U NDERNUTRITION / MALNUTRITION

1. UNDERNUTRITION / MALNUTRITION

2. Answer true or false to the following statements about undernutrition: • The primary cause of undernutrition is poverty. • The greatest risk from undernutrition during pregnancy is borne by the foetus. • The effect from years of undernutrition can be overcome in several weeks on a high-protein, high-carbohydrate diet. • Hunger remains a problem in western nations because of insufficient funds and foods to serve the growing population. • Undernutrition is the most common form of malnutrition.

3. TERMINOLOGY • MALNUTRITION a condition of impaired development or function caused by either a long term deficiency or an excess in energy and / or nutrient intake, the later representing a state of overnutrition. • UNDERNUTRITION  when food supplies are low and the population is large, undernutrition is common, leading to nutritional deficiency diseases, such as goitre (from an iodine deficiency) or xerophthalmia (eye problems caused by poor vitamin A intakes). Undernutrition is the most common form of malnutrition among the poor in both developing and developed countries.

4. HUNGER the physiological state that results when not enough food is eaten to meet energy needs. If hunger is not relieved, the resulting social and medical costs from undernutrition are high – preterm births and mental retardation, inadequate growth and development in childhood, poor school performances, decreased output in adulthood and chronic diseases. • PROTEIN ENERGY MALNUTRITION (PEM) a form of undernutrition caused by an extremely deficient intake of energy or protein generally accompanied by an illness. The typically dramatic results of (PEM) are kwashiorkor and marasmus.

5. FAMINE  is not the same thing as chronic hunger. Although both result from poverty and a lack of food, famine is the extreme form of chronic hunger. Periods of famine are characterised by large scale loss of life, social disruption and economic chaos that slows food production. In the midst of all this, undernutrition rates soar, infectious diseases such as cholera spread and people die in large numbers. • GROWTH FAILURE  The failure to grow in stature or weight. There are two types of growth failure associated with malnutrition, stunting (or shortness) and wasting (or thinness).

6. WASTING AND ACUTE MALNUTRITION  Wasting is the main characteristic of acute malnutrition. Wasting occurs as a result of recent rapid weight loss, malnutrition or a failure to gain weight within a relatively short period of time. Wasting occurs more commonly in infants and younger children, often during the stage when complementary foods are being introduced and children are more susceptible to infectious diseases. Recovery from wasting is relatively quick once optimal feeding, health and care are restored. Wasting occurs as a result of deficiencies in both macronutrients (fat, carbohydrate and protein) and some micronutrients (vitamins and minerals).

7. STUNTING AND CHRONIC MALNUTRITION  Stunting is a failure to grow in stature, and occurs as a result of inadequate nutrition over a longer time period, which is why it is also referred to as chronic malnutrition. It is a slow, cumulative process, the effects of which are not usually apparent until the age of two years, although to prevent stunting action is needed before a child reaches the age of two. Stunting requires a long-term response. The effects of stunting are not completely reversible.

8. Nutritional Deficiency: Signs and Symptoms • Refer to handout where the signs and symptoms of nutritional deficiency are listed.

9. www.australianprescriber.com

10. PEM CONDITIONS • MARASMUS: (http://www.emedicine.com/ped/TOPIC164.HTM#Multimediamedia4) • Marasmus is 1 of the 3 forms of serious protein-energy malnutrition (PEM). The other 2 are kwashiorkor (KW) and marasmic KW. • These forms of serious PEM represent a group of pathologic conditions associated with a nutritional and energy deficit occurring mainly in young children from developing countries at the time of weaning. • They are frequently associated with infections, mainly gastrointestinal infections.

11. The reasons for a progression of nutritional deficit into marasmus rather than KW are unclear and cannot be solely explained by the composition of the deficient diet (i.e., a diet deficient in energy for marasmus and a diet deficient in protein for KW). • Although PEM occurs more frequently in low-income countries, numerous children from higher-income countries are also affected, including children from large urban areas and of low socioeconomic status, children with chronic disease, and children who are institutionalized.

12. Hospitalized children are also at risk for PEM when they experience complex conditions, such as oncologic disease, genetic disease, or neurological disease, requiring prolonged and complicated hospital care. In these conditions, the challenging nutritional management is often overlooked and insufficient, resulting in an impairment of the chances for recovery and the worsening of an already precarious neurodevelopmental situation. • PEM results in not only high mortality (even for hospitalized children, without any improvement during the last 2 decades) but also morbidity and suboptimal neurological development.

13. Signs and symptoms of marasmus vary with the importance and duration of the energy deficit, age at onset, associated infections (e.g., gastrointestinal infections), and associated nutritional deficiencies (e.g., iron deficiency, iodine deficiency). Diets and deficiencies may vary considerably between different geographical regions and even within a country.

14. Failure to thrive is the earliest manifestation, associated with irritability or apathy. Chronic diarrhoea is the most frequent symptom, and infants generally present with feeding difficulties. Presentation may be accelerated by an acute infection.

15. The classic course of a child with Marasmus:

16. A shrunken wasted appearance is the classic presentation. • Stunted children are usually considered to have a milder chronic form of malnutrition, but their condition can rapidly worsen with the onset of complications such as diarrhoea, respiratory infection, or measles.

17. KWASHIORKOR (http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001604.htm) Kwashiorkor is a form of malnutrition caused by inadequate protein intake in the presence of fair to good energy (total calories) intake. It occurs most commonly in areas of famine, limited food supply, and low levels of education, which can lead to inadequate knowledge of proper diet. • Early symptoms of any type of malnutrition are very general and include fatigue, irritability and lethargy. As protein deprivation continues, growth failure, loss of muscle mass, generalized swelling (oedema), and decreased immunity occur.

18. A large, protuberant belly is common. Skin conditions (such as dermatitis, changes in pigmentation, thinning of hair, and vitiligo) are seen frequently. Shock and coma precede death. • This is typically a disease of impoverished countries, and is often seen in the midst of drought or political turmoil. However, one government estimate suggests that as many as 50% of elderly persons in nursing homes in the U.S. suffer from protein-calorie malnutrition.

19. Improving calorie and protein intake will correct kwashiorkor, provided that treatment is not started too late. However, full height and growth potential will never be achieved in children who have had this condition. • Severe kwashiorkor may leave a child with permanent mental and physical disabilities. There is good statistical evidence that malnutrition early in life permanently decreases IQ.

20. Symptoms  • Failure to gain weight and failure of linear growth • Irritability • Lethargy or apathy • Decreased muscle mass • Swelling (oedema) • Large belly that protrudes • Diarrhoea • Dermatitis

21. Changes in skin pigment; may lose pigment where the skin has peeled away (desquamated) and the skin may darken where it has been irritated or traumatized • Hair changes -- hair colour may change, often lightening or becoming reddish, thin, or brittle • Increased and more severe infections due to damaged immune system • Shock (late stage) • Coma (late stage)

22. Many malnourished children will have developed lactose intolerance and will need to be given lactase supplements if they are to benefit from milk products. • Treatment early in the course of kwashiorkor generally produces good results. Treatment of kwashiorkor in its late stages will improve the child's general health, but he or she may be left with permanent physical problems and intellectual disabilities. Without treatment or if treatment comes too late, this condition is fatal.

23. Health consequences of undernutrition • Refer to article 1: “Maternal and Child Undernutrition: global and regional exposures and health consequences” This has given you an understanding of the extent of this problem in the developing world. Can we extrapolate this information to our developed society? If so, how? If not why?

24. In an in vivo study on undernourished rats it was found that undernutrition during gestation and lactation can result in an increase in the level of apoptotic cells in the dentate gyrus. (Jahnke S & Bedi KS 2007, ‘Undernutrition during early life increases the level of apoptosis in the dentate gyrus but not in the hippocampal formation’, Brain Research, vol.1143, pp.60-9)

25. In transitional economies which are most usually represented by a combination of diets of low nutritional quality (low and little food component density and diversity) and decreased levels of physical activities, the most worrying situation is that of maternal undernutrition, with intra-uterine growth retardation, compromised lactation and infant feeding, leading to stunting in early life and to abdominal obesity and its consequences later in life. (Lukito M & Wahlqvist M. 2006, ‘Weight management in transitional economies: the “double burden of disease”, Asia Pacific Journal of Clinical Nutrition, vol 15, pp.21-28)

26. Epidemiological studies have demonstrated a relationship between birth weight, weight in infancy and adult bone mass. Maternal smoking, diet (particularly vitamin D deficiency) and physical activity appear to modulate bone mineral acquisition during intrauterine life. It has also been shown that low birth size and poor childhood growth are directly linked to later risk of hip fracture. (Cooper C et al. 2006, ‘Review: development of origins of osteoporotic fracture”, Osteoporosis International, vol 17, no 3, pp.337-347)

27. Many human foetuses and infants have to adapt to a limited supply of nutrients, and in doing so, they permanently change their physiology and metabolism. These programmed changes may be the origins of a number of diseases in later life such as coronary heart disease, stroke, diabetes and hypertension. This report asked the question  why are the highest rates of coronary heart disease in Western Countries occurring among the poor? It then proposes that foetal origins play a large role because coronary heart disease and the disorders associated with it – hypertension, adult-onset diabetes and stroke – originate through adaptations that the foetus makes when it is under-nourished. These adaptations made during early development tend to have permanent effects on the body’s structure and function. (Barker D. 2004. ‘Fetal and infant origins of adult disease’, Monatsschrift Kinderheikunde, vol.149, no.13, pp.s2-s6)

29. This paper states that environmental factors, particularly undernutrition, act in early life to programme the risks for adverse health outcomes, such as cardiovascular disease, obesity and the metabolic syndrome later in life...... The physiological responses to foetal undernutrition result in the physiological trade off between foetal survival and poor health outcomes.(McMillen I et al. 2008, ‘Developmental origins of adult health and disease: the role of periconceptional and foetal nutrition’, Basic and Clinical Pharmacology & Toxicology, vol.102, no.2, pp.82-9) • Refer to the article: ‘Does foetal undernutrition predispose disease in adult offspring’ and draw up a list of the health effects of undernutrition as the body ages.

30. Now bring this information together to draw up a summary of how undernutrition affects: • Pregnancy • Foetal and infant stages • Childhood • Later years

31. CAN THIS HAPPEN IN AUSTRALIA IN 2012?

32. The objectives of this study were to determine: (i) the prevalence of malnutrition in two Sydney teaching hospitals using Subjective Global Assessment (SGA), (ii) the effect of malnutrition on 12-month mortality and (iii) the proportion of patients previously identified to be at nutritional risk. • A prospective study with a 12-month follow-up to assess mortality. A total of 819 patients was systematically selected from 2194 eligible patients. Patients were excluded if they were under the age of 18, had dementia or communication difficulties, or were under obstetric or critical care. The main outcome measures were prevalence of malnutrition, 12-month incidence of mortality, proportion of patients identified with malnutrition, and hospital length of stay (LOS).

33. The prevalence rate of malnutrition was 36%. The proportion of malnourished patients was not significantly different between the two hospitals (P = 0.4). The actuarial incidence of mortality at 12 months after assessment was 29.7% in malnourished subjects compared with 10.1% in well-nourished subjects (P < 0.0005). Malnourished subjects had a significantly longer median LOS (17 days vs 11 days, P < 0.0005) than well-nourished subjects. Only 36% of the malnourished patients had been previously identified as being at nutritional risk. • Conclusions: Malnutrition in Australian hospitals is a continuing health concern and is associated with increased LOS and decreased survival after 12 months. The present study revealed that malnourished patients were not regularly identified. (Middleton M, Nazarenko G. Nivison-Smith I et al. 2008, Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals, Internal Medicine Journal, vol.31, iss.8, pp.455-461)

34. Refer to the Preface to the book ‘Undernutrition in the elderly’ (article 2) and discuss the main responses to undernutrition that were listed in the book. While we don’t have the statistics / figures, do you feel that in Australia we should see this situation as Thomas sees it – as an epidemic?

35. www.australianprescriber.com

36. www.australianprescriber.com

37. Malnutrition is a major cause of immune deficiency that directly affects the acute phase response and leads to greater frequency and severity of common infections. Primary malnutrition is not uncommon in wealthy industrialized societies due to poverty, lack of education, food allergies, inappropriate or limited diet, or eating disorders. Inadequate intake of micronutrients including vitamin A, E, calcium, iron and zinc are prevalent among children under 10 years of age and often unrecognized. The overall impact of chronic malnutrition in children may determine the quality and duration of immune response. “Malnutrition and infection in industrialized countries” in Pediatric Infectious Diseases Revisited, 2007, Birkhäuser Basel, pp. 117-143

39. Read through the case report (article 3): ‘Deprivation in the desert: a case report from central Australia’. We think undernutrition cannot happen in our country – however, this DOES happen in Australia. What are the implications, both immediate and long term for us working in the health field and for the country’s long term health prognosis?

40. What does this tell us about the state of undernutrition on a global scale?

41. What are the implications of all of this for us as CAM practitioners.