MALNUTRITION

MALNUTRITION

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. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

MALNUTRITION & Undernutrition • Any disorder concerning nutrition it may result from an unbalanced, insufficient, or excessive diet or to the impaired absorption, assimilation, or use of foods. 1 • Mal – bad, or not right, indicating that it is incorrect nutrition for the individual’s needs. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Types of malnutrition • PROTEIN ENERGY MALNUTRITION (PEM) a form of undernutrition caused by an extremely deficient intake of energy or protein generally accompanied by an illness. • Groups at risk include: • Aged, chronically ill, wasting diseases eg Cancer, HIV, GIT – malabsorption and ulceration • Increased BMR and reduced ability to consume increased E needs. • Reduced economic means; • Food choices – lack of knowledge/skills; dementia; anorexia, • Just to name a few. • The typically dramatic results of (PEM) are kwashiorkor and marasmus which can present with cachexia – wasting in cancer. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

WASTING AND ACUTE MALNUTRITION  Wasting is the main characteristic of acute malnutrition. Occurs as a result of • recent rapid weight loss, • malnutrition or a failure to gain weight within a relatively short period of time. • Occurs more commonly in infants and younger children, often during weaning and introduction to childcare. • Recovery from wasting is relatively quick once optimal feeding, health and care are restored. • This may not occur with wasting diseases and terminal illnesses • Wasting occurs as a result of deficiencies in both macronutrients (fat, carbohydrate and protein) and some micronutrients (vitamins and minerals). (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

STUNTING AND CHRONIC MALNUTRITION  Failure to Thrive. • 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. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

GROWTH FAILURE  The failure to grow in stature or weight during significant periods of growth – childhood and puberty. • There are two types of growth failure associated with malnutrition, stunting (or shortness) and wasting (or thinness). • Examples of contributing factors; food choices, availability, healthy issues, perception – anorexia/ bulimia nervosa • Children of low socio-economics groups are at risk of malnutrition and its consequences because of the amount of available of disposable money for food. • Children are also at a higher risk of neglect, abuse, and withholding behaviour. • One intervention the Australian Government has implemented is the breakfast in school program for children at risk, or documented risk. 1 (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

UNDERNUTRITION • Reduced or inadequate nutritional intake due to inadequate food intake, poor digestion, assimilation, co-morbidity. Can be contributed to or compounded by economic, social, skill or knowledge that limits adequate intake. • Measured by the Australian Diagnostic Coding as being : In adults, BMI < 18.5 kg/m² or unintentional loss of weight (5%) with evidence of suboptimal intake resulting in moderate loss of subcutaneous fat and/or moderate muscle wasting. 2. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Characterised by a protein/energy depletion which results from too low an intake of food nutrients relative to an individual’s requirements to maintain • Metabolic rate • Cognition • Weight 1 • Requires a multi faceted assessment including pathological, physical and historical to determine the individual’s risk and state of nutrition. • Under-nutrition is the most common form of malnutrition among those of the high risk groups. • under-nutrition is common, prevalence rates in Australian hospitals have ranged from 6-53%. The wide variation is due to different study settings; the time between admission and assessment, and the assessment tool used. 2 (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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 and sub-clinical deficiency diseases. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Deficiency Diseases • Deficiency Disease - a condition resulting from • the lack of one or more essential nutrients in the diet, • metabolic dysfunction, or • impaired digestion or absorption, • excessive excretion or increased biological requirements. 1.24 • A significant risk of under-nutrition is it leads to nutritional deficiency diseases, such as goitre (from an iodine deficiency) or xerophthalmia (eye problems caused by poor vitamin A intakes). (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

HUNGER  the physiological state that results when not enough food is eaten to meet energy needs. If hunger is not relieved, • 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. This occurs in developing countries. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Nutritional Deficiency: Signs and Symptoms • Depends to some extent the nutrient that is deficient eg. Vit C – compromised immune system and connective tissue weakening, compared to B6 and dry scaling skin. • As a general rule changes in the individual’s appearance will change even in a sub-clinical level. • A thorough assessment of all aspects of the client’s health and total lifestyle will give an indication to possible or likely nutritional deficiencies. It is important to recognise the nutrient associated with the system, and symptom you identify as being substandard. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Cont.. • Observation of skin, nails, hair, voice, cognition and emotional state can suggest a deficiency in associated nutrients • Weight, under and over; change in weight – • growth in children • Rapid gain or loss in adults • Food, exercise, lifestyle choices including recreation and hobbies; stress • Health overall and in particular the gut as it is the place of digestion and absorption • Symptoms, presenting concerns, medications & co-morbidity. • Personal and family medical history. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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. • 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) (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

The paper: McMillen I et al. 2008, reinforces the idea that 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) (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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. • 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). (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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. • 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. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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. • 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. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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. • The following slide demonstrates the progression of marsumas. As indicated poverty, misunderstanding, and limited access to appropriate tools increases the risk of severe total malnutrition. • Communities at risk in Australia include refugees, low socioeconomic groups, low literacy skills, low food preparation knowledge and skills. • This can be translated into migrants, poor, early school leavers, and underprivileged, people with limited access to facilities or support services. • Previous generations who have lived with similar circumstances. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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. • A large, protuberant belly is common. Skin conditions (such as dermatitis, changes in pigmentation, thinning of hair, and vitilago) are seen frequently. Shock and coma precede death. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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 Autralia suffer from protein-calorie malnutrition. • 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. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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 • 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) (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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). (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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) and were significantly older (median 71 years vs 63 years, 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) (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

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 (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Consider the overweight/undernourished • With the considerable portion of the population being obese, which suggests an over consumption of Kj, are people at risk of being malnourished or undernourished. • I would say yes. Just because we eat an abundance of food, doesn’t guarantee we eat the correct types of food to provide the micronutrients we need. • Another point to consider is the length of time it may take for subclinical deficiencies to become clinical states. • Poor eating habits over a long period of time, compounded by colds/flues, stress and environmental onslaughts can all deplete the nutrient reserves a person has, and increase the demand for nutrition at any given moment. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Tests to request Laboratory tests may include:For general screening and monitoring: • Lipids • FBC (full blood count) • Electrolytes and liver function tests • Albumin • Total protein • For nutritional status and deficiencies:Prealbumin (is decreased in malnutrition, rises and falls rapidly, and can be used to detect short-term response to treatment) • Iron tests (such as iron, TIBC and ferritin) • Vitamin and minerals B12 and folate, vitamin D, vitamin K, calcium, and magnesium) (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Cont... • Non-laboratory testsImaging and radiographic scans may be ordered to help evaluate the health of internal organs and the normal growth and development of muscles and bones. These tests may include: • X-rays • CT (computed tomography) • MRI scan (magnetic resonance imaging) Labtestsonline.org.au Complete a malnutrition screening tool, (see link) or SGA tool. Both of these assess the severity of symptoms and risk associated for the individual. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Treatment • Care needs to be taken when increasing nutrition after an extremely low intake, or a state of nutrient depletion. • It is possible to cause refeeding syndrome where the body is unable to cope with the influx of food. • If pathology indicates low to moderate malnutrition via clinically low nutrients and albumin, then a general increase in food can occur. In the initial phase, a supplemental feed may be of use to provide in a predigested state. Generally, community nutritionist may not be involved in this stage unless they are not under medical supervision. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Cont. • 1stly, after a complete and thorough assessment as to where the person is in relation to health, pathology, level of undernutrition, cause of undernutrition, medication co-morbidity and education, decision of treatment needs to be made. • Complete the planning stage of SOAP, • Calculations for current and then expected total Kj and protein needs. • Estimate the amount of food the person may be able to tolerate. • Slowly increase the quantity of food till the body is able to tolerate the estimated total Kj, and protein requirements • For general undernutrition, with functional GI but with some undernutrition symptoms, a slow to moderate change in food choices is suitable. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

Cont.. • Possibly a multivitamin, or liquid supplement to help. • Sustagen, simple proteins such as eggs, lean meat with possibly digestive enzymes can be helpful . • Casseroles, stews or soups that include protein of some kind, vegetables and prebiotics and low in chemicals and Na can be useful. • Provides easy to digest proteins, fibre, minerals, and water. Low chemical load can help reduce the risk of the immune system being irritated. • ‘Healthy’, but low nutritional status based on subclinical symptoms and presentation • Multivitamin, mineral supplement; target clinically low nutrients • Rearrange eating plan to provide nutrient dense eating plan • Avoid nutrient poor food and fluid choices. • Discuss lifestyle choices. (C) 2011. Written by Leah Marmulla for use by Academy of Complementary Health. Use without written permission prohibited.

MALNUTRITION

MALNUTRITION

Presentation Transcript

Malnutrition

MALNUTRITION

Malnutrition

Malnutrition

Malnutrition

Malnutrition

Malnutrition

Malnutrition

Malnutrition

Malnutrition

Malnutrition

MALNUTRITION

Malnutrition

Malnutrition

Malnutrition

Malnutrition

MALNUTRITION

Malnutrition

Malnutrition

Malnutrition

Malnutrition

Malnutrition