public health importance of malnutrition

Public Health Aspects of Malnutrition

Public Health and Community Medicine Department, December 24,2014

Prof .Dr Fatma Abu Hashima

Dr. Marwa Rashad Salem

MALNUTRITION

OBJECTIVES:

At the end of the lecture students should be able to:

• Define and classify malnutrition

• Why public health problem

• Identify impact of malnutrition

• Public health interventions

• Take Home message

2

Definition

Malnutrition is defined as a state in which the physical

function of an individual is impaired to the point where

he or she can no longer maintain natural bodily capacities

such as growth, pregnancy, lactation, learning abilities,

physical work and resisting and recovering from disease .

29-Dec-14 4

Types of Malnutrition

5

Malnutrition

Derived from malus (bad) and nutrire (to nourish)

Includes both

Under nutrition (deficiency of one or more

essential nutrients)

Over nutrition (an excess of a nutrient or

nutrients)


(under nutrition)

• Under nutrition is depletion of energy (calories) resulting form

insufficient food intake over an extended period of time.

• In extreme cases under-nutrition is called Starvation.

Specific Deficiency is the pathological state resulting form a

deficiency of an individual nutrient such as vitamin A deficiency,

iodine deficiency.

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(Over nutrition)

Over nutrition:

• “Over nutrition is the pathological state resulting from theconsumption of excessive quantity of food over an extendedperiod of time”.

• Overweight and obesity are very common conditions indeveloped society and are becoming more common in developingsocieties and those in transition.

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UNDERNUTRITION

ACUTE UNDERNUTRITION

CHRONIC UNDERNUTRITION

• Marasmus• kwashiorkor• Marasmic-

kwashiorkor• Wasting

TYPES OF UNDERNUTRITION

• Stunting•Underweight

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PROTEIN-ENERGY MALNUTRITION

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MARASMUS

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Micronutrient Malnutrition

Major Micronutrient deficiency problems Iron deficiency anemia

Vitamin A deficiency

Iodine deficiency disorders

Zinc deficiency

Folate deficiency

Iron Deficiency Anemia

Keratomalacia

Rickets

Why Malnutrition?

Public health importance

For a health problem or condition to be considered a public health issue,four criteria must be met:

1) the health condition must place a large burden on society, aburden that is getting larger despite existing control efforts;

2) the burden must be distributed unfairly (i.e., certain segmentsof the population are unequally affected);

3) there must be evidence that upstream preventivestrategies could substantially reduce the burden of the condition;and

4) such preventive strategies are not yet in place.


1) the health condition must place a large burden on

society, a burden that is getting larger despite existing

control efforts;

Global Situation

Globally, around 162 million, or a quarter of theworld's children, suffer from stunting,

Around 99 million are underweight,

In addition, around 51 million (8%) of the world'sunder-five children are wasted, with the greatestnumbers are also found in Asia and in Africa.

Global situation

• At the same time, around 44 million of the world’s

under-five children are overweight that is quickly

establishing itself globally, affecting both poor and

rich populations.

Global situation

• 2 billion people are deficient in key vitamins &

minerals

• Globally, 10% of deaths and disability- adjusted- life-

years (DALYs) among children below five years are

caused by micronutrient deficiencies. Iron and

Vitamin A and zinc deficiency represent the highest

health

Situation in Egypt

A reduction in the percentage of stunted children compared to the

levels observed in the earlier EDHS surveys, particularly the 2008

Egypt DHS.? However, the proportion of children who are wasted

has increased gradually over time, from 3 percent in 2000 to 8

percent in 2014. Six percent of children under age of five are

underweight for their age (El Zanaty and Way, 2014).

Situation in Egypt

Situation in Egypt

The HIECS similarly estimates a high stunting rate forchildren aged 6-59 months of 31 percent in 2011 (where 30-39percent is considered “high” by the WHO). In 9 governoratesacross all regions, HIECS data found anemia amongst childrenaged 6-59 months to be an estimated 50.2 percent in 2011.

The Ugly Face of

“Hidden Hunger”

Zinc DeficiencyVitamin A Deficiency Iodine Deficiency

Iron DeficiencyFolic Acid Deficiency

Situation in Egypt

Micronutrient malnutrition often called "hidden hunger" because

clinical manifestations of vitamin and mineral deficiencies usually

only begin to show when the condition is severe and has already

led to serious health burdens. Without proper technology, human

resources, or laboratory facilities, it is difficult to assess true

population deficiencies, and it is usually determined based on the

prevalence of resulting illness (Bhutta et al., 2008).

Situation in Egypt

In Egypt, Overall, more than one in four children in

Egypt suffers from some degree of anemia. Ten percent

were found to be moderately anemic, with the remainder

classified as mildly anemic .

Additionally 40% of women are suffering from anemia

caused by iron deficiency. In 22% of pregnant women

are deficient in vitamin A

Situation in Egypt

Vitamin and mineral deficiencies also affects the well-being of

children in Egypt. Only 79% of households consume iodized salt,

leaving more than 429,000 newborns every year unprotected from

iodine deficiency disorders, adversely affecting their learning

abilities and future development .

In Egypt, the coexistence of high stunting rates, anemia and

obesity highlights the presence of a ‘Triple burden of

malnutrition’

Iodine Deficiency

Decreased IQ, mild neurological deficits, cretinism, goitre

stillbirths & neonatal deaths

Only 79% of households consume iodized salt, leaving more

than 429,000 newborns every year unprotected from

Non-iodized salt Iodized salt

Zinc Deficiency

Low birth weight, preterm deliveries, spontaneous abortions

& congenital malformations

Burden of zinc deficiency No data

Folic Acid DeficiencyNeural tube defects, Megaloblastic Anemia

Mothers and children were slightly more vulnerable for folate

deficiency (14.7-14.9%) than adolescents (12.6%) Dr Hanaa Zagloul

Situation in Egypt(Feeding practices)

Although most infants are breastfed, exclusive breastfeedingis not widely practiced. Only alittle more than half ofchildren age 0-3 months are exclusively breastfed.Supplements are introduced

Breastfed remains high into the second year of life; morethan seven in ten children age 12-17 monthsare beingbreastfed.

Bottle-feeding is not common in Egypt.

Nevertheless, 30 percent of children 0-5 months of age werefed with a bottle with a nipple (El Zanaty and way ,2014).


2) the burden must be distributed unfairly (i.e., certainsegments of the population are unequally affected);

The greatest numbers are also found in Asia and in Africa

(WHO,2013)

Stunting ,Underweight,

Wasting (globally)

Africa Asia

Around one in five children under age five are stunted,

and one in ten children is severely stunted

(EDHS,2014).

Stunting in Children

(under 5 yrs)(Egypt)

Urban

(23) %Age

18-23

months

(25) %

Rural

21%

Reflecting the effects of both chronic and short-term malnutrition, 6

percent of children under

age five are underweight for their age (EDHS,2014).

.

Underweight in children(Egypt)

Upper Egypt and in the Frontier

Governorates

(More)

Urban Governorates

and Lower Egypt.

Wasting in children

(under 5 years)

Frontiers

14%

Age

under 6 months of age

The proportion of children with any anemia in the 2014 EDHS is similar

to the level at the time of the 2000 EDHS (30 percent) and considerably

lower than the level reported in the 2005 EDHS (49 percent).

Anemia in Children

(under 5 yrs)

Urban

(23) %Rural

29%

Mothers and children were slightly more vulnerable for folate

deficiency (14.7-14.9%) than adolescents (12.6%) (TawfiK et al., 2013)

Dr Hanaa Zagloul

Folate in Children

(under 5 yrs)

Upper and lower(Higher) folate

deficiency

Metropolitan and

Costal region

7.4% and 3.9%,

respectively

Justice

Each day over 20,000 children will die from malnutrition.

Over 1/3 of the developing nations children will die due to malnutrition, while 1/4 of developed nations children are diagnosed with obesity.

65% of the worlds population lives in countries where obesity and overnutrition kills more people than undernutrition

Impact of Malnutrition


A) The intergenerational cycle of growth failure

There is an inter-generational component of malnutrition, which means that

poor growth can be transmitted from one generation to the next. This is known

as the cycle of malnutrition. At each stage in the life cycle, malnutrition has

consequences for each successive stage and/or the next generation, particularly

among low-income households in developing countries (Black et al., 2013).

HSERV 544 - Nutrition in Children 48

Intergenerational Cycle of Undernutrition

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

WHO/UNICEF 20-hour Course as adapted by Healthy Children Project for use in Egypt 2009

49

3/1

Origin

al ill

ustr

ation b

y Jenny

Cork

ery

Fatima & Miriam meet at the antenatal clinic


Mothers who suffer chronic caloric or micronutrientdeficiencies are more likely to have low birth weight babies: ineffect, they pass their malnutrition on to the next generation.

These mothers also face increased risk of death in childbirth.Low birth weight babies face higher mortality rates, impairedmental and physical development and increased risk of adultchronic diseases.

Stunted children living with inadequate food, health and careremain stunted as adolescents .


• The girls among them grow up too often as another

generation of malnourished mothers who have low

birth weight babies of their own.

• Adults affected by malnutrition may have a low body

mass index or nutritional edema (retention of fluid).

• If malnourished adults continue to have inadequate

food, health and care into old age, they will remain

malnourished .


B) Costs of Malnutrition

B.1 Non Financial Cost

Taken together, stunting, severe wasting, low birth weights due to

intrauterine growth restriction, sub-optimal breastfeeding (non-exclusive for six

months and discontinued before one to two years) and deficiencies of vitamin A,

zinc and iron lead to the deaths of 3.6 million children under five years of age

each year. Moreover, these forms of malnutrition together account for 35 percent

of all preschooler deaths and 11 percent of the global burden of disease .

Time Magazine, August, 2008

1. Hypoglycemia

2. Hypothermia

3. Dehydration

4. Infection

5. Severe anemia

Direct causes of death:


B) Costs of Malnutrition

B.1 Financial Cost

In Addition, Malnutrition put heavy charges on the economies of

developing countries. Difficult pregnancies and the illnesses that

malnourished mothers and their children experience cost an

estimated $30 billion annually. Lost productivity and income due

to early deaths, poor school performance, disability and

absenteeism likely raise the yearly total into the hundreds of

billions of dollars .


The Cost of Hunger Study in Egypt estimated the economic andsocial cost of child undernutrition at 20.3 billion EGP. Withoutmeasures to combat and eliminate undernutrition, this cost isexpected to increase by about 32% by 2025 to reach to 26.8 billionEGP.

That is an additional cost of an estimated 6.5 billion EGP of nottaking any steps to address undernutrition among children underfive.


C. Effects of Fetal and Early Childhood Malnutrition on Adult Health and

Human Capital

It is concluded that small size at birth and at 2 years of age (particularly height)

were associated with reduced human capital: shorter adult height, less schooling,

reduced economic productivity, and for women, lower offspring birth weight. On

the other hand, larger child size at 24 months of age was alsoa risk factor.


1) Achieved schooling and educational performance

Undernutrition can affect cognitive development by causing

direct structural damage to the brain and by impairing infant

motor development .

Substantial evidence suggests an association between stunting

and present or later cognitive ability or school performance in

children from low-income and middle-income countries. Four of

five longitudinal studies report that height-for-age predicts school

or cognitive test performance in later life .


2)Body-mass index, body composition, and obesity

Maternal nutritional status during pregnancy can affect offspring

body size and composition by production of long-term deficits in

fetal lean body mass altering sensitivity of the hypothalamic-

pituitary-adrenal axis which affects appetite and physical activity

or through the action of specific components of the maternal diet

on gene expression .


3)Insulin resistance and type 2 diabetes

Type 2 diabetes results from a combination of insulin resistance and

insulin secretary failure. The so-called thrifty phenotype hypothesis

proposed that undernourished fetuses and infants make changes

(reduced lean-tissue growth and insulin sensitivity).

There is an increased risk of diabetes associated with very high

birth weight .Three studies from low-income and middle-income

countries (all adjusting for adult weight) showed higher glucose

concentrations in people with lower birth weight


4)Blood pressure

Animal studies provide strong evidence that blood pressure is

raised in offspring of mothers who are exposed to diet restriction

during pregnancy. Inadequate nutrition is postulated to reduce the

size and number of nephrons, thereby restricting adult renal

functional capacity .

Early nutrition can also affect the rennin-angiotensin system .

exposure to glucocorticoids and arterial distensibility and it has

indirect effects on blood pressure through body composition .


5) Cardiovascular disease

Several studies in high-income countries have shown that birth

weight is inversely associated with the risk of coronary heart

disease and stroke. The hazard ratio for coronary heart disease in

the Helsinki cohort study was higher in men who weighed less than

2.5 kg at birth compared with those weighing more than 4.0 kg.

Lower birth weight has also been associated with increased carotid

intima media thickness, reduced arterial compliance, and impaired

endothelial function, which are all considered to be precursors of

cardiovascular disease .


6) Immune function

In Filipino adolescents and Pakistani adults antibody response to

selected vaccines was lower in people who were small at birth than

in those with a birth weight of 2500 g or more.


7.Lung function

Lung architecture develops in utero and during the first 2-3 years

of life .Early impairment of nutrition or oxygen availability can

permanently damage lung structure and function .Forced expiratory

volume in 1 second (FEV1) and forced vital capacity show

pulmonary development and have been used as outcomes in several

studies of early determinants .


8) Cancers

Unlike other outcomes considered here, cancers are associated with

larger size in early life, possibly reflecting increased exposure to

growth factors before or after birth, or both .

In high-income countries, studies have shown consistent positive

association between birth weight and premenopausal breast cancer

Much the same associations were reported for prostate,

haemopoietic, and colorectal cancers .


9)Bone mass, fracture risk, and osteoporosis

Short birth length is associated with an increased risk of bone

fractures in adults .Positive correlations between birth weight

or weight in infancy and adult bone-mineral content or density

suggest that fetal and infant growth make important

contributions to adult bone mass .


10)Mental illness

Specific forms of mental illness are thought to be affected by

adverse intrauterine experience, including maternal undernutrition.

Alterations in brain development, occurring sometime in mid-

gestation, can precipitate evolving malfunction that manifests in

early adulthood. The neurodevelopmental hypothesis is supported

by significant changes in the size and structure of features of the

brain in some adults diagnosed with schizophrenia. Other effects of

prenatal undernutrition, such as changes in arousal and sleep

waves, are consistent with schizophrenia .


11) Blood lipids

Intrauterine malnutrition and early life growth patterns can result in metabolic

and physiological programming, with lifelong effects on the risk of

cardiovascular disease. Unhealthy lipid profiles can be a potential mechanism

underlying these associations and animal studies have supported this notion

In people aged 45 years from Beijing, low birth weight was related to raised

triglycerides and reduced HDL cholesterol, after adjustment for sex and adult

body-mass index .

Impact of Malnutrition Impact on MDG

MDG 1:

Eradicate extreme poverty and hunger

Reducing prevalence of underweight children under five

years of age is an agreed target for MDG 1. Reducing

malnutrition increases economic growth.

MDG 2:

Achieve universal primary education

Reducing malnutrition increases cognitive development and

contributes to learning and school completion rates.

MDG 3:

Promote gender equality

Promoting better nutrition practices contributes to

empowering women and to reducing discrimination against

girls in family feeding practices.

MDG 4:

Reduce child mortality

Malnutrition remains the underlying cause in one in three of all

deaths of children under five.

MDG 5:

Improve maternal health

Improved maternal nutrition and reduced maternal mortality

through iron-folic acid, calcium and other micronutrient

supplements.

MDG 6:

Combat HIV/AIDS, malaria and other diseases

Reduces maternal and child mortality caused by the interaction

of malnutrition with HIV/AIDS and other infectious diseases.

MDG 7:

Ensure environment sustainability

Better nutritional practices mean more effective use of

available food and so better adaptation to environmental stress

(Target 7a), better health from improved access to water and


Impact on SDG

ايه الحل

ايه الحل

!???????

Making the World Fit for Children

Millennium Development Goals(MDG) 2000 United Nations

1. Eradicate extreme poverty & hunger

2. Achieve universal primary education

3. Promote gender equality and empower women

4. Reduce child mortality

5. Improve maternal health

6. Combat HIV/AIDS, malaria, other diseases

7. Ensure environmental sustainability

8. Develop a global partnership for development

New Public Health

Initiative

THE 1,000 DAY WINDOW OF OPPORTUNITY

The 1,000 days from pregnancy to a child s second birthday is the

most critical time for positive impact on a child s cognitive,

intellectual, and physical development. Good nutrition in the first

1,000 days lays the foundation for health, development, and even

prosperity for the next generation.

Sustainable development goalsSDG 2015-2030

Goal 2. End hunger, achieve food security and improved nutrition, and promote sustainable agriculture

2.1 by 2030 end hunger and ensure access by all people, in particular the poor

and people in vulnerable situations including infants, to safe, nutritious and

sufficient food all year round

2.2 by 2030 end all forms of malnutrition, including achieving by 2025 the

internationally agreed targets on stunting and wasting in children under five

years of age, and address the nutritional needs of adolescent girls, pregnant

and lactating women, and older persons

2.3 by 2030 double the agricultural productivity and the incomes of small-

scale food producers, particularly women, indigenous peoples, family

farmers, pastoralists and fishers, including through secure and equal access to

land, other productive resources and inputs, knowledge, financial services,

markets, and opportunities for value addition and non-farm employment

Sustainable development goalsSDG 2015-2030

2.4 by 2030 ensure sustainable food production systems and implementresilient agricultural practices that increase productivity and production, thathelp maintain ecosystems, that strengthen capacity for adaptation to climatechange, extreme weather, drought, flooding and other disasters, and thatprogressively improve land and soil quality

2.5 by 2020 maintain genetic diversity of seeds, cultivated plants, farmed anddomesticated animals and their related wild species, including through soundlymanaged and diversified seed and plant banks at national, regional andinternational levels, and ensure access to and fair and equitable sharing ofbenefits arising from the utilization of genetic resources and associatedtraditional knowledge as internationally agreed

2.a increase investment, including through enhanced international cooperation,in rural infrastructure, agricultural research and extension services, technologydevelopment, and plant and livestock gene banks to enhance agriculturalproductive capacity in developing countries, in particular in least developedcountries

USAID NUTRITION STRATEGY2014-2025

2025 NUTRITION TARGETS ADOPTED AT THE WORLDHEALTH ASSEMBLY IN 2012:

• 40 percent reduction of the global number of

children under five who are stunted;

50 percent reduction of anemia in women of reproductive age;

30 percent reduction of low birth weight;

No increase in childhood overweight;

Increase the rate of exclusive breastfeeding in the

first six months up to at least 50 percent; and

• Reduce and maintain childhood wasting to less than 5 percent.

Situation of nutrition intervention in Egypt

The Egyptian government in partnership with the World Food

Programme (WFP) and Global Alliance for Improved Nutrition

(GAIN) fortified the flour used for making baladi bread with iron

and folic acid. In 2010, the Egyptian government announced a

five-year national project that targets 60 million Egyptians ; this

project will fortify subsidized vegetable oil with Vitamin A and D

as revealed below(MOHP,NNI, UNICEF and WHO, 2012).

Situation of Nutrition intervention in Egypt

Macro level interventions by the Egyptiangovernment and partners:

A-Wheat policy which include; reforms in pricings, production levels and a subsidy on bread.

B- Large-scale food fortification

∘ In 1996 fortification of table salt with Iodine.

∘ In 2008, fortified flour used for making baladi bread with iron and folic acid.

∘ In 2010, fortified subsidized vegetable oil with Vitamin A and D (WFP and GAIN, 2010).

Situation of Nutrition Intervention in Egypt

C- Supplementation programs

∘ Vitamin A supplementation for delivered women (for free)

∘ Iron and folic a tabs supplementation for all pregnant women (forfree)

∘ Vitamin A supplementation for all infants 9 and 18 months( forfree).

∘ Iron supplementation for infants 6 months to 30 months (weeklydose)

∘ Zn supplementation for infants (with diarrheal treatment)(MOHP,NNI, UNICEF and WHO, 2012).

Situation of Nutrition intervention in Egypt

D)Policies

Policy Area (1): promotion of intersectoral collaboration that lead toUniversal Access toadequate food and nutrition

Policy Area (2): Incorporation of Nutrition Objectives (which fall underthe policy areas) into National Development Policies, Plans, Strategies,Programmes, or activities to achieveMillennium Development Goals

Policy Area (3): Improving Household Food Security

Policy Area (4): Monitoring the food and nutrition situation

Policy Area (5): Improving the Quality and Safety of Food relatedServices to protect

consumer health

Situation of Nutrition

intervention inEgypt

Policy Area (8):Capacity building and development at community, institutional and

authority levels

Policy Area (9): Prevention and Control of non-communicable/chronic diet-related

diseases (NCDs)

Policy Area (10):Promotion of infant and young child feeding and protection of

breastfeeding

Policy Area (11):Prevention and control of micronutrients deficiency

Policy Area (12):Promotion of healthy dietary practices and life styles focusing on school

aged children and adolescents

Take Home Message

The SUN approach

The multi-stakeholder platform

Works to align and coordinate action

across sectors.

Women’s Empowerment

Health

Development & Poverty Reduction

Agriculture

Education

Social Protection

“The doctor of the future will no longer treat the human frame with

drugs, but rather will cure and prevent disease with nutrition.”

- Thomas Edison (1847 – 1931), American Inventor, Scientist & Businessman


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