hserv 544 - nutrition in children1 nutrition in children jonathan gorstein clinical associate...

HSERV 544 - Nutrition in Children 1

Nutrition in Children Jonathan GorsteinClinical Associate ProfessorDepartment of Global Health

http://www.who.int/nutrition/topics/elena_video/en/index.html

http://www.youtube.com/watch?v=X-2KA5Ht9YM






Terminology

• Hunger – physiological state when food not able to meet energy needs

• Malnutrition – impaired development linked to both deficient and excessive nutrient intake

• Undernutrition – most common form of malnutrition in developing countries; energy, protein and micronutrients


Major Nutritional Problems in the World

• Protein-energy malnutrition• Obesity• Micronutrient deficiency problems

– Iron deficiency anemia– Vitamin A deficiency– Iodine deficiency disorders– Zinc deficiency– Folate deficiency

• Nutrition-related chronic diseases


Causes of Undernutrition

• Undernutrition is a complex condition that involves multiple, overlapping deficiencies of protein, energy and micronutrients – rarely do these occur in isolation

• The primary cause of undernutrition is an inadequate food intake, but is compounded by illness and malabsorption

• Insufficient access to food, poor health services, the lack of safe water and sanitation, inadequate child and maternal care and poverty are underlying causes


Classification of Malnutrition

• WHO recommends three anthropometric indicators for assessment of nutritional status– Wasting (Low weight-for-height)– Stunting (Low height-for-age)– http://www.undispatch.com/stunting-the-least-under

stood-most-under-appreciated-development-issue-in-the-world

– Underweight (Low weight-for-age)• Classification based on International Growth Reference

http://www.undispatch.com/stunting-the-least-understood-most-under-appreciated-development-issue-in-the-world




Prevention and Management of Undernutrition

• Heightened visibility over past 2-3 years due to successful and innovative programs– Gates …. – Public-private partnerships– GAIN: Ten Year Strategy for Micronutrients– http://www.gainhealth.org/– World Bank: Repositioning Nutrition– Lancet: Special Series on Undernutrition

• Opportunities

http://www.gainhealth.org/


Intergenerational Cycle of Undernutrition

The cycle of poor nutrition perpetuates itself across generations - supported by scientific evidence

Childhood: Child growth failure, impaired mental

development

Adolescents: Low weight and height

Pregnancy Compromised

nutritional status

Adult: Small adult woman, lowered

productivity

Fetal and Infant stages: Low

birthweight baby


Consequences of Undernutrition:Economic costs

• Undernutrition leads to reduced productivity, hampering economic growth and effectiveness of investments in health and education

• Vitamin and mineral deficiencies are estimated to cost some countries the equivalent of more than 5 per cent of their GNP in lost lives, disability and productivity


Infection-Malnutrition Synergism

Weight lossGrowth faltering

Immunity lowered

Appetite lossNutrient loss

MalabsorptionAltered Metabolism

Inadequate dietary intake

Disease IncidenceSeverityDuration


Causes of Mortality among Preschool Children, 2005

23%

18%

15%

10%

5%

25%

4%

Source: WHO (2003)

Deaths associated with undernutrition

55%

Other

HIV/AIDS

Measles

MalariaDiarrhea

Acute Respiratory

Infection

Perinatal


Interventions to improve nutrition and reduce HIV/AIDS progression – from Individual to Community

• Therapeutic• Direct food assistance• Food aid provided in conjunction with ARVs

• Social protection• Cash transfers

• Sustainable Livelihoods• Income generating opportunities• Small-scale fortification• Agriculture, e. small-farmer initiatives


Consequences of Malnutrition:Economic costs

• Malnutrition leads to reduced productivity, hampering economic growth and effectiveness of investments in health and education

• Vitamin and mineral deficiencies are estimated to cost some countries the equivalent of more than 5 per cent of their GNP in lost lives, disability and productivity


Micronutrients

• Micronutrients are needed by the body only in minute amounts, are critical for:– Regulation of growth, activity, development – Immune and reproductive function

• Three primary micronutrient deficiencies include:– Iodine– Vitamin A– Iron


0.0

0.5

1.0

1.5

2.0

2.5

Iodine Iron Vitamin A

People(billions)

1.6

2.0

0.8

Population at Risk of Deficiency - Global

Source: UNICEF (2002)


Iodine Deficiency Disorders (IDD)

• Single most important cause of preventable brain damage and mental retardation

• Significantly raises the risk of stillbirth and miscarriage in pregnant women

• About 50 million people worldwide suffer from varying degrees of brain damage and physical impairment due to iodine deficiency – Concept of IDD (Spectrum of disability)

• The primary intervention for the control of IDD is through salt iodization


Today• Some 70 per cent of households in

the developing world are using iodized salt, compared to less than 20 per cent at the beginning of the decade.

• As a result, 91 million newborns are protected yearly from significant loss in learning ability

Iodine Deficiency Disorders (IDD)

Unfinished Business• There are still 35 countries where less than half the households

consume iodized salt


69

70

28

55

68

70

80

81

0 20 40 60 80 100

World

Developing Countries

Latin America and the Caribbean

East Asia and Pacific

Middle East and North Africa

Sub-Saharan Africa

South Asia

CEE/CIS

Coverage of Iodized Salt – by Region



90% or more

50% to 89%

Less than 50%

No recent data

Levels of Iodized Salt Coverage



19

0

31

1

28

5

28

51

0

83

7073

76 76

87 88 90 919897

0

20

40

60

80

100

1993 2000 1994 1998 1996 2000 1995 2000 1994 2000 1993 2000 1992 2000 1995 1999 1995 1999 1995 1999

Bangladesh Togo Lao PDR MadagascarCentral African

Rep.Jordan Mexico China Eritrea Nigeria

Major Increases in Iodized Salt Coverage



41 Million Newborns Still Unprotected from Learning Disabilities

Sub-Saharan Africa

CEE/CIS

Latin America/CaribbeanMiddle East/

North Africa

South Asia

East Asia/Pacific

17 million

8 million

7 million

4 million

3 million2 million



Vitamin A Deficiency

• Contributing factor in 2.2 million deaths each year from diarrhea and 1 million deaths from measles among preschool children under five

• Severe deficiency can also cause irreversible corneal damage, leading to partial or total blindness

• Results of field trials indicate that VA supplementation of children with can reduce deaths from diarrhea. Four studies showed deaths were reduced by 35-50 per cent.

• VA can reduce by half the number of deaths due to measles


Magnitude of Vitamin A Deficiency

• Pre-school children• Clinically deficient: 3 million (Asia and Africa)• Subclinically deficient (low serum retinol): 100-140 million• 250,000-500,000 become blind each year• 90 % case fatality among those who become blind

• Pregnant women• 25%-30% cases of night blindness reported in some Asian

countries


Interventions to Control VAD

• In 1999, only 10 countries provided two rounds of VA supplementation with high coverage, this has increased to over 50 countries by 2004.

• Between 1998 and 2004, UNICEF estimates that about two million child deaths may have been prevented from vitamin A supplementation

• Food Fortification - A number of countries are successfully fortifying staple foods with vitamin A (e.g. sugar, maize flour, wheat) reaching large populations.

• http://www.one.org/us/living-proof?vid=9sOteg1xwls

http://www.one.org/us/living-proof?vid=9sOteg1xwls

http://www.one.org/us/living-proof?vid=9sOteg1xwls


7066

35 34

80

50

0

20

40

60

80

100

DevelopingCountries(excluding

China)

LeastDevelopedCountries

Sub-SaharanAfrica

East Asia /Pacific (excl.

China)

South Asia Latin America/ Caribbean

Perc

ent

Vitamin A Supplementation Coverage1:Developing world


1 Percent of children aged 6-59 months who received at least one vitamin A supplement within the last six months


70% or more

30 to 69% Less than 30% No data available

VA Supplementation CoverageWhere VAD is a public health problem (U5MR>70)

1 Percent of children aged 6-59 months who received at least one vitamin A supplement within the last six months



Iron Deficiency and Anaemia

• Most common nutritional disorder in the world• Lowers resistance to disease and weakens a child's

learning ability and physical stamina • Significant cause of maternal mortality, increasing the

risk of hemorrhage and infection during childbirth.• Nearly 2 billion people estimated to be anemic and

millions more are iron deficient, the vast majority are women.

• Supplementation and fortification are primary interventions to improve iron intake


Global Prevalence of Anaemia:Pregnant Women

0

10

20

30

40

50

60

70

80A

fric

a

Am

eri

cas

So

uth

-Ea

stA

sia

Eu

rop

e

Ea

ste

rnM

ed

iterr

an

ea

n

We

ste

rnP

aci

fic

Source: WHO (1999)


Main Factors Contributing to Anaemia

• Iron deficiency– Poor bioavailability of consumed iron– Insufficient dietary iron intake

• Chronic and recurrent infections that interfere with food intake and absorption/utilization of iron– Helminth infections, primarily Hookworm– Chronic diarrheal disease– HIV– Malaria


Interventions to Control Anaemia

• Depends on etiology– For iron deficiency: supplementation and

fortification– For parasitic disease control: appropriate

measures for prevention and presumptive treatment


Thank you

hserv 544 - nutrition in children1 nutrition in children jonathan gorstein clinical associate...

Documents

children1 nutrition

productivity slide

cycle of poor nutrition

repositioning nutrition

undernutrition opportunities

low weight

economic costs undernutrition

low height