AAE 350 - Exam 1

What is RUTF, under what circumstances is it used, and what are the advantages of it?

Ready-to-use-therapeutic food, used for severe acute malnutrition in children who have no medical complications and still have an appetite, provides foods that are safe and ensure rapid weight gain. Ready to use paste in packets, doesn't need to be mixed with water, high nutrient composition, can be stored for 3-4 months without refrigeration

What sign indicates that a child is entering the rehabilitation phase? What is encouraged at this point?

Return of the appetite is sign for entering the rehab phase, usually 1 weeks after admission. During this phase, high intakes are encouraged to support weight gain

What is "environmental enteropathy" what is its proposed mechanism?

Small intestinal disorder triggered by constant ingestion of feces, results in bacteria into blood stream from intestinal walls, and infections.

Why must refeeding be done slowly?

So as not to cause heart failure, to allow re-adapation to food to avoid GI complaints, to avoid edemas, to adjust to new metabolic demand, to support gradual weight gain

What problems may stunted women have during pregnancy and delivery?

Stunted women have more trouble in labor, and smallness tends to be transmitted from one generation to another. Stunted women have LBW infants.

What is stunting? Wasting? Underweight?

Stunting - low height for weight Wasting - low weight for height (<2 SD, severe <3 SD) Underweight - low weight for age at <2 SD of the median value

What is the result of the changes in the immune system during PEM?

Susceptibility to sepsis, and predisposition to infections and complications of otherwise less important infectious disease. Cannot fight antigens as well. Overall: decreased immunity

What is the nutrition transition? What dietary changes occur?

The nutrition transition is the change from a traditional diet to a western diet. Transition to high fat, high sugar, low fiber, diverse and varied, and high in animal protein

Why is it important to frequently weigh and measure a child?

To measure progress in growth, which has correlation to disease susceptibility and brain function

Why is good nutrition important for the elderly?

Undernutrition is associated with higher risk of impairments in psychomotor speed and coordination, mobility, ability to carry out activities of daily living. Decreased functional ability, more need for help. Sarcopenia (loss of muscle mass with age) linked to loss of strength, more morbidity and mortality, functional impairment. Increased depression with malnutrition

What nutrient deficiency has a decrease in immune function before the presentation of more obvious clinical signs?

Vitamin A leads to lower immune function

What nutrient is required for energy production and where does it come from when not in the diet?

carbohydrates are needed for glucose, and proteins are converted to glucose when carbs not available

What must people have to make good choices about diet?

education and income

What are the good and bad parts of the nutrition transition?

good - more food and energy consumption, less ID, more medical care, less undernutrition. Bad - obesity, coronary heart disease, diabetes, hypertension, stroke. Inactivity, smoking, alcohol and stress are also involved

What happens in the adolescent period that challenges nutrition?

hormonal changes accelerate growth (puberty), leading to more need for calories and proper diet. Undernourished girls grow longer before a later menarche. Guys grow later, girls can conceive earlier but their babies are ****ed up

How long does the body adapt physiologically to PEM?

hunger subsides in 2-3 days, defecation stops after 3-4, urine output drops after a week, blood glucose levels drop, nausea occurs, decrease in size of body compartments, and hormonal changes (insulin levels low, lowering heat production and oxygen consumption; non-vital hormonal secretion decrease i.e. sex hormones). Overall: Things that are not necessary stop, things that are necessary lessen.

What is a major issue with early pregnancy in undernourished girls?

linear growth of adolescent girls have been shown to stop when they get pregnant. Best way to improve birthweight is to delay pregnancy until 18, and an extra cm of adult height is added for each year that median age of first pregnancy can be delayed beyond age 15

What dietary recommendations have been made to decrease risk?

lower consumption of sugar, oils, fats and animal source foods, higher consumption of fruits and vegetables. Less intake of energy dense, low nutrient, processed foods

What happens metabolically and physiologically in refeeding?

metabolically - overfeeding carbs can result in high blood sugars and dehydration, and edema. Phosphorous leads to decreased blood levels early on, and very low levels can lead to system and cell dysfunction. Magnesium goes into cell from blood with refeedig, and new tissue synthesis. Low levels are bad (arrhythmia, muscle weakness, neurological symptoms). cardiovascular - increases HR, BP, O2 consumption, cardiac output. Congestive heart failure can occur because heart is given metabolic demand too high for it to supply. respiratory - excess CO2 and increased O2 consumption can result from giving too much glucose and overfeeding. Person can get short of breath from malnutrition induced respiratory muscle wasting, pulmonary edema can occur,

What has been hypothesized regarding in utero malnutrition and health in later life?

neurologic dysfunctions like ADD and immune impairment can occur. Low birthweight can result in a higher mortality rate. impaired mental function, and increased risk of adult disease, especially CVD

Who is affected by chronic disease?

the poor are food insecure, those in low and middle income countries, with a large percentage before the age of 70. In high income higher rate of death from chronic diseases (compared to ID), but still more chronic disease deaths occur in low to middle income countries

What are the modifiable risk factors for chronic disease?

unhealthy diet, physical inactivity, tobacco use, harmful use of alcohol

What indicator is used to measure progress in breaking the intergenerational cycle of malnutrition?

weight and height - stunting = low height for age, wasting = low weight for height

What decreases with malnutrition in adults?

work capacity, income, money for food, productivity, ability to work due to illness or exhaustion.

How long did full recovery take in these study subjects?

2 months to 2 years, and there were no long-term effects. Once participants started eating again, stomachs shrunk, some vomited, and some actually lost more weight because of loss of fluid in edemas

How does the body adapt metabolically to malnutrition?

A negative nitrogen balance occurs in the first week (excreted in urine). Skeletal muscle is broken down to produce glucose, from protein, to provide energy. Fat breakdown then provides ketones for tissues

What is the relationship between toilets and stunting?

About 1 billion people worldwide openly defecate, and secondary malnutrition caused by lack of clean water and sanitary waste disposal. If you ingest contaminated water, and have secondary malnutrition, you will have less growth because of parasites taking energy. Toilets prevent open defecation and decrease stunting

What improves learning in children?

Alleviating hunger improves learning by making them better concentrate, complete complex tasks, and miss less days of school due to nutrition-related illnesses

What is the effect of electrolyte changes on muscle tissue?

Body potassium reduced leads to less muscle proteins and intracellular K. Reduced strength of skeletal muscle because K-ATP pump not working, resulting in K loss and increased intracellular Na. This causes increased tiredness

What is the best way to feed an infant? For how long? Be able to give reasons. What actions have been recommended to support this?

Breastmilk is the best method to feed an infant. Recommendation is exclusive breast feeding for 6 months. Breastfeeding has been linked to stronger intellectual development of children, reduced risk of cancer, obesity, chronic diseases. Also extends time interval between children, which improves infant and child survival. Introducing complementary foods between 4 and 6 months has shown no advantage in growth. Breastmilk is clean, in a clean container, has immunologic benefits, and does not compete with rest of family

What happens to the functional capacity of the heart during protein calorie malnutrition? The lungs?

Cardiac output, heart rate, and blood pressure decrease. Central circulation takes precedent over peripheral, leading to cold feet and hands, and allows for less O2 consumption. RBC production decreases. Cardiovascular reflexes change, leading to lightheadedness, and blood pooling. Lower blood filtration in kidneys. Lungs - decrease respiratory muscle strength, vital capacity, and max. voluntary ventilation. Lower BMR decreases ventilatory response, decrease function and emphysema (holes in lungs) like changes occur, increase in infections (upper respiratory infections to pneumonias/TB)

How is nutritional status assessed? What is the result of good nutrition?

Clinical assessment (physical signs - late on), biochemical assessment (lab measurement), dietary assessment (recall and records), anthropometric assessment - middle upper-arm circumference, height, weight and BMI. Stunting = low height for age, wasting = low weight for height

When should complementary foods be introduced and why?

Complementary feeding should be introduced at 6 months, to provide adequate nutrition and stimulate development

What is the major effect of early life PEM?

Decreased brain growth, nerve myelination, neurotransmitter production, velocity of nervous conduction

What is the link between poverty and obesity?

Disordered eating (feast and famine, binge when food is available), energy dense and low nutrient foods inexpensive, fever opportunities for physical activity, high levels of stress, early poverty associated with obesity in young adults.

What might happen to the capacity for work with undernutrition?

Energy levels decrease, more days are missed due to infection, fatigue and weakness are common

What causes diarrhea in refeeding?

Excess water load, and poor re-adaptation to food

Why is exploratory behavior so important in children? What fuels it?

Exploratory behavior helps to stimulate brains and increase intellectual development. Proper nutrition fuels this behavior, because chronic malnutrition makes children less active, and results in fewer brain cells and decreased mental capacity

What is a common complication in refeeding? Why?

Fluid excess is common, because of expansion of the extracellular space. Must be given carefully. Na must be given carefully to prevent expansion, and additional K is needed

Why is there diarrhea with severe PEM?

Impaired intestinal absorption of fats and sugars, lower bile production, microvilli shorten, lower enzyme and bile acid concentration --> diarrhea when fed due to alterations. Low protein levels lead to intestinal edema which decrease luminal absorption leading to diarrhea.

What is the key indicator of malnutrition?

Infant mortality rate - number of children per 1,000 live births who die before their first birthday

Why should prevention focus on the life cycle and not just with fetal and early childhood malnutrition?

Intervening at each point in the life cycle will accelerate and consolidate positive change. Life cycle dynamics of cause and consequence demand inclusive approach

What nutrient has been successfully supplemented in the diet via salt? Sugar?

Iodized salt, vitamin A fortified sugar

What impact do these deficiencies have on life?

Iron - fatigue involved in anemia decreases productivity, ability to work. Vitamin A - blindness, lower resistance to infection. Iodine - brain function, thyroid hormone function

What are the dietary sources of these nutrients and what are the issues associated with availability, intake and absorption?

Iron - heme iron from animal protein, much more easily absorbed than non-heme iron. non-heme iron is in grains, legumes, meat, leafy-green veggies, also in iron cookware. about 25% of heme iron is absorbed from meat. Plant foods (non-heme) are not as easily absorbed as animal (about 50% as much absorbed), due to fiber and phytate. Concurrent vitamin C intake improves absorption. Iron poisoning most common form of poisoning in children. Iodine - iodized salt main intake, also in seawater. Lack of intake causes goiter (enlargement of thyroid). Vitamin A - carrots, beef liver, mustard greens, egg yolk, apricots, fortified foods. Too much vitamin A focuses toxicity, causing nausea, vomiting, headache. Beta-carotene much less toxic in higher doses than is preformed animal forms of vitamin A. Vitamin A is fat-soluble, absorbed and transported with lipids. Pre-formed in animal sources, pro-vitamin A in carotenoids.

Why is obtaining iron and vitamin A different from animal versus plant sources?

Iron - heme iron in animal is much more easily absorbed than non-heme iron, and heme iron is part of hemoglobin. Plant sources are much less absorbed and have lower amounts of iron, and contain non-heme iron. Concurrent vitamin C helps absorption Vitamin A - animals are pre-formed vitamin A, pro-vtaimin A sources are carotenoids from plants

What nutrient deficiencies are associated with decreased cognitive ability? How?

Iron - not enough O2 to brain or decrease amount of neurotransmitters that are also iron dependent. Iodine - key role in cell replication, especially for brain

What are the symptoms of these micronutrient deficiencies?

Iron deficiency - cognitive defects in children, anemia, decreased productivity, maternal death due to severe anemia, fatigue. Vitamin A - impaired immune function, night blindness, dry hard skin, Xerophthalmia (dry cornea and eventual blindness). Iodine - goiter, hypothyroidism, impaired mental function (cretinism - severe cognitive disability), fetal deficiency (still births, neonatal morality)

Who is most likely to be deficient in each of these nutrients?

Iron deficiency - most likely in pregnant women, young children, and older adults. Vitamin A deficiency - children: leading cause of preventable blindness, and increase the risk of disease and death from severe infections. Iodine - children - still births, cretinism. adults get goiter, impaired mental function, hyperthyroidism

What are the major micronutrient deficiencies in the world?

Iron, Vitamin A, Iodine

How did the subjects in the Keyes study adapt to semi starvation?

Loss of active tissue including high loss of lean body mass (muscle), and body fat loss. Reduction in tissue metabolism (lower BMR) and reduced physical activity. Less thermic effect of food due to lower intake, and reduced body weight resulting in less caloric cost of physical activity (reduced activity costs = energy savings)

What are the 2 types of PEM? How do they differ? What has been linked to the microbiome?

Marasmus - wasted appearance, growth failure, sparse hair, dry and thin skin, apathetic patients, sunken cheeks due to loss of bight fat pads, large amounts of food not tolerated. Kwashiorkor "the sickness the older child gets when the next baby is born" - Caused by diet, infection or stress, and gut micro biome. symptoms are edema, low protein-to-energy ratio in diet, fatty liver, hypoalbuminemia, brittle hair. Microbiome influences extraction of calories from ingested food, synthesis of micronutrients, food digestion and absorption.

What are the major effects of refeeding?

Metabolic responses - insulin release stimulated by carbohydrate and protein presence in gut. stops release of fat from stores and production of glucose from protein. stops sodium excretion Cardiovascular - increases in heart rate, BP, O2 consumption, cardiac output respiratory - excess CO2 production, increased o2 consumption

What besides nutrients must be part of the therapy for malnourished children?

ORS, zinc supplements, antibiotics

What are the common chronic diseases? What common condition have many been linked to?

Obesity is linked to diabetes, hypertension, stroke, coronary heart disease, and some cancers. 82% of all NCD deaths are: caused by: CVD, cancer, chronic respiratory diseases, diabetes

What is ORS and what is it used for?

Oral rehydration salts used to prevent and treat dehydration, especially that due to diarrhea. solution of sodium and glucose

What are the 4 types of malnutrition? What causes each type?

Over nutrition - too many calories, not enough exercise. Transition diets, Secondary malnutrition - not directly caused by the diet, condition that prevents proper nutrition like diarrheal infection and worms, malaria, or loss of appetite. Micronutrient malnutrition - deficiencies of Vitamin A, Iodine, Iron, others: Zinc, vitamins B, C, D. Protein energy malnutrition (PEM) - extremely deficient intake of protein and kcal, made worse by illness. Protein deficiency occurs with caloric deficiency

What is a problem in both industrialized and developing countries and why?

Over nutrition that causes obesity, due to transition diets moving into western diets, creating chronic diseases. 90% of chronic disease deaths are in low-middle income countries

What is the effect of maternal nutrition of the fetus?

PEM early pregnancy increased rate of fetal loss and malformations in babies, late in pregnancy resulted in LBW babies. Anemia associated with low birth weight, affect of infant cognition, and increased maternal mortality rate. Iodine deficiency causes cretinism. Stunted women have smaller babies, and smaller pelvic areas increases risk of infant and maternal mortality.

What were the physical and psychological symptoms exhibited during the semi starvation in the Keyes study?

Physical signs - after 3 months of 24 week program, participants had fatigue, muscle soreness, irritability, and hunger pains. Weight loss, weakness, heart rate decrease susceptibility to the cold, anemia, dizziness, hair loss, and edema are also symptoms. Psychological symptoms include depression, loss of concentration, anxiety, irritability, loss of sex drive, apathy, personality change, and inability to stop thinking about food.

What are the major determinants of stunting? What is this linked to in adulthood?

Poor diet and disease leads to shortness. Stunting at age 2 is associated significantly with later deficits in cognitive ability

Describe the changes in the use of carbohydrate, fat and protein during starvation

Protein is broken down to produce glucose when carbohydrate is not available. Fat breakdown occurs after glucose is produced from protein to provide energy, and fats provide ketones for tissues. Fats normally store 90% of energy in the adult.