

•A major role of vitamin A is as part of the visual pigment rhodopsin •Forms of vitamin A are also involved in: ▫ Gene expression ▫ Maintenance of epithelial tissue ▫ Regulation of growth and differentiation of cells, including some cells of the immune system

Absorbability of Iron

•Amount of iron in a food and absorbability can be significantly different in plant foods --> Heme vs. non-heme affects the absorbability ▫ Fiber, phytate, tannins and oxalate bind iron or interfere and prevent absorption ▫ Milk, calcium products can decrease absorption •Concurrent intake of Vitamin C can enhance absorption of non-heme iron up to 6 fold ▫ At least 25 mg of C per meal is needed •"Meat factor" also increases absorption of non-heme (and heme) iron **Better to take an iron supplement with a glass of orange juice rather than a glass of milk

Absorption of Vitamin A and Precursors

•Animal sources (pre-formed vitamin A) ▫ About 90 percent is absorbed •Pro-vitamin A sources (carotenoids from plants) ▫ Dependent on type of plant source and fat content of the meal ▫ Absorption of beta-carotene about 1/3 of retinol and conversion to vitamin A about 1/2

Iron- Why do we need it?

•Because it is readily oxidized, ironis part of many proteins involved in oxygen transport and oxidation/ reduction reactions▫Hemoglobin - the protein of red blood cells that carries oxygen molecules ▫Myoglobin- a protein similar to hemoglobin found in the cytoplasm of muscle cells ▫Enzymes and electron carrier molecules in the energy metabolism pathway ▫ Proteins involved in drug metabolism, the immune system, and protection against free radicals

Iron

•Body iron content (ideal levels) ▫ 2/3 functional - being used ▫ 1/3 stored

Steps in Vitamin A Deficiency

•Body stores are depleted leading to impairment of physiologic functions ▫ 1st integrity of the epithelial barriers and then the immune system is compromised ▫ Finally the visual system is impaired

Dominant Effects

•Cognitive defects in children ▫ Thought to be due to not enough oxygen to brain or a decreased amount of neurotransmitters (Fe dependent) •Lowered effectiveness of money spent on education •Maternal deaths due to severe anemia •Decreased productivity

Vitamin A and Immunity

•Deficiency is associated with decreased resistance to infection •Functions through the cell-mediated and anti-body-mediated responses ▫ such as macrophage and natural killer cell activity, and growth and maintenance of B-lymphcytes •The maintenance of the epithelial tissues and mucus production all act as barriers to invading pathogens as well (non-specific immunity)

Other Causes of Anemia

•Deficient iron intake •Malaria •Parasites •Other infections •Other nutrient deficiencies for blood production (A, B vitamins, etc.)

Fe Deficiency Anemia Symptoms

•Fatigue •Weakness •Pallor •Headache •Brittle &spoon shaped nails •Cold hands/feet-intolerance to cold •Shortness of breath •Pica •Poor appetite (infants/children)

Adult Deficiency

•Goiter and its complications •Hypothyroidism •Impaired mental function/not as productive

What foods contain iron?

•Heme ironis part of hemoglobin and myoglobin and is obtained from meat of all types. ▫ About 25% absorbed •Non-heme ironis found in grains, leafy green vegetables, legumes, and meat and is absorbed at about half (or less) the rate of heme iron. •Non-heme iron can also leach out of iron cookware into food.

What are the symptoms of vitamin A deficiency?

•Impaired immune function •Night blindness(insufficient retinal for rhodopsin formation) •Dry, hard skin •Dry cornea and eventual blindness (Xerophthalmia)

Causes of Iron Deficiency and Iron Deficiency Anemia

•Insufficient intake to cover normal needs or to meet the increased needs for ▫ Blood loss -Menses, GI tumors, parasites (esp. hookworm) ▫ Growth ▫ Pregnancy

Iron is transported by special transport proteins

•Iron can be stored by attachment to a protein called Ferritinin the mucosal lining of the intestine. •Iron is transported through the blood attached to another protein, Transferrin.

Iron deficiency a significant concern worldwide

•Iron deficiency occurs when diet does not provide enough to meet needs ▫Defined as absence of iron stores combined with signs of iron-deficient red blood cell production implying an insufficient supply of iron to various tissues •Iron deficiency Anemia ▫There is not enough hemoglobin produced due to lack of iron. No more iron stores left. (~12mg/dLhemoglobin)

Stages of Iron Deficiency

•Iron depletion ▫ Decrease of stores (ferritin) ▫ Iron deficiency hematopoiesis (RBC production) -Iron stores depleted with insufficient absorption to counteract normal losses -Leads to decreased hemoglobin production▫ Iron deficiency anemia -Hemoglobin falls below a set standard

Other problems in Vitamin A deficiency

•Keratinized cells in the outer layer of skin replace the normal epithelial cells in the underlying skin layers ▫ Hair follicles become plugged with keratin ▫ Skin has a bumpy appearance and rough texture and is very dry •Deficiency also causes a decrease in appetite and poor growth

Economic Sequelae of Deficiency

•Mean value of productivity losses due to iron deficiency thought to be about US$4 per capita ▫ 0.9% GDP for a range of developing countries

Xeropthalmia - Sequence of Events

•Night blindness is a common early symptom of low levels of Vitamin A •Mucus forming cells deteriorate and are no longer able to synthesize the mucus that lubricates the body •The eye especially needs mucus to keep the surface moist and to wash away dirt and other particles that settle on the eye •Deterioration of the eye results from bacterial invasion ▫ Role of A in resistance to infection •Conjunctival xerosis (abnormal dryness of the lining of the eyelids and the outer surface of the eyeball) and Bitots spots (drying out of the eye and appearance of hardened epithelial cells) appear as Vit. A deficiency worsens •Finally, corneal ulcerations and keratomalacia (softening of the cornea) results in scarring ▫ Can see effects from barely detectable to blindness

Cell differentiation function of Vitamin A

•Often accompanied by cell proliferation - the continuous development of cells in tissue formation •Necessary for the production, structure and normal function of epithelial cells in the lungs, trachea, skin, GI tract, etc. •Also essential for the production of mucous-forming cells in these organs

Iodine

•Plays a key role in cell replication ▫ Especially relevant for the brain -Neural cells multiply mainly in utero and during the first 2 years of life ▫ Fetal deficiency leads to -Increased rates of spontaneous abortion -Stillbirths -Congenital anomalies -Cretinism -Psychomotor deficits -Neonatal mortality

Prevalence of Anemia in Developing Countries

•Pregnant women: 56% (18% in developed) •Non-pregnant women: 44% (7% US) •School-age children: 53% (4% US)•Preschool children: 42% •Older adults: 51% (3-9% in US) •Adult men: 33% (2% in US)

In regulation of gene expression, retinoic acid binds to a protein receptor

•Retinoic acid is involved in cell differentiation by activation of DNA receptors ▫ leads to gene expressions for a variety of structural proteins such as enzymes and those in epithelial cells (skin keratins)

Vitamin A occurs in several forms

•Retinoids, including retinol, retinal and retinoic acid, are common in animal tissues; they can serve vitamin A functions directly •Beta-caroteneis a precursor of vitamin A found in plant tissues; it is also an antioxidant

As part of rhodopsin, retinol binds with the protein opsin

•Rhodopsin absorbs light, which signals visual cortex of brain (lose ability to see at night) •Reconversion and replenishing of rhodopsin must occur before it can respond again to light •When amount of rhodopsin is limited, difficult to see in dim light "night blindness" •When Vit. A pool is low, dark adaptation is slowed down

Can you have too much vitamin A?

•Toxic levels can be reached by excess consumption of liver and supplements of preformed vitamin A (not beta-carotene) •Symptoms of toxicity include: ▫ Nausea, vomiting ▫ Headache, blurred vision ▫ Lack of muscular coordination

Absorption, transport and storage of vitamin A

•Vitamin A is a fat-soluble vitamin and is absorbed and transported with lipids •Vitamin A is stored in the liver ▫ recorded instances of toxicity involve excess consumption of polar bear liver by Arctic explorers and supplement use

What happens to people with not enough food or nutrients? (hormonal changes)

▪ Plasma insulin decreases ▪ Plasma cortisol and growth hormone stay the same and glucagon increases ▪ These changes are responsible for the mobilization of use of fat stores for energy ▪ Changes in sympathetic nervous system and metabolism of thyroid and lowers the basal metabolic rate (BMR)

Improving Nutrition WASH (water, sanitation and hygiene) key concepts?

▪ Water quality • Include piped water on-site, public taps or standpipes, tubewells or boreholes, protected dug wells, protected springs and rainwater ▪ Water quantity • Provision of facilities and services that increase the amount of water available for drinking, cooking and maintaining good hygiene practices within households, health care facilities or schools; and reduce the time and effort required to collect the water.

Treating Vitamin A Deficiency- What about food?

▫ Vegetables are the major source of pro-vitamin A in children where animal products are limited ▫ Kids don't like these foods ▫ Insufficient dietary fat intake limits absorption of what they do get•Fortified foods ▫ May provide too much vitamin A -Sugar in Zambia and Central America

UNSCN 2008

"Child stunting is now accepted as one of the best indicators of the quality of future human capital. Damage suffered in early life, associated with the process of stunting, leads to permanent impairments that lower attained schooling and reduce adult income. The success of sustainable action to alleviate poverty is thus best measured by their capacity to reduce the prevalence of stunting in children less than 5 years of age. Although the indicator for monitoring the progress made toward the achievement of MDG 1 was set as child underweight, it is now recommended that countries and development partners report instead on the prevalence of stunting in children less than 5 years of age." 6th Report

IUGR

"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 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."

Z-score

# of standard deviations above or below mean

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

Good dietary sources of vitamin A

**Best sources include: ▫ beef liver ▫ carrots (as beta-carotene) ▫ mustard greens (as beta-carotene) ▫ Egg yolk ▫ apricots (as beta-carotene) •Note that beta-carotene is much less toxic in higher doses than is the preformed animal forms of vitamin A

Goiter develops when Iodine is lacking

**Creates lump in neck that affects swallowing Low or high thyroid --> Goiter doesn't always go away (can affect swallowing)

Normal Metabolic Fuels?

**Glucose (sugar) o We don't store a lot of it and we use it quickly o Stored in liver for access to blood and brain used during overnight fast or used in muscles where it stays o Typically gotten from carbs **Fat (lipid) o 90% of energy stored as fat o Requires oxygen for energy production o Requires carbs for energy cycle to continue **Protein o Normally only 2-5% is used for energy o Broken down to make glucose

Keys Experiment at the University of Minnesota (Procedure)

*12 weeks baseline diet • 24 week semi starvation ▪ Consisted for food designed to represent the food available in Euro famine available ▪ About 1600 calories a day- 71 carbs, 12 protein, and some fat ▪ Served two meals a day • 12 week of rehab

Physical signs after 3 months in the University of Minnesota study?

*Fatigue • Muscle soreness • Irritability • Hunger pains

Normal metabolic fuels?

*Glucose: 50.100mm in liver (for brain while sleeping) -about 350gm in & for muscles *Fat (lipid): 90% of stored energy in adult needs oxygen & some carbohydrate to use *Protein: 2-5% used for energy, broken down to provide glucose

Key Study in starvation?

*Impetus: WW2 about to end, need food relief *Subjects: 32 men, conscientious objectors, ages about 25.5 years old -12 weeks baseline diet -24 weeks semi starvation diet -12 weeks back to normal

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: 5.89 --> Monaco~1.80 (lowest in 2017), Japan~2.00, Finland ~2.50, Italy~3.30, China ~12.00, India ~39.10, Uganda~56.10, Nigeria~69.80, Afghanistan ~110.60 (highest) **Overall it has decreased over time

People living on <$1.25/day?

*USA/Europe: 2% *Brazil/China: 6-20% *Higher in parts of S. central Africa *S. central Africa, Yemen, Afghanistan higher % malnutrition **NOT nonexistent in rich countries (US, Aus, Euro)

Percentage of households consuming adequately iodized salt, 2009-2013

*Universal Salt Iodization Target --> 90% *East Asia and Pacific: 86% *South Asia: 69% *Sub-Saharan Africa: 59% *Least-developed countries: 50% *World: 75%

Body changes in University of Minnesota study

*Weight decreased about 25% • Weigh loss decreased progressively till plateau was reached • High loss of lean body mass • Loss of fat • Loss of activity

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 -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 -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.

"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.

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

What is the role of protein?

8building cells that make up muscles membranes cartilage and hair o Carrying oxygen o Nutrite transport o Antibodies o Protein is a needed enzyme for chemical reactions

Gut Microbiomes of Malawian Twin Pairs Discordant for Kwashiorkor

-317 twin pairs followed during the first 3 years of life -50% of the twin pairs did not develop acute malnutrition -43% of pairs became discordant (one with malnutrition, one without) -7% of pairs developed acute malnutrition Both children in twin pairs discordant for kwashiorkor were treated with a peanut-based RUTF -Microbiome assessments of health twins and of discordant twins -13 discordant kwashiorkor twin pairs and 9 healthy pairs -Weight loss observed in mice that received fecal microbiotic kwashiorkor twin compared to non-malnourished twin **In the future, this could be some way we could help treat these PEM diseases

"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 -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

Adults --> Appears to be a continuous gradient in work capacity and productivity that is linked to body weight- how?

-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

Ways to improve nutrition and health status of children?

-Antihelminthics (i.e. de-worming)Given in conjunction with vitamin A or iron supplementation shows better outcomes -Delivery of micronutrients -Treatment of injuries and routine health problems -Prevent stunting by preventing low birth weight

Evidence of Importance of first 1,000 days?

-Best predictors of school outcomes -5 cohort studies from low- and middle-income countries -Weight gain during the first two years of life followed by birth weight -Studies in other developing countries show diet quality, growth and anemia are important predictors of infant motor milestones -Points to iron deficiency during this period to have lasting effect on neural and behavioral development

What happened in the key study on starvation?

-Body size decreased about 25%, weight loss more apparent at first (then slows) -decreased BMR, decreased activity

PEM Adaptations continued.....

-Cardiac and kidney function -Decreased renal plasma flow and glomerular filtration rate are due to decreased cardiac output -Water clearance and ability to concentrate and acidify urine are not impaired

PEM Adaptations (Cardiac)

-Cardiac function is reduced in proportion to the smaller size of the ventricles, with reduction in cardiac output (CO) and stroke volume (SV) occurring at the same time -If oxygen needs increase (i.e. exertion) the only compensatory mechanisms is through increased heart rate (HR) -CO = SV X HR (Stroke Volume times Heart Rate) -Cardiovascular reflexes are altered can lead to postural hypotension (when you get up really fast and feel light-headed) and decreased venous return -In severe PEM can get peripheral circulation failure comparable to hypovolemic shock

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

PEM- Immune System Changes

-Defects in PEM involves the T lymphocytes (T cells) -T lymphocytes (type of WBC) that kill foreign invaders. -Alteration in monokine metabolism -Especially see decreased activity of IL-1 → Normally: IL-1 → T-cell production -May contribute to the low proliferation of T cells in malnutrition -Marked depletion of lymphocytes from the thymus and atrophy of the thymus gland -Cells from the t-lymphocyte regions of the spleen and lymph nodes are depleted -Thymus important in immunity of child -Production, functions, and activity of the immune system are decreased with PEM → Deficiency may explain high susceptibility to gram negative bacterial sepsis -Phagocytosis, chemotaxis, and intracellular killings are also impaired -B-lymphocytes are relatively normal but may be defects in antibody production, such as secretory IGA → These changes predispose to infection and complications of otherwise less important infectious diseases -Nutritional repletion results in disappearance of decreased immunity

PEM- Central and Peripheral Nervous System Adjustments

-Early life PEM leads to decreased → Brain growth (cell number and size), Nerve myelination, Neurotransmitter production, Velocity of nervous conduction -Long-term implications are multifactorial but now thought to be long-lasting

Maternal Malnutrition

-Effect of malnutrition on pregnancy outcome -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

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 -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 practices that protect, promote and support breastfeeding -152 countries have implemented the initiative

Infant Feeding Recommendations

-Exclusive breast feeding for 6 months -Breastfeeding with complementary feedings starting at 6 months of age -Continued breastfeeding in the second year of life and beyond -Field studies show no advantage in growth or development when complementary foods introduced between 4 and 6 months -Exclusive breastfeeding until 6 months is now the recommendation -Exclusive means nothing else including water

PEM Adaptations- Respiratory System

-Expiratory and inspiratory muscles are catabolized -Reduction in diaphragmatic mass is proportional to the loss of body weight -Decreased respiratory muscle strength, maximum voluntary ventilation, vital capacity and maximum inspiratory pressure

Summary of Lifecycle notes?

-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

Kwashiorkor

-Ghana: "the sickness the older child gets when the next baby is born" -Uganda: "the illness of the dethroned child" -Associated with: Low protein-to-energy ratio in diet, Hypoalbuminemia, Fatty liver, Edema -Cause: diet, infection or other stress? (B vitamin deficiency?), Gut microbiome?? -Normally severe lack of food leads to adaptation with normal plasma proteins -When carbohydrate intake increases and protein intake is very low, adapted system breaks down → Carbohydrate intake stimulates insulin production and release and a reduction in the production of epinephrine and cortisol -Fat breakdown decreases and the action of insulin is enhanced because of the suppression of the inhibitory effects of free fatty acids on the peripheral action of insulin -Muscle protein breakdown decreases and the body pool of free amino acids decreases, leading to decreased visceral protein synthesis -The decreased synthesis of plasma proteins in the liver, particularly albumin, reduces intravascular oncotic pressure leading to edema -Increased fat production in the liver from the excess carbohydrate, impaired fat break down and reduced production of apo-B-lipoproteins for lipid transport leads to fatty infiltration of the liver and enlargement of the liver -Perhaps also potassium deficiency, since not all with decreased albumin levels get edema -Appearance/physical signs: Soft, pitting edema, Dry skin with lesions ("flaky paint"), Hair brittle, without normal sheen, can be pulled out easily, Curly hair becomes straight and hypopigmented -Can have "flag sign" with banding of hair due to periods of malnutrition and adequate nutrition

The Role of the Microbiome

-Gut microbiota influence the growth and differentiation of gut epithelial cells and play pivotal nutritive, metabolic, immunological and protective functions. -Efficient extraction of calories from ingested food → fermentation of non-digestible polysaccharides, provision of short-chain fatty acids -Enzymatic reactions of the microbiome aid in → host homeostasis, food digestion/absorption, synthesis of micronutrients (Vitamins K, multiple B vitamins, H2, CO2, Methane, Lysine, Conversion of Urea to Ammonia) -Detoxification: Modulates enterohepatic circulation of compounds detoxified by the liver -Epithelial Development -Immune Function: stimulates the growth of enterocytes, commensal organisms protect from pathogens

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 -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 cardiovascular disease, diabetes and high blood pressure

Maternal Malnutrition- Effects 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

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

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 -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

Types of PEM (Protein-energy (calories) malnutrition (moderate energy and protein deficit) (growth, infections, and trauma put great nutritional demands on the body)

-Kwashiorkor → edema with maintenance of some subcutaneous fat tissue → moderate energy deficit with severe protein deficit, especially in light of increased needs due to infections - Marasmus → severe energy and protein deficits → skin and bones appearance with little or no subcutaneous fat tissue

Child- 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

PEM- Respiratory Adjustments

-Lowered basal metabolic rate leads to a decreased ventilatory response to a lack of oxygen in the blood and an increase in carbon dioxide -Deterioration of function and emphysema like changes have been seen -Decreased surfactant synthesis, storage and secretion -Also see increase in infections due to decrease in immune function, reduced ability to clear secretions, and impaired muscle function From "simple" upper respiratory infections to pneumonias and tuberculosis

Child- 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

Improving Nutrition WASH (water, sanitation and hygiene)

Improving nutrition through clean water, sanitation, and hygiene

WHO Recommendations 2010

-National health authorities are encouraged to recommend one infant feeding practice for HIV-positive mothers to be promoted and supported by maternal, newborn and child health services. WHO is now explicit that health authorities should endorse either breastfeeding while receiving ARVs (to the mother or infant), or avoidance of all breastfeeding. Mothers will still need on-going counseling and support to optimally feed their infant. -WHO recommends that women who breastfeed and receive ARVs (or whose infants are receiving ARVs) should exclusively breastfeed their infants for 6 months and continue breastfeeding until 12 months of age and only then consider stopping. - The way in which national authorities implement these recommendations should depend on a careful assessment taking into account major factors including HIV prevalence, background infant and child mortality rates, current infant and young child feeding practices and nutritional status of infants, availability of clean water and sanitation, socio-economic status of the population and quality of health services, including provision of interventions for PMTCT (Prevention of Mother to Child Transmission).

PEM- Gastrointestinal Function

-Severe protein deficiency results in impaired intestinal absorption of fat and carbs decrease rate of glucose absorption -The greater the protein deficit, the greater the functional impairment -Malnutrition causes decreased production of enterocytes and decreased height of the villi -Results in decreased absorptive capacity -Also see a decrease in gastric, pancreatic and bile production with normal to low enzyme and conjugated bile acid concentration -Diarrhea when fed due to these alterations and perhaps also irregular gastrointestinal motility and GI bacterial overgrowth -Low blood protein levels leads to intestinal edema which decreases luminal absorption which leads to diarrhea -Diarrhea worsens the malabsorption and can further decrease nutritional status -Diarrhea disappears with nutritional recovery

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

Preventing Low Birth Weight

-Studies in women who have had more than one baby shows that nutritional supplementation... -Improves birth weight in malnourished women -In marginally malnourished women the mother benefits but there is no effect on maternal weight gain or birth weight -Micronutrient supplementation during pregnancy increases birth weight as well as balanced protein-energy micronutrient supplements -Multiple micronutrient supplements yield a bigger increase than just iron and folate supplements alone -Mothers should be reached prior to or in 1st trimester for greatest effect of supplementation

Child measures of malnutrition

-Stunting -Wasting -Underweight

Global nutrition targets 2025WHO Member States endorsement

-Stunting: 40% reduction in the number of children under 5 who are stunted -Anemia: 50% reduction of anemia in women of reproductive age -Low birth weight: 30% reduction in LBW -Childhood overweight: no increase in -Breastfeeding: increase rate of exclusive breastfeeding in the first 6 months up to at least 50% -Wasting: reduce and maintain childhood wasting to less than 5%

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

The Microbiome

-The ecological community of commensal, symbiotic, and pathogenic microorganisms within our bodies -100 trillion microorganisms → Anaerobic bacteria, Archaea, Yeast, Parasites -Individual "finger-print" specificity- each person has a unique profile of organisms regulating their microbiome -Complex and dynamic- it is constantly evolving and changing based on exposure

Kwashiorkor and the Gut Microbiota

-The microbiota in persons with kwashiorkor have an altered metabolic profile -That comprises efficient energy metabolism on the Malawian diet

PEM Electrolytes

-Total body potassium is reduced in PEM → Due to decreased muscle proteins and loss of intracellular potassium -Decreased amounts of ATP, due to decreased energy substrates, probably changes cellular exchange of sodium and potassium -Serum potassium stays stable -Na-K-ATP pump actively pumps potassium into and sodium out of cells → when this is not working, results in potassium loss and increased intracellular sodium -Water goes with sodium, so there may be intracellular overhydration -May explain, in part, the increased fatigability and reduced strength of skeletal muscle

PEM Adaptations

-Various body systems adapt as much as possible to the decreased nutrient availability Insulin levels low -Leads to hormonal changes that ultimately affect thyroxine and lowers heat production (thermogenesis) and oxygen consumption (lowers basal metabolic rate) -Non-vital hormonal secretion decrease i.e. sex hormones -Red blood cell production decreases due to decreased oxygen demands due to lowered amount of lean body mass -Heart muscle reduces in size in parallel with loss of lean body mass -Catabolism of cardiac cells/proteins -Cardiovascular and kidney function changes -Cardiac output, heart rate and blood pressure decrease -Central circulation takes precedence over peripheral circulation -Allows heart to function in setting of reduced oxygen consumption (not circulatory failure)

Marasmus

-Wasted appearance -Marked growth failure -Hair is sparse, thin and dry without normal sheen, easily pulled out without pain -Skin dry, thin and with little elasticity and wrinkles easily -Patients are apathetic but usually aware and have a look of anxiety on their faces -Sunken cheeks due to loss of Bichat fat pads → Among the last subcutaneous adipose depots to disappear → Leads to look of an older person -Large amounts of food are not tolerated - vomiting and diarrhea

Growth on kids

-low height for age= stunting -low weight for height= wasting -low weight for age= underweight

Metabolic response to starvation

-negative Nitrogen balance --> skeletal muscle brokendown (3/3 pounds per day) -gradually slows down over 1 month -shift in metabolic fuels -serum fatty acid levels increase, albumin normal until late in starvation *weight loss *basal metabolic rate decreases, total energy expenditure decreases, decreased activity & body temp.

Low birth rate is an effect 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, especially cardiovascular disease

Global Nutrition Targets 2025: Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% (World Health Assembly Resolution)

Actions to drive progress in increasing exclusive breastfeeding 1.Provide hospital- and health facilities-based capacity to support exclusive BF, including revitalizing, expanding and institutionalizing the Baby-friendly Hospital Initiative in health systems. 2.Provide community-based strategies to support exclusive breastfeeding, including implementing communication campaigns tailored to the local context.

Effects of Refeeding on the Gastrointestinal System

Activity of the brush border enzymes and pancreatic enzyme secretion return to normal with refeeding Requires a period of readaptation to food to minimize GI complaints Diarrhea, nausea and vomiting

Adolescents

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

Controlled Starvation

Important to note that these volunteers were starving under medically ideal conditions in a controlled setting which varied greatly from the conditions that those living in authentic conditions in Europe were living in

Elderly- Older Adult

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

Incidence of stunting is estimated at..?

22.9% 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 1/2yrs if NOT born with LBW or severely stunted in infancy

Actions to drive progress in increasing exclusive breastfeeding (continued)

3. Significantly limit the aggressive and inappropriate marketing of break-milk substitutes by strengthening the monitoring, enforcement and legislation related to the International code of marketing of breast-milk substitutes and subsequent relevant World Health Assembly resolutions. 4. Empower women to exclusively breastfeed, by enacting 6 months of mandatory paid maternity leave as well as policies that encourage women to breastfeed in the workplace and in public. 5. Invest in training and capacity-building in breastfeeding protection, promotion and support.

Homemade ORS

8 level teaspoons of sugar 1 level teaspoon of salt 1 liter of clean water OR 1 packet of ORS in 1 liter of clean(boiled) water

Treatment of the Malnourished Child

Essential features of the initial feeding are Frequent small feeds of low osmolality and low in lactose Oral or nasogastric feeds (never IV feeds) 100 kcal/kg/day (to begin with) Protein 1-1.5 gm/kg/day Liquid: 130 ml/kg/day (100 if child has severe edema) Continue with breastfeeding but give scheduled amounts of formula first Clinical status must be monitored carefully Child should be fed every 2 hours for the 1st day or 2, then every 3 hours until day 6 If child's intake does not reach 80 kcal/kg/day despite frequent feeds, coaxing and re-offering, the remaining feed should be given by nasogastric tube (tube through nose to stomach) Return of the appetite is the sign for entering the rehabilitation phase Usually about 1 week after admission During this phase very high intakes are encouraged to support a weight gain of >10g/kg/day Must be alert to avoid heart failure (rapid pulse and fast breathing) if intake is high suddenly Modified porridges or complementary foods can be used if comparable in energy and pro

Effects of Refeeding on the Respiratory System

Excess carbon dioxide production and increased oxygen consumption can result from giving too much glucose and overfeeding A person with malnutrition-induced respiratory muscle wasting can get short of breath Can't sustain an increased ventilatory drive Pulmonary edema may develop in some due to increased water load

WHO Consensus Statement on HIV and Infant Feeding - March 2008

Exclusive breastfeeding for up to 6 months was associated with a 3 to 4-fold decreased risk of HIV transmission compared to non-exclusive breastfeeding -Where free infant formula was provided, the combined risk of HIV transmission and death was similar whether infants were formula fed or breastfed from birth -Early breastfeeding cessation was associated with reduced HIV transmission but also with increased risk of morbidity and child mortality in infants born to HIV-infected mothers

Food security

Exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life

Famine

Extreme shortage of food with underlying crop failure due to bad weather, war, and civil strife

Production of Ketones

Fat turned to energy using a small amount of carbs. When carb is not available ketones or glucose are made instead • Production of ketones makes breath smell fruity

Micronutrient Deficiencies

Focus is on ▫Iron (Fe) ▫Iodine ▫Vitamin A

Malnutrition (undernutrition) →

Food insecurity → decreased immune function → infection with enteropathogens → impaired absorption (for example, environmental enteropathy) → Host Genotype → Malnutrition (undernutrition) **Gut Microbiota in the middle that contributes (or makes worse) all these things

State of Food Insecurity in the World (reading)

Global hunger has continued to decline, albeit gradually, to an estimated 795 million undernourished people, or a reduction of 167 million hungry people over the last ten years. This decline has been most pronounced in developing countries, despite significant population growth. The year 2015 is a milestone, marking the end of the Millennium Development Goal (MDG) monitoring period. For the developing regions as a whole, the target to reduce the proportion of the world's hungry by 50 percent by 2015 was missed by a small margin. Some regions, such as Latin America, the eastern and south-eastern regions of Asia, the Caucasus and Central Asia, and the northern and western regions of Africa have reached the target, as they made fast progress in reducing Undernourishment. As many as 72 developing countries out of 129 have reached the MDG hunger target. Most of these enjoyed stable political conditions and economic growth, along with sound social protection policies aimed at assisting the most vulnerable.

Metabolic Consequences of Refeeding- Magnesium

Goes into the cell from the blood with refeeding and new tissue synthesis Important cofactor in many enzyme systems involving energy storage and utilization and protein synthesis Important for the proper functioning of the CNS, the peripheral neuromuscular system, and the cardiovascular system Low blood magnesium levels may cause irregular heart rhythm, hypocalcemia (low blood calcium), mu

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

Good nutrition is..?

Growth, activity/productivity, disease prevention

Micronutrient Malnutrition --> Protein Calorie Malnutrition aka Protein Energy Malnutrition

Hard to have a protein deficiency without having a calories

What is optimal birthweight?

Highest risk of undesirable outcome is usually found below 2.5 kg (5.5 lb) -Lowest risk is usually in the 3.5 to 4 kg range (7.7-8.8 lb) -2 standard deviations above the mean -"This means that shifting the mean of the distribution benefits the whole population." WHO 6threport

Ready-to-use Therapeutic Food (RUTF)

Home-based treatment for severe acute malnutrition in children who have no medical complications and still have an appetite Identification made with plastic measure of mid-upper arm circumference by community health worker Provides foods that are safe to use at home and ensure rapid weight gain RUTF is a ready-to-use paste in packets that doesn't need to mixed with water Based on peanut butter mixed with dried skimmed milk and vitamins and minerals Name brand "Plumpy-nut" Can be stored for 3 to 4 months without refrigeration Similar in nutrient composition to F100

Physiologic response to starvation?

Hunger subsides after 2-3 days *nausea in 1/3 (ketone produced from fat breakdown) *NO drop in K, other necessary electrolytes *Decrease of size of body compartments

Alleviating hunger helps children perform better.. how?

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