The Biology of Malnutrition – Part 4

1. The Biology of Malnutrition – Part 4 Effects of Nutritional Insult at Different Points in the Lifecycle

2. 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: 8 • Italy 5 • Finland 4 • China 31 • India 70 • Nigeria 76 • Uganda 88

4. Maternal Malnutrition • 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

5. Maternal Malnutrition • 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

6. Maternal Malnutrition • Effect 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

7. 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

8. 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

9. Effects of Malnutrition on the Infant • 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

10. 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

11. Effects of IUGR • 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 CVD, DM and HBP, esp. if insult is in the 3rd trimester

12. Effects 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

13. 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

14. 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

15. Infant Nutritional Status • 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

16. Infant Nutritional Status • 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

17. Infant Nutritional Status • 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

18. Infant Feeding Recommendations • Exclusive breast feeding for 4 to 6 months • Breastfeeding with complementary feedings starting at about 6 months of age • Continued breastfeeding in the second year of life and beyond

19. Infant Feeding Recommendations • Field studies show no advantage in growth or development when complementary foods introduced between 4 and 6 months • UNICEF and many ministries of health in general recommend exclusive breastfeeding for 6 months • WHO recommends exclusive breast feeding for 4-6 months, so some confusion on this issue

20. 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

21. Infant Feeding Recommendations • 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

22. Infant Feeding Recommendations • 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.

23. Breastfeeding and HIV/AIDS • Breastfeeding is a significant and preventable mode of HIV transmission • Observational data have shown that 3 month old infants of HIV-positive women who were exclusively breastfed have the same risk of contracting HIV as infants who were never breastfed • Partially breastfed infants had a significantly higher risk

24. Breastfeeding and HIV/AIDS • New guidelines call for urgent action to educate, counsel, and support HIV-positive women in making decisions about how to feed their infants safely. • In order for a mother to make a decision, she must have access to • Voluntary and confidential testing and counseling • Information about feeding options and risk associated with them

25. Breastfeeding and HIV/AIDS • Previous recommendations stated that infants of HIV-positive mothers in developing countries should be breastfed because mortality was still lower in the breastfed infants. • Shorter duration of breastfeeding is one option suggested in the new UNAIDS/WHO/UNICEF guidelines • Awaiting confirmation of protective effect of exclusive breastfeeding

26. 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

27. “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

28. “The Code” • 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

29. “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.

30. 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

31. 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

32. The WHO/UNICEF Baby Friendly Hospital Initiative • 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 the Ten Steps • 14,500 hospitals in over 142 countries have been certified

33. The Maternal Milk • Protects the baby from • Diarrhea • The flu • Infection • allergies

34. Mobile Restaurant • Tax free • All free • Perfectly balanced • No infections • Natural nourishment • Attractive • Open 24 hours • Service with love

35. Maternal Lactation: come in , the most nutritious, exquisite, free food

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

37. Child • 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

38. Child • 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

39. Child • Measures of malnutrition • Stunting • Wasting • Underweight

40. 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

41. 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

42. Child • Chronic low intake leads to STUNTING • Growth charts key indicators • Linear growth • <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

43. Child • Incidence of stunting is estimated at 32.5% 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 /12 if NOT born with LBW or severely stunted in infancy

44. Child • Stunting at age 2 is associated significantly with later deficits in cognitive ability • Alleviating hunger improves learning • School feeding, both breakfast and lunch programs, has been shown t improve school performance in both developing and industrialized countries

45. Child • Alleviating hunger helps children perform better • 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

46. Child • 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

47. Child Catch Up

48. Child • 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

49. Child • Ways to improve nutrition and health status of children • Antihelminthics • Given in conjunction with vitamin A or iron supplementation shows better outcomes • Delivery of micronutrients • Treatment of injuries and routine health problems

50. Adolescents • Adolescent hormonal changes accelerate growth • Growth is faster than at any other postnatal time except the first year