HSERV 544 - Nutrition in Children Jonathan Gorstein Clinical Associate Professor Department of Global Health http://www.who.int/nutrition/topics/elena_video/en/index.html http://www.youtube.com/watch?v=X-2KA5Ht9YM HSERV 544 - Nutrition in Children

HSERV 544 - Nutrition in Children Terminology Hunger – physiological state when food not able to meet energy needs Malnutrition – impaired development linked to both deficient and excessive nutrient intake Undernutrition – most common form of malnutrition in developing countries; energy, protein and micronutrients HSERV 544 - Nutrition in Children

Major Nutritional Problems in the World Protein-energy malnutrition Obesity Micronutrient deficiency problems Iron deficiency anemia Vitamin A deficiency Iodine deficiency disorders Zinc deficiency Folate deficiency Nutrition-related chronic diseases HSERV 544 - Nutrition in Children

Causes of Undernutrition Undernutrition is a complex condition that involves multiple, overlapping deficiencies of protein, energy and micronutrients – rarely do these occur in isolation The primary cause of undernutrition is an inadequate food intake, but is compounded by illness and malabsorption Insufficient access to food, poor health services, the lack of safe water and sanitation, inadequate child and maternal care and poverty are underlying causes HSERV 544 - Nutrition in Children

Classification of Malnutrition WHO recommends three anthropometric indicators for assessment of nutritional status Wasting (Low weight-for-height) Stunting (Low height-for-age) http://www.undispatch.com/stunting-the-least-understood-most-under-appreciated-development-issue-in-the-world Underweight (Low weight-for-age) Classification based on International Growth Reference HSERV 544 - Nutrition in Children

Prevention and Management of Undernutrition Heightened visibility over past 2-3 years due to successful and innovative programs Gates …. Public-private partnerships GAIN: Ten Year Strategy for Micronutrients http://www.gainhealth.org/ World Bank: Repositioning Nutrition Lancet: Special Series on Undernutrition Opportunities HSERV 544 - Nutrition in Children

Intergenerational Cycle of Undernutrition The cycle of poor nutrition perpetuates itself across generations - supported by scientific evidence Childhood: Child growth failure, impaired mental development Fetal and Infant stages: Low birthweight baby Pregnancy Compromised nutritional status Adolescents: Low weight and height Adult: Small adult woman, lowered productivity HSERV 544 - Nutrition in Children

Consequences of Undernutrition: Economic costs Undernutrition leads to reduced productivity, hampering economic growth and effectiveness of investments in health and education Vitamin and mineral deficiencies are estimated to cost some countries the equivalent of more than 5 per cent of their GNP in lost lives, disability and productivity HSERV 544 - Nutrition in Children

Infection-Malnutrition Synergism Weight loss Growth faltering Immunity lowered Inadequate dietary intake Disease Incidence Severity Duration Appetite loss Nutrient loss Malabsorption Altered Metabolism HSERV 544 - Nutrition in Children

Causes of Mortality among Preschool Children, 2005 Other Perinatal Deaths associated with undernutrition 55% HIV/AIDS Acute Respiratory Infection Measles Malaria Diarrhea Source: WHO (2003) HSERV 544 - Nutrition in Children

HSERV 544 - Nutrition in Children Interventions to improve nutrition and reduce HIV/AIDS progression – from Individual to Community Therapeutic Direct food assistance Food aid provided in conjunction with ARVs Social protection Cash transfers Sustainable Livelihoods Income generating opportunities Small-scale fortification Agriculture, e. small-farmer initiatives HSERV 544 - Nutrition in Children

Consequences of Malnutrition: Economic costs Malnutrition leads to reduced productivity, hampering economic growth and effectiveness of investments in health and education Vitamin and mineral deficiencies are estimated to cost some countries the equivalent of more than 5 per cent of their GNP in lost lives, disability and productivity HSERV 544 - Nutrition in Children

HSERV 544 - Nutrition in Children Micronutrients Micronutrients are needed by the body only in minute amounts, are critical for: Regulation of growth, activity, development Immune and reproductive function Three primary micronutrient deficiencies include: Iodine Vitamin A Iron HSERV 544 - Nutrition in Children

Population at Risk of Deficiency - Global 2.0 1.6 0.8 Source: UNICEF (2002) HSERV 544 - Nutrition in Children

Iodine Deficiency Disorders (IDD) Single most important cause of preventable brain damage and mental retardation Significantly raises the risk of stillbirth and miscarriage in pregnant women About 50 million people worldwide suffer from varying degrees of brain damage and physical impairment due to iodine deficiency – Concept of IDD (Spectrum of disability) The primary intervention for the control of IDD is through salt iodization HSERV 544 - Nutrition in Children

Iodine Deficiency Disorders (IDD) Today Some 70 per cent of households in the developing world are using iodized salt, compared to less than 20 per cent at the beginning of the decade. As a result, 91 million newborns are protected yearly from significant loss in learning ability Unfinished Business There are still 35 countries where less than half the households consume iodized salt HSERV 544 - Nutrition in Children

Coverage of Iodized Salt – by Region Source: UNICEF (2002) HSERV 544 - Nutrition in Children

Levels of Iodized Salt Coverage 90% or more 50% to 89% Less than 50% No recent data Source: UNICEF (2002) HSERV 544 - Nutrition in Children

Major Increases in Iodized Salt Coverage Source: UNICEF (2004) HSERV 544 - Nutrition in Children

41 Million Newborns Still Unprotected from Learning Disabilities Source: UNICEF (2002) HSERV 544 - Nutrition in Children

HSERV 544 - Nutrition in Children Vitamin A Deficiency Contributing factor in 2.2 million deaths each year from diarrhea and 1 million deaths from measles among preschool children under five Severe deficiency can also cause irreversible corneal damage, leading to partial or total blindness Results of field trials indicate that VA supplementation of children with can reduce deaths from diarrhea. Four studies showed deaths were reduced by 35-50 per cent. VA can reduce by half the number of deaths due to measles HSERV 544 - Nutrition in Children

Magnitude of Vitamin A Deficiency Pre-school children Clinically deficient: 3 million (Asia and Africa) Subclinically deficient (low serum retinol): 100-140 million 250,000-500,000 become blind each year 90 % case fatality among those who become blind Pregnant women 25%-30% cases of night blindness reported in some Asian countries HSERV 544 - Nutrition in Children

Interventions to Control VAD In 1999, only 10 countries provided two rounds of VA supplementation with high coverage, this has increased to over 50 countries by 2004. Between 1998 and 2004, UNICEF estimates that about two million child deaths may have been prevented from vitamin A supplementation Food Fortification - A number of countries are successfully fortifying staple foods with vitamin A (e.g. sugar, maize flour, wheat) reaching large populations. http://www.one.org/us/living-proof?vid=9sOteg1xwls HSERV 544 - Nutrition in Children

Vitamin A Supplementation Coverage1: Developing world 1 Percent of children aged 6-59 months who received at least one vitamin A supplement within the last six months HSERV 544 - Nutrition in Children Source: UNICEF (2000)

VA Supplementation Coverage Where VAD is a public health problem (U5MR>70) 70% or more 30 to 69% Less than 30% No data available 1 Percent of children aged 6-59 months who received at least one vitamin A supplement within the last six months HSERV 544 - Nutrition in Children Source: UNICEF (2000)

Iron Deficiency and Anaemia Most common nutritional disorder in the world Lowers resistance to disease and weakens a child's learning ability and physical stamina Significant cause of maternal mortality, increasing the risk of hemorrhage and infection during childbirth. Nearly 2 billion people estimated to be anemic and millions more are iron deficient, the vast majority are women. Supplementation and fortification are primary interventions to improve iron intake HSERV 544 - Nutrition in Children

Global Prevalence of Anaemia: Pregnant Women Source: WHO (1999) HSERV 544 - Nutrition in Children

Main Factors Contributing to Anaemia Iron deficiency Poor bioavailability of consumed iron Insufficient dietary iron intake Chronic and recurrent infections that interfere with food intake and absorption/utilization of iron Helminth infections, primarily Hookworm Chronic diarrheal disease HIV Malaria HSERV 544 - Nutrition in Children

Interventions to Control Anaemia Depends on etiology For iron deficiency: supplementation and fortification For parasitic disease control: appropriate measures for prevention and presumptive treatment HSERV 544 - Nutrition in Children

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