Protein Energy Malnutri�on:

Systemic approach towards supplementa�on with adequate nutri�on.

Vol. 72, No. 1 January - March 2021

Protein Energy Malnutri�on:

Systemic approach towards supplementa�on with adequate nutri�on.

Index:

1. Introduc�on

2. Epidemiology

3. Pathophysiology & Clinical features

4. Causes of malnutri�on

5. Nutri�onal approach

6. Preven�on and control

7. Summary

8. References

Page No.

- 1 -

- 2 -

- 6 -

- 12 -

- 14 -

- 19 -

- 20 -

- 20 -

Dr. Jaydeb Ray HOD (Pediatric Medicine)

MBBS (Hon), DCH (CU), MD (Paed), DNB (Paed), MD (Com Med), FIAMS, FNNF, FIAPPaediatrician & Neonatologist, Ins�tute of Child Health, Kolkata

The World Health Organiza�on (WHO) defines malnutri�on as ‘‘the cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific func�ons”. Malnutri�on is considered to be one of the major public health problem in the developing

1,2countries, including India. Diets in these countries are deficient in macronutrients (protein, carbohydrates and fat, leading to protein–energy malnutri�on), micronutrients (electrolytes, minerals and vitamins, leading to

3,4specific micronutrient deficiencies) or both.

Increasing prevalence of bacterial and parasi�c diseases in developing countries also contributes to malnutri�on.5,6 Malnutri�on increases one's suscep�bility to and severity of infec�ons, and is thus a major component of illness and death from disease.7,8

Malnutri�on is an important risk factor for the burden of disease in developing countries. It directly results into 300 000 deaths per year and is indirectly responsible for about half of all

9,10deaths in young children. The incidence of death is directly propor�onal with the degree

11 ,1 2of malnutri�on.

In developing countries, there is inadequate food supply caused by socioeconomic, poli�cal, and occasionally environmental factors such as natural disasters, therefore the children with primary PEM are found in such countries. There are four principal causes of mortality in young children worldwide, undernutri�on has been ascribed to be the cause of death in 60.7% of children with diarrheal diseases, 52.3% of those with pneumonia, 44.8% of measles

13cases, and 57.3% of children with malaria.

More than 50% of all the childhood deaths are a�ributable to undernutri�on, with rela�ve risks of mortality being 8.4 for severe malnutri�on, 4.6 for moderate malnutri�on, and 2.5 for mild malnutri�on as es�mated by analyses of 28 epidemiologic studies done across 53 countries.

Most of the deaths (> 80%) occur among those with mild or moderate malnutri�on (weight for age 60% to 80%). This is explained by the fact that although the risk of death is greatest for those with severe malnutri�on, these extreme cases only make up a small frac�on of total

14,15number of children with malnutri�on.

1. Introduc�on

There are many factors which are responsible for degree and distribu�on of protein–energy

malnutri�on and micronutrient deficiencies: the poli�cal and economic situa�on, the level of educa�on and sanita�on, the season and climate condi�ons, food produc�on, cultural and religious food customs, breast-feeding habits, prevalence of infec�ous diseases, the existence and effec�veness of nutri�on programs and the availability and quality of

16,17health services.

Adequate Nutri�on is essen�al for human development. Benefits of good health are perceived not only at the individual level but also at the level of society and country level as well.

Founda�on of an individual’s health is laid in early phase of life. It is a well-known fact that in some developing na�ons, India being one of them, nearly half of children under 5 years of age succumb to death every year due to poor nutri�on. The irony is, India being the world’s second largest food producer and yet is also home to the large number of undernourished children in the world.

2. Epidemiology

In India there are around 4.66 crore stunted children, a third of world’s total as per Global Nutri�on Report 2018. Nearly half of all under-5 child mortality in India is a�ributable to undernutri�on. Children of today are ci�zens of tomorrow, and hence improving nutri�onal status of children becomes extremely important. Early childhood cons�tutes the most crucial period of l i fe, when the founda�ons are laid for cogni�ve, social and emo�onal , language, phys ica l/motor development and cumula�ve lifelong learning.

Malnutri�on is a common problem affec�ng everyone whether its rich, poor, from any age group. Malnutri�on in various forms is associated with various forms of ill health and higher levels of mortality. Undernutri�on explains around 45% of deaths among children under-5, mainly in low and middle-income countries.

3

Growth failure and infec�ons are quite important adverse effects of child malnutri�on. Malnourished children do not a�ain their op�mum poten�al in terms of growth and development, physical capacity to work and economic produc�vity in later phase of life. It is

commonly observed that school absenteeism is much higher in such child that leads to poor performance in the class.

C o g n i � ve i m p a i r m e nt re s u l � n g f ro m

malnutri�on may result in diminished produc�vity. Apart from these, Under-nutri�on increases the risk of infec�ous diseases like diarrhoea, measles, malaria and pneumonia and chronic malnutri�on can impair a young child’s physical and mental development. As per es�mates of World Bank, childhood stun�ng may result in a loss of height among adults by 1%, which may further lead to a re d u c � o n i n i n d i v i d u a l s e co n o m i c produc�vity by 1.4%.

Micronutrient deficiencies are responsible for poor health and development in children. Overweight and obesity can lead to diet-related

noncommunicable diseases such as heart disease, high blood pressure (hypertension), stroke, diabetes and cancer.

Along with a social issue, malnutri�on is an economic problem also which holds back d e ve l o p m e n t a c ro s s t h e w o r l d w i t h unacceptable human consequences.

Malnutri�on costs billions of dollars a year and imposes high human capital costs-direct and indirect-on individuals, families and na�ons. The consequences of malnutri�on are increases in childhood death and future adult disabi l i ty, including diet-related non-communicable diseases (NCDs),n as well as

enormous economic and human capital costs.18 According to UNICEF, one in three malnourished children in the world is Indian. It is es�mated that reducing malnutri�on could add some 3% to India’s GDP.

India is one among the many countries where child under-nutri�on is severe and also under-nutri�on is a major underlying cause of child mortality in India. Pa�ern of stun�ng prevalence among Indian districts is shown in Figure below.

3. Pathophysiology and clinical features

The second most common cause of protein-energy malnutri�on a�er insufficient supply of protein, carbohydrates and fat is severe and chronic infec�ons - par�cularly those producing diarrhea, but also other diseases such as helminthic infec�ons. The underlying mechanisms include decreased food intake because of anorexia, decreased nutrient absorp�on, increased metabolic requirements

19and direct nutrient losses.

The term protein-energy malnutri�on

describes the most important cause that is imbalance between nutrient supplies and requirements which is more than the

20pathogenesis of starva�on. The pathologic changes include immunologic deficiency in the humoral and cellular subsystem from protein deficiency and lack of immune mediators (e.g., t u m o u r n e c r o s i s fa c t o r ) . M e t a b o l i c disturbances also play a role in impaired intercellular degrada�on of fa�y acids because of carbohydrate deficiency. Synthesis of pigments in the hair and skin fails (e.g., hair co lour may change and sk in become hyperpigmented) because of a lack of substrate

21(e.g., tyrosin) and coenzymes.

Marasmus results from both energy and protein deficiency and is characterized by was�ng, fa�gue, and apathy. Kwashiorkor is caused by acute or chronic protein deficiency and chronic energy deficit and is characterized by edema, was�ng, stun�ng, and mild hepatomegaly.

Marasmus is diagnosed when subcutaneous fat and muscle are lost because of endogenous mobiliza�on of all available energy and nutrients. Clinical aspects typically include a tr iangular face, primary or secondary amenorrhea, extended abdomen (from muscular hypotonia) and anal or rectal

22prolapse (from loss of perianal fat).

Kwashiorkor usually manifests with edema, changes to hair and skin colour, anaemia, hepatomegaly, lethargy, severe immune deficiency and early death. The role of aflatoxins and insufficient protein intake has been stressed because the presence of edema and ascites seems related to reduced osmolarity in the blood, which is thought to be

23caused mostly by severe anaemia. It is puzzling that total protein concentra�ons in the plasma do not differ between children with

24marasmus and those with kwashiorkor. More recently, a role for free radicals in the e�ology of kwashiorkor has been considered. 25,26,27,28,29,30,31,32,33,34

One essen�al aspect of severe protein–energy malnutri�on is the fa�y degenera�on of such diverse organs as the liver and heart. This degenera�on is not just a sign of severe malnutri�on; it causes subclinical or overt cardiac insufficiency, especial ly when

35malnutri�on is accompanied by edema. If the myocardial insufficiency is not corrected, iatrogenic fluid and sodium overload quickly escalate it into cardiac failure. A second injurious aspect is the loss of subcutaneous fat, which markedly reduces the body's capacity for

36,37,38temperature regula�on and water storage.

As a consequence, malnourished children become dehydrated, hypothermic and hypoglycemic more quickly and severely than others. Finally, severe protein- energy malnutri�on is associated with atrophy of the mucosa of the small bowel, leading to a loss of absorp�on as well as of diges�on capacity.

Severe malnutri�on affect many aspects of macronutrient metabolism and endocrine func�on. In contrast to severe was�ng, which is associated with a starva�on- induced response of subcutaneous fat loss and muscle was�ng,

kwashiorkor has been speculated to be associated with a maladap�ve metabolic response; a high-carbohydrate, low-protein diet is thought to lead to a con�nuous glycoly�c response and protein catabolism that is i n a d e q u ate to m e e t t h e a m i n o a c i d requirements necessary to maintain essen�al protein synthesis pathways. Indeed, protein

breakdown has been shown to be lower in children with kwashiorkor than in children with severe was�ng and in those in a recovered state. In addi�on, reduced concentra�ons of essen�al and some nonessen�al amino acids have been reported, and these deficits were even more pronounced in children with kwashiorkor.

Reduced secre�on of insulin contributes to a catabolic state in both kwashiorkor (part a) and severe was�ng (part b). In severe was�ng, the reduced secre�on of insulin leads to a lipoly�c and proteoly�c response and the release of free fa�y acids (FFAs) and amino acids into the bloodstream. FFAs are taken up by muscle �ssue for oxida�on. Both FFAs and amino acids are also par�ally taken up by the liver and are used for ATP produc�on and the synthesis of essen�al proteins and glucose. In kwashiorkor, this adap�ve response is disturbed, which causes a reduced release of FFAs from adipose �ssue and amino acids from muscle �ssue.

Mitochondrial damage in the liver is associated with increased reac�ve oxygen species (ROS) produc�on and reduced glutathione. Arrow thickness represents the amount of metabolites in that pathway. TGs, triglycerides.

Metabolic changes in severe malnutri�on.

Metabolism of lipid is also differen�ally affected in kwashiorkor and severe was�ng. Adipocyte lipolysis is a �ghtly regulated process, with a central role for insulin in inhibi�ng hormone-sensi�ve lipase. Lipolysis is s�mulated during starva�on (that is, when insulin levels are low) and lipolysis has been shown to be increased in a small cohort of children with severe malnutri�on compared with a control cohort.

However, another study did not show elevated lipolysis in children with severe malnutri�on at hospital admission compared with those in a state of nutri�onal recovery, although reduced FFA (palmitate) flux and oxida�on were noted in children with kwashiorkor compared with children with severe was�ng. One caveat of this study is that lipolysis was assessed when children were in the semifasted state, when insulin levels were likely low and lipolysis was

s�mulated. Thus, how lipolysis is altered in the postprandial state is unknown. A recent study iden�fied high acylcarni�ne levels in the early period of hospital admission for severe malnutri�on regardless of the presence of oedema, sugges�ng preferen�al fa�y acid oxida�on.

In children with severe malnutri�on glucose homeostasis is also disrupted; hypoglycaemia is common, although frequent or con�nuous glucose measurement studies have not yet been

Metabolic changes in severe malnutri�on.

Reduced secre�on of insulin contributes to a catabolic state in both kwashiorkor (part a) and severe was�ng (part b). In severe was�ng, the reduced secre�on of insulin leads to a lipoly�c and proteoly�c response and the release of free fa�y acids (FFAs) and amino acids into the bloodstream. FFAs are taken up by muscle �ssue for oxida�on. Both FFAs and amino acids are also par�ally taken up by the liver and are used for ATP produc�on and the synthesis of essen�al proteins and glucose. In kwashiorkor, this adap�ve response is disturbed, which causes a reduced release of FFAs from adipose �ssue and amino acids from muscle �ssue.

Mitochondrial damage in the liver is associated with increased reac�ve oxygen species (ROS) produc�on and reduced glutathione. Arrow t h i c k n e s s re p re s e nt s t h e a m o u nt o f metabolites in that pathway. TGs, triglycerides. carried out to characterize this ful ly. Kwashiorkor is associated with reduced endogenous glucose produc�on compared with produc�on in children with severe was�ng or in healthy children, likely contribu�ng to the development of hypoglycaemia. This finding is co n s i s te nt w i t h t h e hy p o t h e s i s t h at kwashiorkor is associated with a maladap�ve metabolic response.

In addi�on, glucose clearance from the blood and uptake by �ssues, which is regulated by insulin, are affected; several studies have reported impaired glucose clearance in both

kwashiorkor and severe was�ng. A striking feature that seems to contribute to impaired glucose clearance is the blunted pancrea�c endocrine response, with insulin sensi�vity likely unaffected.

However, despite the reports of impaired glucose clearance in metabolic studies, hyperglycaemia has not been specifically reported in children with severe malnutri�on (likely due to glucose levels usually being checked only when pa�ents are symptoma�c for hypoglycaemia), and its prevalence is unknown.

The mechanisms of impaired pancrea�c func�on in children with severe malnutri�on are poorly understood, but studies in preclinical models have implicated a more-polarized membrane poten�al, changes in cAMP-dependent protein kinase cataly�c subunit-α protein levels and a reduced ability to increase intracellular Ca2+ levels in response to glucose. In addi�on, no clear data are available regarding the pancrea�c glucagon response (which is responsible for s�mula�ng glucose produc�on) in children with severe malnutri�on.

Glucagon concentra�ons have been reported to be either mildly reduced during the acute phase of malnutri�on compared with levels at recovery or elevated in children with severe was�ng compared with controls , but s�mula�on tests or systema�c glucagon r e s p o n s e m e a s u r e m e n t s d u r i n g hypoglycaemia have not been carried out.

In the 2018 Global Hunger Index, India ranks 103rd out of 119 qualifying countries. With a score of 31.1, India suffers from a level of hunger that is serious. Below figure depicts dimensions and indicators of Hunger index and its rela�onship with child malnutri�on.

Diagramma�c representa�on of child undernutri�on with Hunger Index.

Many studies have shown a reduc�on in thyroid func�on in children with severe malnutrit ion, but the clinical relevance of this r e m a i n s u n c l e a r. I n a d d i � o n , l e p � n concentra�ons are low in children with severe malnutri�on, reflec�ng the extent of adipose �ssue loss. Lep�n has a direct role in immune func�on, metabolism and appe�te regula�on, and its levels are inversely associated with mortality.

Severe malnutri�on is also associated with

chronic hypovolemia, which leads to secondary hyperaldosteronism, and further complicates fluid and electrolyte balance. Because the development of muscular dystrophy mobilizes much of the body's potassium, which is then lost through urinary excre�on, affected

39children do not show signs of hyperkalemia.

Most children with severe protein–energy malnutri�on have asymptoma�c infec�ons because their immune system fails to respond w i t h c h e m o t a x i s , o p s o n i z a � o n a n d

phagocytosis of bacteria, viruses or fungi. So depressed is the system that the body cannot produce even the fever that is typical of inflamma�on.

Malnutri�on is diagnosed by anthropometric measurements and physical examina�on. W h e r e a v a i l a b l e , s o m e l a b o r a t o r y inves�ga�ons are helpful.

Laboratory features of severe malnutri�on

Blood or plasma variables The informa�on derived

Hemoglobin, hematoctrit, erythrocytecount, mean corpuscular volume

Degree of dehydra�on and anaemia; type ofanaemia (iron/folate and vitamin B12 deficiency, hemolysis, malaria)

GlucoseHypoglycemia

Electrolytes and alkalinity Sodium Potassium Chloride, pH, bicarbonate

Hyponatremia, type of dehydra�onHypokalemiaMetabolic alkalosis or acidosis

Total protein, transferrin, (pre-) albumin Degree of protein deficiency

Crea�nine Renal func�on

C-reac�ve protein, lymphocyte count,serology, thick and thin blood films

Presence of bacterial or viral infec�onor malaria

Stool examina�on Presence of parasites

4. Causes of malnutri�on

There are various mul�faceted causes of malnutri�on in India. Malnutri�on in children

occurs as a complex interplay among various factors like socio-demographic, maternal, gender, home environment, dietary prac�ces, hand washing and other hygiene prac�ces, etc.

Factors s ignificantly associated with malnutri�on among under-5 children.

Home environment: large family size, food insecurity, toilet facility, sanita�on and hygiene prac�ces, water storage and handling prac�ces are extremely important factors.

Poor hand hygiene: role of hand hygiene is quite important in preven�on of infec�ons and thereby malnutri�on. Availability of soap and water is an important determinant. Hand

washing before prepara�on, serving and ea�ng meals and a�er going to toilets can prevent malnutrit ion to a great extent.

Diarrhoeal disease: diarrhoea is a leading cause of malnutri�on in children under 5 years old. Poor sanita�on, lack of access to clean water and inadequate personal hygiene are responsible for an es�mated 88% of childhood diarrhoea in India. Based on current evidence, washing hands with soap can reduce the risk of diarrheal diseases by 42–47%. A survey

conducted by UNICEF in 2005 on well-being of children and women had shown that only 47% of rural children in the age-group 5–14 wash hands a�er defeca�on.

Socio-economic and demographic factors: literacy status of parents especially mother’s educa�on, caste, birth order of child, gender of household head, residence, type of house, type of family (single/joint) lower socio-economic status, poverty, food insecurity, etc. are such important factors.

Maternal factors: short stature, mother’s

nutri�on, mother’s age, antenatal and natal care, infec�ons, smoking and exposure to second hand smoke are important maternal factors.

Breas�eeding prac�ces : inadequate , insufficient, inappropriate breas�eeding prac�ces lay down founda�on of malnutri�on. Breas�ed children are protected from infec�ons in be�er way than who are not breas�ed. Early ini�a�on of breas�eeding and right �ming of ini�a�on of complementary feeding are also quite important.

5. Nutri�onal approach

Despite the manifold dietary approaches to 40,41

severe malnutri�on that have been tried, pa�ents with kwashiorkor (including marasmic kwashiorkor) con�nue to die much more

42,43frequently than those with marasmus alone. In sub- Saharan Africa and, increasingly, India, an addi�onal concern is that many pa�ents with severe malnutri�on are also infected with

44HIV.

The most important preven�ve strategy worldwide is to reduce poverty and improve nutri�onal educa�on and public health measures.

Recommenda�ons

● Usually oral feeding preferred

● Possibly avoidance of lactose (eg, if persistent diarrhea suggests lactose intolerance)

● Suppor�ve care (eg, environmental changes, assistance with feeding, orexigenic drugs)

● For children, feeding delayed 24 to 48 hours

M i l d o r m o d e r a t e p r o t e i n - e n e r g y undernutri�on, including brief starva�on, can be treated by providing a balanced diet, preferably orally. Liquid oral food supplements (usually lactose - free) can be used when solid food cannot be adequately ingested. Diarrhea o�en complicates oral feeding because starva�on makes the gastrointes�nal tract more likely to move bacteria into Peyer patches, facilita�ng infec�ous diarrhea. If d iarrhea pers ists ( sug ges�ng lactose intolerance), yogurt-based rather than milk-based formulas are given because people with lactose intolerance can tolerate yogurt. Pa�ents should also be given a mul�vitamin supplement.

Severe protein energy malnutri�on requires treatment in a hospital with a controlled diet. The first priority is to correct fluid and electrolyte abnormali�es and treat infec�ons. A recent study suggested that children may benefit from an�bio�c prophylaxis. The next

priority is to supply macronutrients orally or, if necessary (eg, when swallowing is difficult), through a feeding tube, a nasogastric tube (usually), or a gastrostomy tube (enteral nutri�on). Parenteral nutri�on is indicated if malabsorp�on is severe.

Other treatments may be needed to correct specific deficiencies, which may become evident as weight increases. To avoid d e fi c i e n c i e s , p a � e n t s s h o u l d t a k e m i c r o n u t r i e n t s a t a b o u t t w i c e t h e recommended daily allowance un�l recovery is complete.

For children with diarrhea, feeding may be delayed 24 to 48 hours to avoid making the diarrhea worse; during this interval, children require oral or IV rehydra�on. Feedings are given o�en (6 to 12 �mes/day) but, to avoid overwhelming the limited intes�nal absorp�ve capacity, are limited to small amounts (< 100 mL). During the first week, milk-based formulas with supplements added are usually given in progressively increasing amounts; a�er a week, the full amounts of 175 kcal/kg and 4 g of p ro t e i n / k g c a n b e g i v e n . Tw i c e t h e r e c o m m e n d e d d a i l y a l l o w a n c e o f micronutrients should be given, using commercial mul�vitamin supplements.

A�er 4 weeks, the formula can be replaced with whole milk plus cod liver oil and solid foods, including eggs, fruit, meats, and yeast. Energy distribu�on among macronutrients should be about 16% protein, 50% fat, and 34% carbohydrate. An example is a combina�on of powdered cow’s skimmed milk (110 g), sucrose (100 g), vegetable oil (70 g), and water (900 mL). Many other formulas (eg, whole [full- fa t] fresh milk plus corn oil and maltodextrin) can be used. Milk powders used in formulas are diluted with water.

The high mortality indicates a need for a systema�c approach to the severe ly malnourished pa�ent that goes beyond an appropriate diet. To reduce mortality, a

45complex management scheme is pivotal. Essen�al steps include a reduced intake of volume, protein and sodium during the first phase while emergency measures are taken to reduce the risk of hypoglycaemia, hypothermia

46,47,48and dehydra�on.

Oral, enteral and parenteral volume loads must be checked carefully to avoid imminent heart failure; con�nuous monitoring of central venous blood pressure is very desirable. In this early phase of rehabilita�on, a protein intake exceeding 1 g/kg body weight in combina�on with impaired liver func�on (with breakdown of the urea cycle) and li�le urine excre�on (a

result of dehydra�on) easily exceeds the malnourished child's metabolic capacity to rid him- or herself of excess ammonia.

Although the effec�veness of the World Health Organiza�on (WHO) 10-step scheme is proven, there are s�ll pi�alls for certain pa�ents, such as those with extreme anaemia and those who

49are close to cardiac failure. The need for transfusions must be weighed against the risk of heart failure; combining transfusions with diuresis or applying exchange transfusion can resolve the dilemma. The WHO is currently revising its protocol to address 3 difficul�es: the specific nutri�onal problems of children with HIV infec�on or AIDS; different dietary regimens, par�cularly for infants younger than 6 months; and the limited availability of potass ium- magnesium- z inc- copper

50prepara�ons.

The need to reduce the high sodium content (90 mEq/ L) of common oral rehydra�on solu�ons for starving children has led to the p ro d u c � o n o f Re S o M a l ( a 4 5 - m Eq / L rehydra�on solu�on for the malnourished). Now that a 75-mEq/L oral rehydra�on solu�on has become a standard treatment for non-

51,52secretory diarrhea, there is less need for a s p e c i a l s o d i u m - re d u c e d re hy d ra � o n prepara�on. Nevertheless, modifica�on of the standard ora l rehydra�on so lu�on i s recommended, with dilu�on to reduce the sodium concentra�on and enrichment with potassium, magnesium, zinc, copper and

53selenium. Finally, the severely malnourished child should always be given an effec�ve broad-spectrum an�bio�c, even in the absence of any

54,55signs of infec�on.

People's diets can benefit from preven�ve interven�ons ranging from income genera�on and nutri�onal educa�on to maternal support, food supplementa�on and food prize subsidies. High immuniza�on coverage and early and correct management of cases of infec�ous

disease play major roles in the preven�on and treatment of protein-energy malnutri�on. In poor communi�es, the treatment of helminth infec�ons 3 �mes per year improved child growth and development.

Protein-energy malnutri�on and diarrhea typically interact in a vicious cycle, but the control of diarrhea depends on more than medical help.56 Although growth monitoring is considered poten�ally important in child health clinics, there is o�en a lack of

57,58,59appropriate follow-up ac�on. As much as func�onal health services may need to be made available, in order to address infec�ous diseases as a cause of protein-energy malnutri�on it is likewise important to promote breast-feeding, improve the water supply and sanita�on, and educate people

6 0 , 6 1 , 6 2 , 6 3about hygiene. The mul�faceted horizontal approach of the WHO-supported Integrated Management of Childhood Illness ini�a�ve has recently been shown to be an

64,65effec�ve strategy.

Problem Management

Hypothemia Warm pa�ent up; maintain and monitor body temperature

Hypoglycemia Monitor blood glucose; provideoral for intra-venous glucose

Dehydra�on Rehydrate carefully with oral solu�on containingless sodium and more potassium than standard mix

Micronutrients Provide copper, zinc, iron, folate, mul�vitamins

Infec�ons Administer an�bio�c and an�malarial therapy,even in the absence of typical symptoms

Electrolytes Supply plenty of potassium and magnesium

Starter nutri�on Keep protein and volume load low

Tissue-building nutri�on Furnish a rich diet dense in energy, protein and allessen�al nutrients that is easy to swallow and digest

S�mula�on Prevent permanent psychosocial effects ofstarva�on with psychomotor s�mula�on

Preven�on of relapse Start early to iden�fy causes of protein-energymalnutri�on in each case; involve the family andthe community in preven�on

The life-course approach on malnutri�on

Micronutrient Deficiencies & management

Deficiencies in iron, iodine, vitamin A and zinc are s�ll major public health problems in developing countries, but vitamin C, D and B deficiencies have declined considerably in

66recent decades. Micronutrient deficiencies

affect at least 2 billion people worldwide. As 5 there are o�en no reliable biochemical indices of marginal micronutrient status, randomized controlled trials of supplementa�on are the best method to study the rela�on between micronutrient deficiencies and health

67parameters in human popula�ons.

Babies and children● Low birth weight● Higher mortality rate● Impaired mental development● Stun�ng● Reduced mental capacity● Frequent infec�ons● Reduced learning capacity

Pregnant women● Increased mortality

● Increased perinatal complica�ons

Adults● Reduced produc�vity

● Poor socioeconomic status

● Malnutri�on

● Increased risk of chronic disease

Adolescents● Stun�ng

● Reduced mental capacity

● Fa�gue

● Increased vulnerability to infec�on

Micronutrient deficiencies in diet

Globally, 74 crore people are deficient in iodine, including up to 30 crore with goitre and 2 crore with brain damage from maternal iodine

68,69,70deficiency during their fetal development.

About 2 billion people are deficient in zinc; 1 billion have iron-deficiency anaemia. Vitamin A

deficiency affects some 250 million, mainly young children and pregnant women in

71,72,73,74developing countries.

The main causes worldwide of these 4 major micronutrient deficiencies are shown in below table.

Not only do protein–energy malnutri�on and micronutrient deficiencies overlap, but a lack of 1 micronutrient is typically associated with deficiencies of other micronutrients. The pathophysiology and manifesta�ons of the main deficiencies are summarized in above table.

Iron is an essen�al part of haemoglobin, myoglobin and various enzymes. Its deficiency thus leads mainly to anaemia, but also to several other adverse effects. Lack of iodine reduces the produc�on of thyroid hormone and increases that of thyroid s�mula�ng hormone. As a result, the thyroid gland becomes hyperplas�c and goitrous, and hypothyroidism develops.

Vitamin A deficiency contributes to anaemia by immobilizing iron in the re�culoendothelia l system, reducing hemopoiesis and increasing suscep�bility to infec�ons. Vitamin A is essen�al for the func�oning of the eyes as well

as the immune system. Although diarrhea and related mortality has clearly been shown to be associated with vitamin A deficiency, the evidence for associa�ons with acute infec�ons of the lower respiratory tract and with malaria is much weaker.

Zinc is essen�al for the func�oning of many enzymes and is thus involved in a large number of metabolic processes, including RNA and DNA synthesis. Consequently, zinc deficiency interferes with a variety of biological func�ons, such as gene expression, protein synthesis, skeletal growth, gonad development, appe�te and immunity. Zinc plays a central role in the func�on of cel ls media�ng unspecific immunity, such as neutrophils and natural killer cells, and is needed for specific immune processes, such as balancing T helper cell func�ons. Z inc defic iency i s a major determinant for diarrhea and pneumonia, but evidence about its role in

Causes, manifesta�ons, management and preven�on of the major micronutrient deficiencies

Nutrient

Iron

Iodine

Vitamin A

Zinc

Thyroidhormone

Eyesimmune system

Many enzymesImmune system

Essen�al forthe produc�onor func�on of

Causes ofdeficiency

Manifesta�onsisolated deficiency

Managementand preven�on

HemoglobinVarious enzymesMyoglobin

Poor dietelevated needs (e.g., while pregnant in early childhood)Chronic loss from parasite infec�ons(e.g., hookworms, schistosomiasis,whipworm)

Anaemia and fa�gueImpaired cogni�ve developmentReduced growth and physical strength

Foods richer in iron and withfewer absorp�on inhibitorsIron-for�fied weaning foodsLow-dose supplements inchildhood and pregnancyCooking in iron pots

Iodine supplementFor�fied saltSeafood

More dark green leafyvegetables, animal productsFor�fica�on of oils and fatsRegular supplementa�on*

Zinc treatment for diarrheaand severe malnutri�onImproved diet

Goitre, hypothyroidism, cons�pa�onGrowth retarda�onEndemic cre�nism

Night blindness, xerophthalmiaImmune deficiencyIncreased childhood illness, early deathContributes to development of anaemia

Immune deficiencyAcroderma��sIncreased childhood illness, early deathComplica�ons in pregnancy, childbirth

Except where seafood or salt for�fiedwith iodine is readily available, mostdiets, worldwide, are deficient

Diets poor in vegetables andanimal products

Diets poor in animal productsDiets based on refined cereals (e.g.,white bread, pasta, polished rice)

m a l a r i a a n d g r o w t h r e t a r d a � o n i s 75,76,77,78,79

conflic�ng. B-complex vitamins at twice the recommended daily allowance are given parenterally for the first 3 days, usually with vitamin A, phosphorus, zinc, manganese, copper, iodine, fluoride, molybdenum, and selenium.

Because absorp�on of oral iron is poor in children with malnutri�on, oral or IM iron supplementa�on may be necessary.

6. Preven�on and control

The management of children with severe malnutri�on has several components:

● Therapeu�c feeding with macronutrients and micronutrients to achieve homeostasis and overcome the nutrient deficits

● T h e i m m e d i a t e i d e n � fi c a � o n a n d management of life-threatening infec�ons and complica�ons such as sepsis and metabolic derangements

● The treatment of subclinical infec�ons and underlying condi�ons, such as HIV or tuberculosis

● The cogni�ve s�mula�on and emo�onal support of the child and psychosocial support for their parents or caregivers

● Linkage to medical, nutri�onal and social services during therapy and recovery Foods w i t h a h i g h c o n t e n t o f a b s o r b a b l e micronutrients are considered the best means

80,81,82for preven�ng micronutrient deficiencies. In communi�es where supplies of such foods are unavailable, specific preven�ve and

83cura�ve interven�ons are needed.

There is growing opinion on the importance of mul�ple micronutrient interven�ons in popula�ons with a high prevalence of malnutri�on. However, synergis�c and a n t a g o n i s � c i n t e r a c � o n s b e t w e e n micronutrients have to be taken into considera�on during the development of

84,85,86appropriate formula�ons. A special kind of interven�on is the provision of fat-based spreads (e.g., peanut bu�er) and “sprinkles” containing mul�ple micronutrients to be mixed with food. A principle limita�on of all these interven�ons (except dietary diversifica�on, of course) is their orienta�on toward single nutrients rather than plant ingredients (e.g., phytosterols and fibre), despite the desirability of plant ingredients for the preven�on of cancer and cardiovascular diseases.

Micronutrient supplementa�on is usually provided through the exis�ng health services and can be taken orally or (more rarely) by injec�on. Priority should be given to vulnerable popula�ons, such as pregnant women and

87children. Supplementa�on is mandated in cases of a specific deficiency when other approaches are too slow. Although some micronutrients must be taken daily or weekly (e.g., iron and zinc), others can be stored in the body and need only be taken at intervals of

88months to years (e.g., vitamin A and iodine). However, modes of de l ivery, pa�ent compliance and poten�al toxicity all need to be considered.

Diet-based strategies are probably the most promising approach for a sustainable control of micronutrient deficiencies. Increasing dietary diversifica�on through consump�on of a broad variety of foods, preferably from home gardens and small livestock produc�on, is effec�ve. Households should be educated and supported to increase produc�on of dark-green leafy vegetables, yellow and orange fruits, poultry, eggs, fish and milk.

When adequate weight gain is concern, in the management of PEM, acute and persistent diarrhoea, non-milk complementary food providing ra�o of rice and moong dal 2:1 is recommended for op�mum weight gain.

Doctor Rudolph Ballan�ne in his book Diet and Nutri�on - A Holis�c Approach confirms, Right ra�o of Cereals and Pulses (2:1) provides three �mes higher weight gain.

A possible future strategy to prevent micronutrient deficiencies is to breed micronutrient-rich crops, through either conven�onal breeding techniques or gene�c modifica�on of exis�ng crops. So far, however, the micronutrient concentra�ons achieved are very low. For vitamin A, nobody knows if β-carotene from the new “golden rice” variety is bioavailable and how much rice must be consumed to meet an individual's needs, and iron concentra�ons in bio-engineered rice are no higher than those in natural varie�es such as

89basma� or jasmine rice.

7. Summary

The facts discussed in this ar�cle highlights the worrying unacceptably high prevalence and universality of malnutri�on in all its forms in Indian communi�es, but it is both preventable and treatable. Beyond health, malnutri�on is also influencing the social and economic development. In Indian context, poverty, maternal health illiteracy, LBW, diseases like diarrhoea, home environment, dietary prac�ces, hand washing and poor hygiene prac�ces are few important factors responsible for very high prevalence of malnutri�on. Government of India has rolled out various community nutri�onal programmes to combat malnutri�on and to get nutri�on on track.

In spite of various challenges, India has made considerable progress in tackling hunger and under-nutri�on in the past two decades, yet this pace of change has been unacceptably slow, uneven and many have been le� behind. But with sustained priori�za�on, increased resource alloca�on, adop�ng comprehensive, coordinated and holis�c approach with good governance and help of civil society, India has the poten�al to end malnutri�on in all its forms and turn the ambi�on of the Sustainable Development Goals into a reality for everyone.

Because malnutri�on has many causes, only mul�ple and synergis�c interven�ons

embedded in true mul�sectoral programs can 90

be effec�ve. A variety of ac�ons are needed, including agricultural and micronutrient interven�ons and the provision of safe drinking water and sanita�on, educa�on about and support for be�er diets, special a�en�on to gender issues and vulnerable groups such as pregnant women and young children, and

91quality health services.

Nutri�on educa�on about locally available protein- and micronutrient-rich plants & protein rich supplements is par�cularly

92,93effec�ve and sustainable.

8. References:1. Schofield C, Ashworth A. Why have mortality rates for severe malnutri�on remained so high? Bull World Health Organ 1996;74:223-9.

2. World Health Organiza�on. World health report. Geneva: The Organiza�on; 2002.

3. Pinstrup–Andersen P, Burger S, Habicht JP, Peterson K. Protein–energy malnutri�on. In: Jamison DT, Mosley WH, Measham AR, Bobadilla JL, editors. Disease control priori�es in developing countries. 2nd ed. Oxford (UK): Oxford University Press; 1993. pp. 391-420.

4. Levin HM, Polli� E, Galloway R, McGuire J. Micronutrient deficiency disorders. In: Jamison DT, Mosley WH, Measham AR, Bobadilla JL, editors. Disease control priori�es in developing countries. 2nd ed. Oxford (UK): Oxford University Press; 1993. pp. 421-451.

5. Dickson R, Awasthi S, Williamson P, Demellweek C, Garner P. Effects of treatment for helminth infec�on on growth and cogni�ve performance in children: systema�c review of randomized trials. BMJ 2000;320:1697-701.

6. Stoltzfus RJ, Chway HM, Montresor A, Tielsch JM, Jape JK, Albonico M, et al. Low dose daily iron supplementa�on improves iron status and appe�te but not anaemia, whereas quarterly an�helminthic treatment improves growth, appe�te and anaemia in Zanzibari preschoo l children. J Nutr 2004;134:348-56.

7. Murray CJL, Lopez AD. Global mortality, disability, and the contribu�on of risk factors: Global Burden of Disease Study. Lancet 1997;349:1436-42.

8. Rice AL, Sacco L, Hyder A, Black RE. Malnutri�on as an underlying cause of childhood deaths associated with infec�ous diseases in developing countries. Bull World Health Organ 2000;78:1207-21.

9. Nemer L, Gelband H, Jha P; Commission on Macroeconomics and Health. The evidence base for interven�ons to reduce malnutri�on in children under five and school-age children in low- and middle-income countries. CMH working paper no WG5:11. Geneva: World Health Organiza�on; 2001.

10. Müller O, Garenne M, Kouyaté B, Becher H. The associa�on between protein – energy malnutri�on, malaria morbidity and all-cause mortality in West African children. Trop Med Int Health 2003;8:507-11.

11. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226-34.

12. Chen LC, Chowdhury AKMA, Huffman SL. Anthropometric

assessment of energy–prote in malnutri�on and subsequent risk of mortality among preschool aged children. Am J Clin Nutr 1980;33:1836-45.

13. Caulfield LE, de Onis M, Blo¨ssner M, et al. Undernutri�on as an

underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr 2004;80:193–8.14. Pelle�er DL, Frongillo EA Jr, Habicht JP. Epidemiologic evidence for a poten�a�ng effect of malnutri�on on child mortality. Am J Public Health 1993;83(8):1130–3.

15. Pelle�er DL, Frongillo EA Jr, Habicht JP. The effects of malnutri�on on child mortality in developing countries. Bull World Health Organ 1995;73:443–8.

16. Salama P, Spiegel P, Talley L, Waldman R. Lessons learned from complex emergencie s over past decade. Lancet 2004;364:1801-13.

17. Young H, Borrel A, Holland D, Salama P. Public nutri�on in complex emergencies. Lancet 2004;364:1899-909.

18. Rice AL, Sacco L, Hyder A, Black RE. Malnutri�on as an underlying cause of childhood deaths associated with infec�ous diseases in developing countries. Bulle�n of the World Health Organiza�on. 2000;78:1207-1221

19. Chen LC, Scimshaw NS. Diarrea and malnutri�on: interac�ons, mechanisms, and interven�ons. New York: United Na�ons University Press; 1983.

20. Reilly JJ. Understanding chronic malnutri�on in childhood and old age: role of energy balance research. Proc Nutr Soc 2002;61:321-7.

21. Lerner AB. On the e�ology of vi�ligo and gray hair. Am J Med 1971;51:141-7.

22. Bhan MK, Bhandari N, Bahl R. Management of the severely malnourished child: perspec�ve from developing countries. BMJ 2003;326:146-51.

23. Hendrickse RG. Of sick turkeys, kwashiorkor, malaria, perinatal mortality, heroin addicts and food poisoning: research on the influence of aflatoxins on child health in the tropics. Ann Trop Med Parasitol 1997;91:787-93.

24. Reid M, Badaloo A, Forrester T, Morlese JF, Heird WC, Jahoor F. The acute phase protein response to infec�on in edematous and non-edematous protein– energy malnutri�on. Am J Clin Nutr 2002;76:1409-15.

25. Ramdath DD, Golden MH. Elevated glutathione S-transferase ac�vity in erythrocytes from malnourished children. Eur J Clin Nutr 1993;47:658-65.

26. Becker K, Leichsenring M, Gana L, Bremer HJ, Schirmer RH. Glutathione and associated an�oxidant systems in protein energy malnutri�on: results of a study in Nigeria. Free Radic Biol Med 1995;18:257-63.

27. Lenhartz H, Ndasi R, Anninos A, Bo�cher D, Mayatepek E, Tetanye E, et al. The clinical manifesta�on of the kwashiorkor syndrome is related to increased lipid peroxida�on. J Pediatr 1998;132:879-81.

28. Golden MHN. Oedematous malnutri�on. Br Med Bull 1998;54:433-44.

29. Manary MJ, Leewenburgh C, Heinecke JW. Increased oxida�ve stress in kwashiorkor. J Pediatr 2000;137:421-4.

30. Jackson AA. Glutathione in kwashiorkor. Am J Clin Nutr 2002;76:495-6.

31. Badaloo A, Reid M, Forrester T, Heird WC, Jahoor F. Cysteine supplementa�on improves the erythrocyte glutathione synthesis rate in children with severe edematous malnutri�on. Am J Clin Nutr 2002;76:646-52.

32. Krawinkel M. Kwashiorkor is s�ll not fully understood. Bull World Health Organ 2003;81:910-1.

33. Ciliberto H, Ciliberto M, Briend A, Ashorn P, Bier D, Manary M. An�oxida nt supplementa�on for the preven�on of kwashiorkor in Malawian children: randomised, double blind, placebo controlled trial. BMJ 2005;330:1109.

34. Fuchs GJ. An�oxidants for children with kwashiorkor. BMJ 2005;330:1095-6.

35. Rossi MA, Zucoloto S. Ultrastructural changes in nutri�onal cardiomyopathy of protein-calorie malnourished rats. Br J Exp Pathol 1982;63:242-53.

36. Gracey M. Nutri�onal effects and management of diarrhoea in infancy. Acta Paediatr Suppl 1999;88:110-26.

37. Alam NH, Hamadani JD, Dewan N, Fuchs GJ. Efficacy and safety of a modified oral rehydra�on solu�on (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea. J Pediatr 2003;143:614-9.

38. Van der Hoek W, Feenstra SG, Konradsen F. Availability of irriga�on water for domes�c use in Pakistan: its impact on prevalence of diarrhoea and nutri�onal status of children. J Health Popul Nutr 2002;20:77-84.

39. Manary MJ, Brewster DR. Potassium supplementa�on in kwashiorkor. J Pediatr Gastroenterol Nutr 1997;24:194-201.

40. Brown KH. Appropriate diets for the rehabilita�on of malnourished children in the community se�ng. Acta Paediatr Scand Suppl 1991;374:151-9.

41. Khanum S, Ashworth A, Hu�ly SR. Controlled trial of three approaches to the treatment of severe malnutri�on. Lancet 1994;344:1728-32.

42. Gernaat HB, Dechering WH, Voorhoeve HW. Mortality in severe protein– energy malnutri�on at Nchelenge, Zambia. J Trop Pediatr 1998;44:211-7.

43. Ahmed T, Ali M, Ullah MM, Choudhury IA, Haque ME, Salam MA, et al. Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol. Lancet 1999;353:1919-22.

44. Ambrus JL Sr, Ambrus JL Jr. Nutri�on and infec�ous diseases in developing countries and problems of acquired immunodeficiency syndrome. Exp Biol Med (Maywood) 2004;229:464-72.

45. Heikens GT. Rehabilita�on of sick malnourished children — environments, requirements, prognosis and feasibility. Amsterdam: Rozenberg Publica�ons; 2003.

46. Beaufrere B, Bresson JL, Briend A, Ghisolfi J, Goulet O, Navarro J, et al. [Protein and energy needs of the infant with severe malnutri�on: applica�on in a hospital environment for the treatment of malnutri�on caused by deficient intake] [review]. Arch Pediatr 1998;5:763-71.

47. World Health Organiza�on. Management of severe malnutri�on: a manual for physicians and other senior health workers. Geneva: The Organiza�on; 1999.

48. World Health Organiza�on. Management of the child with a serious infec�on or severe malnutri�on. Guidelines for care at the first-referral level in developing countries. Geneva: The Organiza�on; 2000.

49. Ashworth A, Chopra M, McCoy D, Sanders D, Jackson D, Karaolis N, et al. WHO guidelines for management of severe malnutri�on in rural South African hospitals: effect on case fatality and the influence of opera�onal factors. Lancet 2004;363:1110-5.

50. World Health Organiza�on. Informal consulta�on to review current literature on severe malnutri�on. Geneva: The Organiza�on. In press. Highl ights avai lable:www.who.int/hac/about/ donorinfo/13September04_MondayHighlights.pdf.

51. World Health Organiza�on, United Na�ons Children's Fund. Expert consulta�on on oral rehydra�on salts (ORS) formula�on. Report from a mee�ng of experts jointly organized by UNICEF and WHO; 2001 Jul 18; New York.

52. World Health Organiza�on. World health report. Geneva: WHO; 2004.

53. Makonnen B, Venter A, Joubert G. A randomized controlled study of the impact of dietary zinc supplementa�on in the management of children with protein- energy malnutri�on in Lesotho. II: Special inves�ga�ons. J Trop Pediatr 2003; 49:353-60.

54. Golden MH, Briend A. Treatment of malnutri�on in refugee

camps. Lancet 1993; 342:360.

55. Ibekwe VE, Ashworth A. Management of protein–energy malnutri�on in Nigeria: an evalua�on of the regimen at the Kersey Nutri�on Rehabilita�on Centre, Nigeria. Trans R Soc Trop Med Hyg 1994;88:594-5.

56. Thapar N, Sanderson I. Diarrhoea in children: an interface between developing and developed countries [review]. Lancet 2004;363:641-53.

57. Pyle DF. Growth charts don't cure malnutri�on. World Educ Rep 1986; (25): 15-7.

58. Sauerborn R, Nougtara A, Sorgho G, Bidiga J, Diesfeld HJ. Assessment of MCH services in the district of Solenzo, Burkina Faso. III. Effec�veness of MCH services in detec�ng of and caring for mothers and children at risk. J Trop Pediatr 1989;35(1 Suppl):14-7.

59. Melville B, Fidler T, Mehan D, Bernard E, Mullings J. Growth monitoring: the role of community health volunteers. Public Health 1995;109:111-6.

60. Feachem RG, Koblinsky MA. Interven�ons for the control of diarrheal diseases among young children: promo�on of breast-feeding. Bull World Health Organ 1984;62:271-91.

61. Marek T, Diallo I, Ndiaye B, Rakotosalama J. Successful contrac�ng of preven�on services: figh�ng malnutri�on in Senegal and Madagascar. Health Policy Plan 1999;14:382-9.

62. Victora CG, Kirkwood BR, Ashworth A, Black RE, Rogers S, Sazawal S, et al. Poten�al interven�ons for the preven�on of childhood pneumonia in developing countries: improving nutri�on. Am J Clin Nutr 1999;70:309-20.

63. Shah D, Gupta P. Management of severe malnutri�on: facilita�ng learning [le�er]. Lancet 2003;361:2088.

64. Armstrong Schellenberg JR, Adam T, Mshinda H, Masanja H, Kabadi G, Mukasa O, et al. Effec�veness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet 2004;364:1583-94.

65. El Arifeen S, Blum LS, Hoque DME, Chowdhury EK, Khan R, Black RE, et al. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster - randomised study. Lancet 2004;364:1595-602.

66. Diaz JR, de las Cagigas A, Rodriguez R. Micronutrient deficiencies in developing and affluent countries [review]. Eur J Clin Nutr 2003;57:S70-2.

67. Shankar A. Nutri�onal modula�on of malaria morbidity and mortality [review]. J Infect Dis 2000;182(Suppl 1):S37-53.

68. De Benoist B, Clugston G. Elimina�ng iron deficiency disorders [editorial]. Bull World Health Organ 2002;80:341.

69. Hetzel BS. Elimina�ng iodine deficiency disorders — the role of the Interna�onal Council in the global partnership. Bull World Health Organ 2002;80: 410-17.

70. Black MM. Micronutrient deficiencies and cogni�ve func�oning [review]. J Nutr 2003;133(11 Suppl 2):3927S-31S.

71. Stoltzfus RJ, Dreyfuss ML. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. Washington: Interna�onal Life Sciences Ins�tute Press; 1998.

72. Fleming AF, de Silva PS. Haematological diseases in the tropics. In: Cook GC, Zumla AI, editors. Manson's tropical diseases. London: Saunders; 2003. pp. 169-244.

73. Krawinkel MB, Bethge M, el Karib AO, Ahmet HM, Mirghani OA. Maternal ferri�n values and foetal iron stores. Acta Paediatr Scand 1990;79:467.

74. Hesham MS, Edariah AB, Norhaya� M. Intes�nal parasi�c infec�ons and micronutrient deficiency: a review. Med J Malaysia 2004;59:284-93.

75. Sazawal S, Black RE, Bhan MK, Bhandari N, Sinha A, Jalla S. Zinc supplementa�on in young children with acute diarrhea in India. N Engl J Med 1995; 333: 839-44.

76. Brown KH, Peerson JM, Allen LH. Effect of zinc supplementa�on on children's growth: a meta-analysis of interven�on trials. Bibl Nutr Dieta 1998; 54: 76-83.

77. Bhu�a ZA, Black RE, Brown KH, Gardner JM, Gore S, Hidayat A, et al; for Zinc Inves�gators' Collabora�ve Group. Preven�on of diarrhea and pneumonia by zinc supplementa�on in children in developing countries: pooled analysis of randomized controlled trials. J Pediatr 1999;135:689-97.

78. Müller O, Becher H, [Baltussen] van Zweeden A, Ye Y, Diallo DA, Konate AT, et al. Effect of zinc supplementa�on on malaria and other causes of morbidity in west African children: randomized double blind placebo controlled trial. BMJ 2001; 322:1567-72.

79. Müller O, Garenne M, Reitmaier P, [Baltussen] van Zweeden A, Kouyate B, Becher H. Effect of zinc supplementa�on on growth in West African children: a randomized double-blind placebo-controlled trial in rural Burkina Faso. Int J Epidemiol 2003;32:1098-102.

80. Gibson RS, Yeudall F, Drost N, M��muni B, Cullinan T. Dietary interven�ons to prevent zinc deficiency. Am J Clin Nutr 1998;68(2 Suppl):484S-7S.

81. Ton�sirin K, Nantel G, Bha�acharjee L. Food-based strategies to meet the challenges of micronutrient malnutri�on in the developing world. Proc Nutr Soc 2002;61:243-50.

82. Interna�onal Zinc Nutri�on Consulta�ve Group. Assessment of the risk of zinc deficiency in popula�ons and op�ons for its control. Food Nutr Bull 2004; 25: S91-204.

83. Holmes W, Toole M. Micronutrient supplements in pregnant Nepalese women. Lancet 2005;365:916-7.

84. Shrimpton R, Gross R, Darnton-Hill I, Young M. Zinc deficiency: What are the most appropriate interven�ons? BMJ 2005;330:347-9.

85. Baly DL, Golub MS, Gershwin ME, Hurley LS. Studies of marginal zinc depriva�on in rhesus monkeys. 3. Effects of vitamin A metabolism. Am J Clin Nutr 1984;40:199-207.

86. Bloem MW, Wedel M, van Agtmaal EJ, Speek AJ, Saowakontha S, Schreurs WH. Vitamin A interven�on: short-term effects of a single, oral, massive dose on iron metabolism. Am J Clin Nutr 1990;51:76-9.

87. Osrin D, Vaidya A, Shrestha Y, Baniya RB, Manandahar DS, Adhikari RK, et al. Effects of antenatal mul�ple micronutrient supplementa�on on birth weight and gesta�onal dura�on in

Nepal: double-blind, randomised controlled trial. Lancet 2005;365:955-62.

88. Siddiqui IA, Rahman MA, Jaleel A. Efficacy of daily vs. weekly supplementa�on of iron in schoolchildren with low iron status. J Trop Pediatr 2004;50: 276-8.

89. Gregorio GB. Progress in breeding for trace minerals in staple crops. J Nutr 2002; 132:500S-2S.

90. Bhargava A; Commission on Macroeconomics and Health. Nutri�on, health, and economic development: some policy priori�es. CMH working paper no. Geneva: World Health

Organiza�on; 2001.

91. Victora CG, Hanson K, Bryce J, Vaughan P. Achieving universal coverage with health interven�ons. Lancet 2004;364:1541-8.

92. Penny ME, Creed-Kanashiro HM, Robert RC, Narro MR, Caulfield LE, Black RE. Effec�veness of an educa�onal interven�on delivered through the health services to improve nutri�on in young children: a cluster-randomised controlled trial. Lancet 2005;365:1863-72.

93. Dewey KG. Infant nutri�on in developing countries: What works?

Lancet 2005; 365:1832-4.

Feedback form: January - March 2021

Protein Energy Malnutrition:Systemic approach towards supplementation with adequate nutrition.

Dear Doctor,

Malnutri�on in various forms is associated with various forms of ill health and higher levels of mortality. Undernutri�on explains around 45% of deaths among children under-5, mainly in low and middle-income countries. In India there are around 4.66 crore stunted children, a third of world’s total as per Global Nutri�on Report 2018. Nearly half of all under-5 child mortality in India is a�ributable to undernutri�on. Early childhood cons�tutes the most crucial period of life, when the founda�ons are laid for cogni�ve, social and emo�onal, language, physical/motor development and cumula�ve lifelong learning. Children of today are ci�zens of tomorrow, and hence improving nutri�onal status of children becomes extremely important.

It is indeed a pleasure to present to you this QMR issue by Dr. Jaydeb Ray, renowned Paediatrician & Neonatologist. In this issue, he is enlightening us on “Protein Energy Malnutri�on: Systemic approach towards supplementa�on with adequate nutri�on.”

I signoff by once again reminding you to con�nue sending your comments and sugges�on regarding the QMR. Do write to me at rahul.badwaik@raptakos.com with your write-ups, notes or �tbits on various topics of interest that can make for informa�ve and interes�ng reading.

Dr. Rahul Badwaik

Vice President - Medical