Global Malnutrition: A Public Health Perspective Parmi Suchdev, MD, MPH Assistant Professor of Pediatrics & Global Health, Emory Medical Epidemiologist, CDC Core Curriculum Lecture October 31, 2011
Lecture Pre-Test
What is your position? a) R1 (intern) b) R2 or R3 (senior resident) c) Fellow d) Medical student e) Faculty
Malnutrition contributes to approximately what percent of under-five deaths? a) 5% b) 10% c) 30% d) 50% e) 90%
Which of the following nutrition interventions has the highest benefit-cost ratio? a) Iron supplementation b) Salt iodization c) Zinc supplementation d) Vitamin A supplementation e) Nutrition interventions are not cost-effective
Which of the following is a measure of acute malnutrition? a) Stunting (low height-for-age) b) Wasting (low weight-for-height) c) Underweight (low weight-for-age) d) None of the above
Child height for age is the best predictor of human capital a) True b) False
Objectives Define malnutrition Identify factors influencing nutritional status Appreciate the global prevalence of undernutrition Understand how nutritional status is measured Describe the consequences of malnutrition Evaluate effective nutrition interventions
www.globalnutritionseries.org
What is Malnutrition? Malnutrition = bad nutrition a state in which the physical function of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance process such as growth, pregnancy, lactation, physical work and resisting and recovering from disease -WFP Three principle constituents: Protein-energy malnutrition Deficiency in micronutrients Overnutrition/obesity Undernutrition
Causes of under 5 mortality, worldwide 9.7 million children under 5 die each year WHO, 2008
Slide adapted from Keith West
Underlying causes of malnutrition Malnutrition Immediate Causes Inadequate Food Intake Infection Underlying Causes Household Food Security Social and Care Environment Access to Health Care & Healthy Environment Basic Causes Formal & Informal Infrastructure Political Ideology Resources Poverty is the root cause of malnutrition!
Classification of undernutrition in children Protein-energy malnutrition Acute (wasting) Chronic (stunting) Marasmus Kwashiorkor
Lancet, 2008
Acute and chronic proteinenergy malnutrition Acute Acute shortage of food Produces recent rapid weight loss Results in wasting Is reversible Measured by weight-forheight Adults can become wasted Is most important type in emergencies Chronic Chronic shortage of nutrients or presence of multiple infections Occurs over a long period Results in stunting In children > 2 years, may be irreversible Measured by height-forage Adults cannot become stunted Is very common in stable populations
Acute Malnutrition: Marasmus Loss of subcutaneous fat and muscle In 1 st year of life associated with contaminated bottle-feeding Clinical features Triangular face Skinny arms and legs Extended abdomen Rectal prolapse
Kwashiorkor Associated with severe immune deficiency and early death Clinical signs Edema Changes to hair and skin color Anemia Hepatomegaly Lethargy
What is the estimated mortality rate from severe acute malnutrition? a) <5% b) 10% c) 25% d) 50%
Which of the following children has malnutrition? a) This 2 year-old in Vietnam b) This 3 year-old in Nepal
Lancet, 2008
How to measure nutritional status? Anthropometry = measurement of body parameters to indicate nutritional status Individuals Defines who has adequate nutrition and who is malnourished Populations Determines prevalence of malnutrition in surveyed populations
Who to measure? Usually children 6 to 59 months of age Children most vulnerable in emergencies Health and nutrition assessments and interventions target young children Nutritional status of children proxy for overall population Vulnerable adults Women of child-bearing age
What do you do after you have the measurements? Calculation of Anthropometric Indices Interpreting anthropometric data using reference curves CDC/NCHS WHO Classification of malnutrition using Z-scores Percentiles % median
Which Growth Chart to Use? CDC recommends that health care providers: Use the WHO growth standards to monitor growth for infants and children ages 0 to 2 years of age in the U.S. Use the CDC growth charts for children age 2 years and older in the U.S. www.cdc.gov/growthcharts
WHO Child Growth Standards A growth chart for the 21 st 1 year 2 years 3 years 4 years 5 years century www.who.int/childgrowth/standards
Classification of individual malnutrition Classification Z-score Values Percentile Adequate -2 < z-score < +2 5% to 95% Moderately malnourished z-score < -2 <3% Severely malnourished z-score < -3 Unreliable
What is Malnutrition? Malnutrition = bad nutrition Three principle constituents: Protein-energy malnutrition Deficiency in micronutrients Overnutrition/obesity
IMMPaCt - International Micronutrient Malnutrition Prevention and Control Program http://www.cdc.gov/immpact
5 Major Micronutrient Deficiencies Iron Iodine Vitamin A Zinc Folate Anemia Iodine Deficiency Disorders (IDD) Xeropthalmia Multiple disorders Neural tube defects
Acrodermatitis Enteropathica- Zinc Deficiency
Corneal Xerosis- Vitamin A Deficiency
Iron Deficiency Anemia
Goiter- Iodine Deficiency
What are the health consequences of malnutrition?
Consequences of malnutrition during the life cycle
Leading causes of attributable global mortality and burden of disease, 2004 Attributable Mortality % 1. High blood pressure 12.8 2. Tobacco use 8.7 3. High blood glucose 5.8 4. Physical inactivity 5.5 5. Overweight and obesity 4.8 6. High cholesterol 4.5 7. Unsafe sex 4.0 8. Alcohol use 3.8 9. Childhood underweight 3.8 10. Indoor smoke from solid fuels 3.3 Attributable DALYs % 1. Childhood underweight 5.9 2. Unsafe sex 4.6 3. Alcohol use 4.5 4. Unsafe water, sanitation, hygiene 4.2 5. High blood pressure 3.7 6. Tobacco use 3.7 7. Suboptimal breastfeeding 2.9 8. High blood glucose 2.7 9. Indoor smoke from solid fuels 2.7 10. Overweight and obesity 2.3 59 million total global deaths in 2004 1.5 billion total global DALYs in 2004 Health Statistics and Informatics
DALYs in Children < 5 Years Attributable to Nutritional Status Measures Years (millions) 100 90 80 70 60 50 91 44 Together these risk factors are responsible for 35% of under-five deaths and 11% of the global total disease burden. 40 30 20 21 10 0 Poor growth* Sub-optimal breastfeeding Vitamin A and Zinc deficiency * Intrauterine growth restriction, stunting and wasting Lancet, 2008
Long-term Consequences of Malnutrition
How do you treat and prevent malnutrition?
Key Nutrition Interventions Public health measures Infection control Hygiene Immunization Dietary diversification and breastfeeding promotion Supplementation Single or multiple micronutrients Fortification Staple foods (flour, oil, sugar, salt) Home-fortification
Evidence-based Interventions that Work www.globalnutritionseries.org
Impact of Micronutrient Interventions www.unitedcalltoaction.org
www.copenhagenconsensus.com
Nutrition Interventions are Cost- Effective For only $347 million a year, 80% of the world s hungry can get essential micronutrients adding up to > $5 billion in reduced healthcare spending and future earnings Intervention Cost/Person/ Year Benefit:Cost Ratio Vitamin A Supplementation $1.20 17:1 Zinc Supplementation $1.00 13:1 Salt Iodization $0.05 30:1 Flour Fortification $0.12 8:1 Micronutrient Powders $2.00 37:1 www.unitedcalltoaction.org
Take Home Points Nutrition is a central component for human, social and economic development Countries should focus resources on interventions with proven effectiveness and implement them to scale Through scaled-up nutrition efforts, we can: Reduce all child deaths by ¼ in the short-term Avert 60 million DALYs
Thank you!
Lecture Post-Test
Malnutrition contributes to approximately what percent of under-five deaths? a) 5% b) 10% c) 30% d) 50% e) 90%
Which of the following nutrition interventions has the highest benefit-cost ratio? a) Iron supplementation b) Salt iodization c) Zinc supplementation d) Vitamin A supplementation e) Nutrition interventions are not cost-effective
Which of the following is a measure of acute malnutrition? a) Stunting (low height-for-age) b) Wasting (low weight-for-height) c) Underweight (low weight-for-age) d) None of the above
Child height for age is the best predictor of human capital a) True b) False
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