NUTRITION. Kate Godden RNutr (Public Health)

Transcription

1 NUTRITION Kate Godden RNutr (Public Health)

2 Aims 2 To present an overview of the different types of malnutrition of the impacts in terms of health, wealth and mortality cost-effective interventions To direct you to further information sources

3 Undernutrition matters 3 Impacts are dose related Significant morbidity and lost DALYs variable. Impaired cognitive development Mortality, 1/3 of global U5MR. Lancet 2008 The economic costs of undernutrition, in terms of lost national productivity and economic growth, are significant ranging from 2 to 3% of GDP in some countries and up to 11% of GDP in Africa and Asia each year (2017)

4 Undernutrition led to 45% of all child deaths in IUGR, stunting, wasting, vitamin A & zinc deficiency and sub-optimal breastfeeding is responsible for 45% of all child deaths in Average stunting African 35%, Asia 29% Average wasting African 8%, Asia 10% Lancet, June 2013 Maternal & Child Undernutrition series Impacts are reversible in the first 1000 days of life.

5 Source: WHO Global Health Risks Report,

6 Interventions before 36 months age, can reduce stunting by 36%, mortality by about 25% and DALYS by 25%. Key messages - Lancet 2008/2013 Maternal and child malnutrition is the underlying cause of >1/3 (3.5 million) of all child deaths under 5 years of age. Conception to 2 yrs (-9 to 24 months) is critical window of opportunity to get a child back on track 90% of worlds malnourished live in 36 countries

7 Undernutrition and Infection 7 Inadequate food intake Loss of appetite, malabsorption, increased metabolism Weight loss, lowered CMI growth faltering Increased vulnerability, severity, duration of disease

8 8 Humanitarian Development UNICEF Conceptual Framework for Malnutrition

9 9 Nutrition programming has a good and established evidence base Lancet - maternal & child undernutrition series, in 2008 & Black et al; 1/3 of deaths <5yrs attributed under nutrition. Largest risk factor for global burden of disease Victora et al; Reinforces evidence re the positive health and economic outcomes of good nutrition Bhutta et al; Outlines 13 evidence based cost-effective interventions for developing countries. World Bank; Scaling up nutrition what will it cost? 2010

10 What works for children? 10 Lancet, 2008 World Bank, Exclusive breastfeeding 2. Complementary/infant feeding 3. Hygiene 4. VAS 5. Therapeutic zinc 6. Iodised salt 7. Preventative zinc 8. CMAM / CTC 1. Breast feeding support 2. Complementary feeding 3. Handwashing with soap 4. VAS 5. Therapeutic zinc 6. Multiple micronutrients 7. Deworming 8. Prevent/treat MAM <2 yrs 9. CMAM / CTC

11 Micronutrients focus point 11 Vitamin A & Zinc 600,000 & 500,000 deaths/yr 9.8% global childhood DALYS Iron & Iodine Effects on cognitive development, education & economic productivity Fe def ~ 115,000 maternal deaths/yr

12 What works for adults? 12 Lancet, 2008 World Bank, Maternal Fe & folate supplementation 2. Maternal multi-nutrient supplementation 3. Maternal iodine, salt iodisation 4. Maternal calcium supplementation 5. Reduce tobacco consumption/indoor air pollution 1. Fe & folate for pregnant 2. Fe fortification of staples 3. Salt iodisation 4. Iodine supplements

13 13 Undernutrition - terminology Chronic vs Acute Long term Reduced growth Height for age Rapid drop in food intake Reduced growth +/- weight loss Weight for height Ht/Age Wt/Ht Rates of 40% not uncommon Rates >10% merit investigation Related to poverty more than disasters Linked with increased morbidity and mortality

14 Kwashiorkhor vs Marasmus two syndromes of acute undernutrition 14 Acute undernutrition with bilateral oedema Acute undernutrition Disadaptation to starvation starvation Common post weaning Moon face, flaky paint skin, hair changes Higher mortality Old mans face Wt/Ht <80% MUAC <11.5

15 Kwashiorkhor 15 Kenya, 2008

16 Marasmic Child 2 year old, Tajikistan,

17 Mortality in undernutrition - focus point 17 Case fatality rates of 20-30% are typical for malnourished <5 s in developing countries. <10% often achieved in emergency situations The major causes of the mortality are Hypoglycaemia Hypothermia Dehydration Infections

18 Classification of acute malnutrition 18 Indicators MUAC - gained acceptance Wt/Ht gold standard measure? growth standards NCHS vs WHO/CDC 2006 Bilateral oedema

19 Cut offs 19 Wt/Ht MUAC - <80% median or 2 z-scores moderate - <70% median or 3 z-scores severe - <12.5cm, <11.5 cm for <5yrs established - <22cm typical for pregnant women Bilateral oedema - severe malnutrition

20 Programme types 20 Supplementary feeding lacking in evidence base Therapeutic feeding Community based therapeutic care CTC/CMAM ww.validinternational.org Traditional TFC, inpatient

21 Community based management of acute 21 malnutrition (CMAM) Established evidence base on effectiveness Based on Good community sensitization and participation High levels of coverage Requires stabilisation centre (SC), outpatient therapeutic care (OTP) and food support after discharge

22 22 Inpatient Therapeutic Feeding Stabilisation centre (SC)/ phase 1 If fail appetite test Lasts up to one week, for those unable to eat or with complications High mortality - hypothermia, hypoglycaemia, dehydration and infections Continue breastfeeding Provide kcal/kg body weight / day A 75kcal/100ml feed (F75), 2-3 hourly 0.9g protein/100ml (a low to moderate level) No iron supplementation TLC

23 Additional treatment in SC 23 Antibiotics, broad spectrum Measles vaccination for >6months Vitamin A Antihelminths, during rehabilitation phase Treat specific vitamin/mineral deficiencies Modified ORS Zinc No iron at this stage

24 24 Rehabilitation / OTP / phase 2 If pass appetite test, lasts 2+ weeks Switch gradually to F100, then slowly increase volume or use ready to use therapeutic foods (RUTF) 100kcal/100ml feed plus solids if appropriate Aim to provide 150+ kcal/kg body weight / day Iron supplementation begins TLC

25 25 What of babies and infants? Support or recommence breastfeeding and feed the mum Support to breastfeeding is the single most effective health intervention. Lancet 2005 Jones et al MAMI management of acute malnutrition in infants, WHO project.

26 More breastfeeding gives more protection

27 Breastfeeding in disaster contexts. 27 Why is exclusive breastfeeding the priority in disasters?

28 Quality water & poor sanitation Shortage of fuel & utensils Time limitations Uncertain supplies of formula Lack of knowledge on preparation 28

29 Infant milk formula is not sterile Powdered infant formulas are NOT sterile products They can become contaminated at factory level with heat resistant, pathogenic bacteria Enterobacter sakazakii is highly virulent and found in infant formula Bali, March 2008

30 The International Code The Code aims to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution. Bali, March 2008

31 Micronutrient Deficiencies 31 Unusual to find specific nutrient deficiencies in the absence of undernutrition Common MNDs Vitamin A can be visible but rare Zinc not visible, common Anaemia Iodine deficiency disorders very common, can be visible. Also nicotinic acid, vitamin C

32 Vitamin A Deficiency Xeropthalmia Bitots spots (X1B) are foamy white areas on the white of the eye. Be careful not to confuse them with other types of eye problems. These signs will most often be seen in children. Corneal Xerosis(X2) Keratomalacia (X3) 32

33 Niacin Deficiency - Pellagra Casal s collar A rash (dermatitis) which is on both sides of the body, and on skin normally exposed to sunlight is a sign of pellagra. Check the face, neck, hands, arms and legs. 33

34 Iodine Deficiency Goiter examination Goitre can be examined by looking or by feeling the neck (palpating). If the goiter is not large it may only be seen if the head is tilted gently backwards. The visible goitres seen in the 2 pictures on the top left are Grade 2. Iodine deficiency can also cause developmental problems in children such cretinism 34

35 35 WHO classification of goitre 0 Not palpable or visible 1 Only visible with extended neck. Palpable, moves up with swallow 2 Enlarged visible goitre

36 Iron Deficiency Anaemia Pale mucous membranes in the eye and the tongue are signs of anaemia. You may see these signs in males and females of all ages. 36

37 Information sources - academic 37 Lancet 2008 Maternal and Child Undernutrition series Bhutta et al. What works? Interventions for maternal and child survival World Bank 2010 Scaling up nutrition - What will it cost? Malnutrition and infection: May 2007, vol 4, issue 5,

38 Information sources - practical 38 The Field Exchange, Special supplement Nov 2004, Community-based Therapeutic Care. Online at The Global Nutrition Reports CMAM guidelines, see or UNICEF, USAID guidelines The CMAM Forum MSF or ACF Nutrition Guidelines