Approach to Disorders of Nutrition in Resource Poor Countries AAFP Global Health Conference October 2013 Jeff Heck Shoulder to Shoulder

Three views The Individual The Community The Society

Anthropometrics and Nutrition What are the basic anthropometric measures and how are they interpreted What is the impact of undernutrition on the population and the individual How does one design a feeding program

Anthropometrics- assessment of nutritional status Individuals- measure over time Communities- –assess communities compared to mean –Assess individuals – improved with clinical assessment Measure: Ht Wt Mid upper arm circumference (age 1-5) Head circumference

Calculate Weight for Height (WH) and BMI for Age (BMIA) Low WH or BMIA = Acute undernutrition (wasting)

Calculate Height for Age (HA) Low HA indicates chronic undernutrition or stunting –Prevalence as high as 60% in some communities –It is not possible to “catch up” after the first five years –Clinical diagnosis not obvious

Gomez Classification: Weight for age compared to average percent at age –Grade 0: >90%, normal –Grade I: 81-90%, mild malnutrition –Grade II: 60-80%, moderate malnutrition –Grade III: 60 %, severe malnutrition.

Classification of underweight categories BMI(kg m-2) Normal >=18.5 Grade I Grade II Grade III<=15.9 (adapted from Ferro-Luzzi et al, )

WHO Classification

Mid Upper Arm Circumference A cutoff point of 13.5 cm detects most children with severe malnutrition. Measure from the tip of the shoulder to the olecranon

Definitions of Malnutrition –Wasting = acute current, short-duration malnutrition where weight for age and weight for height are low but height for age is normal –Stunting = past chronic malnutrition, where weight for age and height for age are low but weight for height is normal –Wasting and stunting = acute on chronic, or current long-duration malnutrition, where weight or age, height for age, and weight for height are all low

Effects of inadequate food intake on physical activity and growth A study of Guatemalan children showed that children compensated for: – a 10% reduction in adequate caloric intake for 1 month by reducing physical activity without growth being affected –a 20% reduction in adequate caloric intake for 1 month affected both the level of physical activity and growth

Malnutrition and hospital mortality

Malnutrition Most common cause of immunodeficiency worldwide Increases risks and complications of pneumonia, diarrhea, measles and tuberculosis Increases risk of intestinal parasites Increases risk of developmental disability and lifetime cognitive ability

Impact of Poor Nutrition Impairs Cell mediated immunity Impairs Phagocyte Production Impairs Cytokine Production Impairs Humoral Response Impairs Complement System Impairs Physical Barriers

Treatment of Severe Malnutrition Feeding: Ready to Use Therapeutic Food (eg peanut paste, milk powder, oil, sugar micronutrients – rather than Fortified Milk Antibiotics: NEJM Jan 31,2013 -Antibiotics as Part of Management of Severe Malnutrition. Mortality: Amoxicillin: 4.8% Cefdnir: 4.1% vs Placebo: 7.4% Anti-parasitic Meds Outpatient management possible for most and preferred!

Severe malnutrition is the tip of the iceberg of a community’s nutrition

Field Assessment of Malnutrition of Children Under 5

Community Assessment –Under 5s

Village: Aggregate data Sample Size: 188 Date: 1/23/06-1/31/06 IndicatorSignificance% Z-score -2  -3 % Z-score < -3 Clinical Malnutrition Height for Age (HfA) Stunting21.39 Weight for Age (WfA) Underweight Weight for Height (WfH) Wasting Anemia % with HCT < 33 or HB < %

Table 1. Classification for assessing severity of malnutrition by prevalence ranges among children under 5 years of age Indicator Severity of malnutrition by prevalence ranges (%) LowMediumHighVery high Stunting Height for Age < >=40 Underweight Weight for Age< >=30 Wasting Weight for Height< >=15

Interventions Feeding programs at school Under five Programs Community Food Supplementation Programs

Critical indicator of food security = grain (cereal) production Grain –Directly and indirectly provides about 2/3 of all food energy –Average annual world consumption rate = 327 kg per head –US consumption rate = 800 kg per head –India consumption rate = 200 kg per head

Identifying the Intervention Point Kwashiorkor and Marasmus Undernutrition and growth stunting Food Insufficiency Reasons for inadequate food production in developing countries: Ineffective translational science: from new knowledge to effective agricultural extension Unavailability of improved seeds and breeds Lack of appropriate land tenure policies Lack of credit for necessary fertilizer and pesticides Cultural beliefs and misperceptions about food and nutrition Counterproductive procurement prices and undue promotion of cash crops

Identifying the Intervention Point Kwashiorkor and Marasmus Undernutrition and growth stunting Food Insufficiency Reasons for inadequate food production in developing countries: Ineffective translational science: from new knowledge to effective agricultural extension Unavailability of improved seeds and breeds Lack of appropriate land tenure policies Lack of credit for necessary fertilizer and pesticides Cultural beliefs and misperceptions about food and nutrition Counterproductive procurement prices and undue promotion of cash crops Disaster relief

Identifying the Intervention Point Kwashiorkor and Marasmus Undernutrition and growth stunting Food Insufficiency Reasons for inadequate food production in developing countries: Ineffective translational science: from new knowledge to effective agricultural extension Unavailability of improved seeds and breeds Lack of appropriate land tenure policies Lack of credit for necessary fertilizer and pesticides Cultural beliefs and misperceptions about food and nutrition Counterproductive procurement prices and undue promotion of cash crops Disaster relief Plumpy Nut. World Vision, PMA.

Identifying the Intervention Point Kwashiorkor and Marasmus Undernutrition and growth stunting Food Insufficiency Reasons for inadequate food production in developing countries: Ineffective translational science: from new knowledge to effective agricultural extension Unavailability of improved seeds and breeds Lack of appropriate land tenure policies Lack of credit for necessary fertilizer and pesticides Cultural beliefs and misperceptions about food and nutrition Counterproductive procurement prices and undue promotion of cash crops Disaster relief Plumpy Nut. World Vision, PMA. Zamarano – Hon. Gov. FAO, Peace Corps Micro lending NGOs World, national market Honduran Gov. FAO

Structure of Programs-Related to Success?? Food Source Program Design Program Governance Community NGO Partnership - Comm. & NGO