HSERV 544 - Nutrition in Children1 Nutrition in Children Jonathan Gorstein Clinical Associate...
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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
HSERV 544 - Nutrition in Children 2
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
HSERV 544 - Nutrition in Children 3
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
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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
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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
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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
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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
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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
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Infection-Malnutrition Synergism
Weight lossGrowth faltering
Immunity lowered
Appetite lossNutrient loss
MalabsorptionAltered Metabolism
Inadequate dietary intake
Disease IncidenceSeverityDuration
HSERV 544 - Nutrition in Children 10
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
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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
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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
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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
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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)
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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
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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
HSERV 544 - Nutrition in Children 17
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
Source: UNICEF (2002)
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90% or more
50% to 89%
Less than 50%
No recent data
Levels of Iodized Salt Coverage
Source: UNICEF (2002)
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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
Source: UNICEF (2004)
HSERV 544 - Nutrition in Children 20
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
Source: UNICEF (2002)
HSERV 544 - Nutrition in Children 21
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
HSERV 544 - Nutrition in Children 22
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
HSERV 544 - Nutrition in Children 23
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
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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
Source: UNICEF (2000)
1 Percent of children aged 6-59 months who received at least one vitamin A supplement within the last six months
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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
Source: UNICEF (2000)
HSERV 544 - Nutrition in Children 26
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
HSERV 544 - Nutrition in Children 27
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)
HSERV 544 - Nutrition in Children 28
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
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Interventions to Control Anaemia
• Depends on etiology– For iron deficiency: supplementation and
fortification– For parasitic disease control: appropriate
measures for prevention and presumptive treatment
HSERV 544 - Nutrition in Children 30
Thank you