Nutrition and the Physiology of Malnutrition

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Nutrition and the Physiology of Malnutrition

• Lia Fernald, Ph.D., M.B.A.
• Human Biology Lecture
• May 14, 2002

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Male, 17, Oakland, weekly diet
Mon Tues Wed Sat
Sausage, egg cheese burrito (McD) Nothing Frosted Flakes Hot link with mustard, ketchup, Coke
Personal size pepperoni pizza Double cheese burger, fries, Coke (BK) Pepperoni pizza (PH) and french fries Nations cheeseburger, large fries, Coke
Burrito from vending machine, Lays Banana nut muffin and carton of milk 2 ham cheese sandwiches and can of soda 2 hot dogs, blueberry muffin
Spaghetti, fried chicken, fruit punch Small round pizza Baked pork chops, mac cheese, Pepsi Fries, BBQ bacon cheese burger (McD)
B
L
S
D
3,045 (38)
2,400 (41)
2,739 (33)
3,163 (36)
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Overweight 9th graders in the Bay Area

• Overweight defined as more than 25 body fat
  for boys and more than 32 for girls. Less than
  1 of students are out of shape because they are
  too thin.

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Todays Class

• Overview of Nutritional Requirements
• Definition of Malnutrition
• Causes and correlates of Malnutrition
• Measurement and Types of Malnutrition
• Severe Malnutrition
• Mild/Moderate Malnutrition (Underweight and
  Stunting)
• Specific Nutritional Deficiencies (Iodine and
  Iron)

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Nutritional requirements
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Macro v. micro nutrients

• Macro-nutrients
• Protein (amino acids)
• Energy (carbohydrates)
• Fat (fatty acids)
• Micro-nutrients
• Water soluble vitamins (assist in energy-release
  of carbohydrates and red blood cell formation)
• Fat soluble vitamins (development metabolism)
• Minerals

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Macro-nutrients

• Energy
• Necessary for all bodily function
• Protein
• Necessary for structural development (muscle and
  bone)
• Fat
• Necessary for cell membrane and skin cell
  development

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Dietary Reference Intakes
Macronutrient F (19-30 y.o.) M (19-30 y.o.)
Energy (Kcal) Protein (g) 1940 2200 36 46 2550 2900 44 60
Fat 15 33 15 33
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Water soluble vitamins

• Thiamin B
• nervous system function, enzymatic energy release
  of carbohydrates (beef, pork, liver, legumes,
  breads)
• Riboflavin B2
• Participants in enzymatic energy release of
  carbs, fat protein (milk, dairy, dark green
  vegetables, yogurt)
• Niacin
• Participates in enzymatic energy release of
  energy nutrients (beef, pork, liver, breads,
  nuts)
• Folate
• Red blood cell formation, new cell division (veg,
  seeds)
• Vitamin B12 (Cobalamin)
• Red blood cell formation, nervous system
  maintainance (animal prod)
• Pantothenic Acid
• Biotin (Vitamin H, CoEnzyme R)
• Vitamin B6 (Pyridoxine)
• Vitamin C

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Fat soluble vitamins

• Vitamin A
• Essential to vision, fetal development, immune
  response
• Found in dairy products, fish liver oils as
  B-carotene found in many plants (e.g. carrots,
  mango)
• Vitamin D
• Bone formation, calcium metabolism and absorption
• Found in sunlight, egg yolk, dairy products and
  fish liver oil
• Vitamin E
• Cell membrane construction and maintenance
• In fats and oils, green leafy vegetables,
  poultry, fish
• Vitamin K
• Blood clotting, protein synthesis
• In green leafy vegetables, liver, cabbage

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Minerals

• Major Bone Minerals Trace Minerals
• Calcium (bones) Iodine (thyroid function)
• Phosphorus (DNA) Iron (hemoglobin)
• Magnesium (bones) Zinc (enzyme, hormone)
• Sodium (nerve impulse) Copper (abs. of iron)
• Chloride (fluid balance) Flouride (bone teeth)
• Potassium (prot. syn) Chromium (energy rel.)
• Sulfur (some a.a.s) Molybdenum (enzymes)
• Manganese (enzymes)
• Selenium (antioxidant)
• Cobalt (part of B12)

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Summary Nutritional requirements

• In order to live and function, humans need macro-
  and micro- nutrients
• Macro-nutrients are fat, protein and
  carbohydrates
• Micro-nutrients are water-soluble vitamins,
  fat-soluble vitamins, and minerals (bone and
  trace) the most critical micro-nutrients are
  iron, iodine, zinc, vitamin A and vitamin D.

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Todays Class

• Overview of Nutritional Requirements
• Definition of Malnutrition
• Causes and correlates of Malnutrition
• Measurement and Types of Malnutrition
• Severe Malnutrition
• Mild/Moderate Malnutrition (Underweight and
  Stunting)
• Specific Nutritional Deficiencies (Iodine and
  Iron)

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What is malnutrition?

• World Health Organization definition
• The term is used to refer to a number of
  diseases, each with a specific cause related to
  one or more nutrients (for example, protein,
  iodine or iron) and each characterized by
  cellular imbalance between the supply of
  nutrients and energy on the one hand, and the
  body's demand for them to ensure growth,
  maintenance, and specific functions, on the
  other.

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Countries at risk of malnutrition
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Geneva Declaration

• 1924 Declaration of the Rights of the Child
  (also known as the Declaration of Geneva).
• Adopted after World War I by the League of
  Nations through the efforts of British child
  rights pioneer
• Marks the beginning of the international child
  rights movement and is also the first
  international affirmation of the right to
  nutrition.
• Affirms that "the child must be given the means
  needed for its normal development, both
  materially and spiritually" and states that "the
  hungry child should be fed."

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Death from malnutrition



At least 70 of childhood diseases are related
with one of these conditions



Source WHO, based on C.J.L. Murray and A.D.
Lopez, The Global Burden of Disease, Harvard
University Press, Cambridge (USA) 1996 and
American Journal of Public Health 1993-83.
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Summary Definition of malnutrition

• Malnutrition is having the inappropriate level of
  a micro- or macro- nutrient
• In some cases (i.e. the US), malnutrition can be
  associated with being grossly overweight
• In most of the world, malnutrition is defined as
  a LACK of nutrients
• Malnutrition contributes to over 50 of deaths in
  children in the world.

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Todays Class

• Overview of Nutritional Requirements
• Definition of Malnutrition
• Causes and correlates of Malnutrition
• Measurement and Types of Malnutrition
• Severe Malnutrition
• Mild/Moderate Malnutrition (Underweight and
  Stunting)
• Specific Nutritional Deficiencies (Iodine and
  Iron)

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Causes of malnutrition
Child malnutrition death and disability
Inadequate Disease Diet
Inadequate maternal and child care
Poor water/ sanitation inadequate health services
Insufficient access to food
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Impaired mental development
Higher mortality rate
Increased risk of adult chronic disease
Reduced capacity to care for baby
Baby Low Birth Weight
Elderly Malnourished
Untimely/inadequate weaning
Frequent Infections
Inadequate catch up growth
Inadequate food, health care
Inadequate fetal nutrition
Inadequate food, health care
Child Stunted
Reduced mental capacity
Start here
Woman Malnourished Pregnancy
Low Weight Gain
Adolescent Stunted
Inadequate food, health care
Reduced mental capacity
Inadequate food, health care
Higher maternal mortality
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Correlate Unsafe Water
11 urban and 38 rural households do not have
access to safe water
Source for photos Overseas Aid
www.nat.uca.org.au, Statistics, UNICEF State of
the Worlds Children 2000
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Correlate Inadequate Sanitation
21 urban and 75 rural households do not have
access to adequate sanitation
Source for photos Overseas Aid
www.nat.uca.org.au, Statistics, UNICEF State of
the Worlds Children 2000
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Correlate Poor Education
25 of girls and 19 of boys do not enter primary
school 54 of girls and 45 of boys do not
enter secondary school
Source for photos Overseas Aid
www.nat.uca.org.au, Statistics, UNICEF State of
the Worlds Children 2000
25
Correlate Poverty
28 of the population lives at below 1 per
day Average GNP per capita is 1299 (compared
with 29,080 in USA)
Source for photos Overseas Aid
www.nat.uca.org.au, Statistics, UNICEF State of
the Worlds Children 2000
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Correlate Poor Stimulation
39 of females and 21 of males over the age of
15 cannot read or write
199 radios per 1000 population 154 TVs per 1000
population
Source for photos Overseas Aid
www.nat.uca.org.au, Statistics, UNICEF State of
the Worlds Children 2000
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Correlate Poor Public Health
About 30 of 1-year olds are not fully immunized
for TB, DPT (Diptheria, Pertussis, and Tetanus),
polio and measles
Source for photos Overseas Aid
www.nat.uca.org.au, Statistics, UNICEF State of
the Worlds Children 2000
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Correlate No Breastfeeding
Babies are twins (boy and girl) Mother was told
that she wouldnt have enough breast milk for
both, so should bottle feed girl . . . girl
died the day after this photo was taken 56
babies in developing countries are not breastfed
from 0-3 months
Source Childrens Hospital Islamabad
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Summary Causes/correlates

• Malnutrition rarely exists in isolation, and many
  other factors contribute to its detrimental
  impact
• Poor physical resources, and overcrowded homes
• Poor sanitation and water supply
• Low income
• Parents with little education
• Minimal interaction/stimulation in the home
• Malnutrition has repercussions throughout the
  life cycle and is thus multi-generational
  (diagram with lots of arrows)

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Todays Class

• Overview of Nutritional Requirements
• Definition of Malnutrition
• Correlates of Malnutrition
• Measurement and Types of Malnutrition
• Severe Malnutrition
• Mild/Moderate Malnutrition (Underweight and
  Stunting)
• Specific Nutritional Deficiencies (Iodine and
  Iron)

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Types of malnutrition

• Severe Protein-Energy Malnutrition (gt3 S.D.)
• Kwashiorkor (low protein)
• Marasmus (low calories)
• Mild/moderate undernutrition (gt2 S.D.)
• Stunting
• Underweight
• Wasting
• Micro-nutrient deficiency
• Iodine
• Iron
• Vitamin A
• Vitamin D

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Measurement of Malnutrition

• STUNTING Height for age height compared to a
  reference population of the same age.
• represents long term growth retardation
• UNDERWEIGHT Weight for age weight compared to
  age in a reference population
• WASTING Weight for height weight compared to a
  reference population of the same height.

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Growth Curves (0-3 years)
Length/ Height
Weight
Age
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Summary Measurement

• There are several types of malnutrition, micro-
  and macro-malnutrition
• Measurement of severe malnutrition (gt3 S.D.) and
  micro-nutrient deficiency usually occurs due to
  presence of critical signs (to be discussed)
• Measurement of mild/moderate malnutrition (gt2
  S.D.) occurs with growth charts.

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Todays Class

• Overview of Nutritional Requirements
• Definition of Malnutrition
• Correlates of Malnutrition
• Measurement and Types of Malnutrition
• Severe Malnutrition
• Mild/Moderate Malnutrition (Underweight and
  Stunting)
• Specific Nutritional Deficiencies (Iodine and
  Iron)

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Severe malnutrition lt5 y.o.

• Developing Countries 12
• Least Developed Countries 13
• (India 21, Bangladesh 21, Cambodia 18)

Data for 1992-98, UNICEF State of the Worlds
Children 2000
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Severe PEM Real Numbers

• Example India
• 21 of all children under 5
• children under 5 is 115,615,000
• 24M children severely malnourished (Bigger than
  population of Texas 20M)
• Example All developing countries
• Total lt5 in developing countries 536,105,000
  and 12 of that is
• 64M children under 5y.o. severely malnourished
  (California New York Florida)
• Example World (total number is 603,449,000)
• 11 66M (France or England)

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Kwashiorkor
Infection
Sparse hair
Swollen belly
Decreased muscle mass
Pellagra
Apathy
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Kwashiorkor (low protein)

• Decreased muscle mass (failure to gain weight and
  of linear growth)
• Swollen belly (edema and lipid build-up around
  the liver)
• Changes in skin pigment (pellagra) may lose
  pigment where the skin has peeled away
  (desquamated) and the skin may darken where it
  has been irritated or traumatized
• Hair lightens and thins, or becomes reddish and
  brittle.
• Increased infections and increased severity of
  normally mild infection, diarrhea
• Apathy, lethargy, irritability
• ? Death does not occur from actual starvation but
  from secondary infection

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Kwashiorkor mechanisms

• Occurs in reaction to emergency situations
  (famine)
• Kwashiorkor more likely in areas where cassava,
  yam, plantain, rice and maize are staples, not
  wheat
• Increased carbohydrate intake with decreased
  protein intake eventually leads to edema (water)
  and fatty liver

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Marasmus (low calories)
Ravenously hungry
Gross weight loss no fat
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Marasmus

• Deficit in calories marasmus comes from Greek
  origin of word to waste
• Gross weight loss
• Hyper-alert and ravenously hungry
• Children have no subcutaneous fat or muscle
• ? eventually starve to death (immediate cause
  often is pneumonia)

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Marasmus mechanism

• Energy intake is insufficient for bodys
  requirements body must draw on own stores
• Liver glycogen exhausted in a few hours
  skeletal muscle protein used via gluconeogenesis
  to maintain adequate plasma glucose
• When near starvation is prolonged, fatty acids
  are incompletely oxidized to ketone bodies, which
  can be used by brain and other organs for energy
• High cortisol and growth hormone levels
• ? Mechanism is same as anorexia

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Severe Malnutrition Consequences

• Mental development
• Lower IQ levels
• Poorer school performance
• Behaviors of recovered severely malnourished
  children
• shy, isolated, withdrawn
• decreased attention span
• immature, emotionally unstable
• fewer peer relationships/reduced social skills
• played less/stayed nearer to mothers

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Summary Severe malnutrition

• Severe malnutrition is defined as gt 3 s.d. away
  from median reference standards
• 66M children under the age of 5 are severely
  malnourished (64M of these in developing
  countries)
• Key types of severe malnutrition are kwashiorkor
  (low protein) and marasmus (low calories)
• Severe malnutrition results in severe deficits
  for children

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Todays Class

• Overview of Nutritional Requirements
• Definition of Malnutrition
• Correlates of Malnutrition
• Measurement and Types of Malnutrition
• Severe Malnutrition
• Mild/Moderate Malnutrition (Underweight and
  Stunting)
• Specific Nutritional Deficiencies (Iodine and
  Iron)

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Stunting Height for Age

• Height for age reflects pre- and post- natal
  linear growth
• Stunting refers to shortness that is not
  genetic, but due to poor health or nutrition
• Most standard definition lt 2 S.D.
• Stunting is good cumulative measure of
  well-being for populations of children (because
  not affected by weight recovery)

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Stunting
These girls are From same school and the same
neighborhood Both have the same birthday
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Stunting lt5 y.o.

• Developing Countries 39
• Least Developed Countries 47

(India 52, Bangladesh 55, Cambodia 56)
Data for 1992-98, UNICEF State of the Worlds
Children 2000
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Stunting Real Numbers

• India where 52 of all children under 5 (total lt5
  is 115,615,000) are stunted
• 60M children in India are stunted (as many
  people live in the MidWest)
• Example all developing countries, where 39 of
  all children under 5 (536,105,000)
• 209M children in dev world
• In world, the total of children lt5 is
  603,449,000 and 37 of that is
• 223M children in world (US popn 272M US minus
  California and Texas)

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Stunting Causes

• Poor nutrition plays major role
• Role of environment improvements in average
  height shown by populations over last century
  (impact of genetic influence subsumed by level of
  socio-economic development)
• In 1833, British children were as tall as
  children today from India and Guatemala
• All immigrant populations have same height after
  3 generations in US

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Stunting Timing

• Age of onset varies, but usually in first 2-3
  years of life
• First few months, infants in developing countries
  grow just as quickly as children in reference
  populations
• Growth retardation starts from 2-6 month of life
  (often associated with weaning)
• Infants at risk during this time because of high
  nutritional requirements and high rates of
  infections (breast fed infants often protected)

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Stunting Consequences

• Cross-sectional associations Low height for age
  associated with
• Reduced cognitive development
• Poor motor skills
• Poor neuro-sensory integration
• Quiet, reserved, withdrawn, timid, passive
• Difficulty making decisions
• Decreased involvement with environment, toys,
  tasks
• Less able to deal with stressor such as hunger or
  parasites

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Hypothesized Mechanisms
alterations in development of CNS
poor mental development behavior
poor nutrition
emotional reactivity, impaired stress response
functional isolation
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Summary Mild/moderate maln.

• Stunting refers to growth retardation (gt2 S.D.)
  secondary to malnutrition
• Almost 40 (223M) of children lt5 in the
  developing world are stunted
• Children are most at risk for stunting in the
  first 2-3 years of life
• Stunting is associated with poor mental
  development and altered behavior.

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Todays Class

• Overview of Nutritional Requirements
• Definition of Malnutrition
• Correlates of Malnutrition
• Measurement and Types of Malnutrition
• Severe Malnutrition
• Mild/Moderate Malnutrition (Underweight and
  Stunting)
• Specific Nutritional Deficiencies (Iodine, Iron,
  Vitamin A, Vitamin D)

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Specific Nutritional Deficiencies

• Iodine Deficiency
• Iron Deficiency
• Vitamin A
• Vitamin D

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Iodine deficiency - thyroid
Simple goiter is the easiest of all known
diseases to prevent . . . It may be excluded
from the list of human diseases as soon
as society determines to make the effort David
Marine 1923
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Iodine Deficiency Disorders
Source State of the Worlds Children, 1998
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Causes of Iodine Deficiency

• Mountainous areas at risk (soils leached by high
  rainfall, melting snow, flooding)
• Culturally induced behavioral change
• Tasmanian Aboriginals migrated every season until
  European invasion, became sedentary and had
  incidence of thyroid problems

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Iodine Deficiency Severe

• Goiter most commonly recognized consequence
  (enlarged thyroid)
• Occurs when thyroid gland is unable to meet the
  metabolic demands of the body through sufficient
  hormone production thyroid compensates by
  enlarging (works in short term)
• Cretenism proximal pyramidal signs, intellectual
  impairment, primitive reflexes
• Only occurs with severe fetal iodine deficiency

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Iodine Deficiency Moderate

• Studies comparing 2 Villages
• Consistent results meta-analysis showed 13.5 IQ
  point difference between groups
• Intervention Studies
• Prenatal supplementation (esp. 1st trimester)
  clear impact prevents cretenism, and affects
  mental development in children
• Childhood supplementation many mediocre studies,
  but positive impact

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Iron deficiency - anemia

Source UN-ACC-SCN-IFPRI-4 Report on World
Nutrition Situation
64
Iron Deficiency

• Iron is critical for body
• Carries oxygen to tissues from lungs
• Transports electrons within cells
• Integral part of important enzyme reactions
• Anemia is caused most commonly by iron deficiency
  (anemia is found in 40-60 of women and children
  in developing countries)

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Iron Deficiency Consequences

• Iron deficiency results in
• Decreased work capacity and work productivity
• Permanently impaired development
• Psychomotor development of anemic children will
  be reduced by 5-10 IQ points
• Increased morbidity and mortality from infections
• Decreased growth

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Vitamin A Deficiency

• Vitamin A is important because it is essential to
  vision, fetal development, immune response
• 250 million children of pre-school age lack
  sufficient Vitamin A in their diet.
• 350,000 become blind each year, and half of them
  die within a year of becoming blind.

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Vitamin A Deficiency

• Associated with blindness and increased severity
  of infections such as measles and diarrhoeal
  disease
• WHO estimates that 2.8 million children under 5
  years old have signs of clinical xerophthalmia
  (childhood blindness)
• WHO estimates that 14 million pre-school
  children already have some eye damage from
  Vitamin A deficiency

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Vitamin D Deficiency Rickets
http//www.spoilheap.co.uk/rickets.htm
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Summary Micronutrient deficiency

• Iodine is critical for thyroid function
  deficiency results in cretinism goiter
• Iron is critical for blood and muscles
  deficiency results in anemia
• Vitamin A is critical for visual development
  deficiency results in blindness
• Vitamin D is critical for bone development
  deficiency results in rickets

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Where do we go from here?
Poverty reduction
Economic growth
Increased productivity
Improved child nutrition
Social sector investments
Enhanced human capital
From UNICEF, State of the Worlds Children
Adapted from Stuart Gillespie, John Mason and
Reynaldo Martorell, How nutrition improves,
ACC/SCN, Geneva 1996.