Ministry of Public Health Session 3: Malnutrition in Afghanistan Public Nutrition Department Sept 2005

Objectives Different types of malnutrition Underlying causes of malnutrition Intergenerational and seasonal cycles

So what is malnutrition? .. malnutrition is a term that covers a wide range of clinical conditions in children and adults. (So what is malnutrition? Malnutrition (also called ‘undernutrition’)— a broad range of clinical conditions that result from deficiencies in one or a number of nutrients. Examples include: iodine deficiency disorders (i.e. goiter), vitamin A deficiency which can cause blindness, or weight loss from lack of macronutrients. When we talk in this course about malnutrition, we are talking specifically about UNDERNUTRITION- overnutrition will be covered in different courses- but just for your reference: Overnutrition— a broad range of clinical conditions that result from overconsumption or overdosing in one or a number of nutrients. Examples include: overweight and obesity.

PROTEIN ENERGY MALNUTRITION (PEM) ...a result of deficiencies in any or all nutrients (includes micronutrients, as well as macronutrients). MICRONUTRIENT DEFICIENCY DISEASES (MDD’S) ...occur as a result of deficiencies in specific micronutrients (vitamins or minerals). There are two main kinds of malnutrition-The kind that we are most familiar with- PEM-As well as MDDs

Children with PEM all suffer GROWTH FAILURE either: Occurs as a result of recent rapid weight loss or a failure to gain weight ACUTE MALNUTRITION WASTING (thinness) Occurs as a result of inadequate nutrition over a long period of time CHRONIC MALNUTRITION STUNTING (shortness) We differentiate between the types of PEM based on how they developed- over a short time or over a long time. (Review wasting, stunting and underweight) Acute malnutrition= determined by weight-for-height measurement and may be mild, moderate or severe. It includes wasting (low weight for height) and in some cases, oedema (kwashiorkor). Acute malnutrition may be mild, moderate or severe according to the weight-for-height measurement. Moderate acute malnutrition can be easily reversible once the underlying conditions improve. Severe acute malnutrition is a serious physiological complication and requires specialized intensive treatment and carries a high risk of death if not treated properly. Acute malnutrition is caused by short term macronutrient (& micronutrient) malnutrition and/ or prolonged or recurrent illness. In Afghanistan 6-10% of children U5 have acute malnutrition (moderate & severe). Chronic malnutrition= includes growth failure in a child that occurs over a long time, detected by low height-for-age (stunting). It is caused by long-term inadequate food intake and/ or repeated infections. We will go into the details of assessment and determination of type and severity of malnutrition in other trainings- not in this particular one. Underweight  Acute / Chronic

The two clinical forms of PEM: Marasmus severe loss of body weight or wasting Kwashiorkor nutritional oedema. Marasmic kwashiorkor combines symptoms of marasmus and kwaskiorkor In acute malnutrition, there are two types that look different from each other- Marasmus and Kwashiorkor. Some signs of each include: Marasmus A thin ‘old man’ face ‘Baggy pants’ loose skin around the buttocks The children concerned are usually active and may appear to be alert in their condition No nutritional oedema Prominent ribs Kwashiorkor Nutritional oedema Loss of appetite Hair changes Skin lesions and de-pigmentation Children with kwashiorkor are usually apathetic, miserable and irritable. Marasmic Kwashiorkor Mixture of the two

- prominent ribs, spine, scapulae Thin, flaccid skin hanging in folds Normal hair Alert and irritable Severe wasting - prominent ribs, spine, scapulae Thin, flaccid skin hanging in folds (So what do we see here? What signs or symptoms?) A thin ‘old man’ face ‘Baggy pants’ loose skin around the buttocks The children concerned are usually active and may appear to be alert in their condition No nutritional oedema Prominent ribs This is marasmus - Source: NutritionWorks

Oedema (symmetrical oedema involving at least the feet) Hair - thinner and lighter Apathetic and miserable Moon face No appetite Oedema (symmetrical oedema involving at least the feet) And what signs do we see here? Nutritional oedema- Oedema hides the loss of body weight, especially on the lower limbs –the child looks unusually “fat” at first. Loss of appetite Hair changes Skin lesions and de-pigmentation Children with kwashiorkor are usually apathetic, miserable and irritable. This is Kwashiorkor. In general we assess acute malnutrition using weight and height, but for a child with oedema like this in kwashiorkor, the weight no longer has a meaning, as it is not their actual tissues (it is fluid). Instead we diagnose nutritional oedema with applying gentle pressure on the upper part of the foot, for 3 seconds, to see if the impression remains. If it does, then this is pitting oedema. And indicates nutritional oedema and kwashiorkor. Skin lesions Source: NutritionWorks

What are the most common micronutrient deficiency diseases? Iron Iron deficiency anaemia (IDA) Vitamin A Xeropthalmia The other type of malnutrition is micronutrient deficiency diseases (also called MDDS). These are identifiable with specific clinical or biochemical signs. The 3 MDDs that are widespread throughout the world, including Afghanistan, are Iron- manifesting as iron deficiency anemia Vitamin A- often manifesting as xeropthalmia (also called VAD) And iodine- in iodine deficiency disorders Main causes of MDDs Poverty and poor diet Lack of clean water and sanitation Illness and malabsorption of nutrients from food Dietary diversification increased variety of food in the diet Fortification adding vitamins and minerals to food that is widely consumed by people, in a way that doesn’t change the smell or taste of the food Supplementation direct provision of the vitamin through a capsule- like vitamin A, C, iron folate, mutlivitamins, and iodine Control of infectious diseases Of course what we hope for is dietary diversification, that people can access and utilize them in a way that preserves the MN content- and that they are healthy enough for their body to be able to absorb them Iodine Iodine deficiency disorders (IDD) MDDs are associated with specific clinical signs and symptoms.

Iron deficiency Anemia Clinical signs and symptoms: fatigue, pallor increased risk of hemorrhaging and maternal mortality during child birth Population at Risk: Women of reproductive age. The main function of iron in the body is to transport oxygen to cells through hemoglobin, this is required for cells to survive Iron is found in these foods: meat, liver and dark green vegetables Iron deficiency is caused by the deficiency of iron, and/ or other micronutrient deficiencies, infections that cause loss and destruction of blood cells (where much of body iron is found) especially from malaria and hookworm. Anemia is a severe form of iron deficiency. Consequences: In Afghanistan, 71.5% of children U5 have Iron Deficiency, and 65.3% of women of reproductive age. 40%-60% <2 children are at risk of disrupted brain development. About 28,000 Afghan infants died annually due to IDA Significant number of women die during pregnancy/child birth, high levels of LBW and pre-natal mortality Lower productivity of adult work-force Consequences

Vitamin A deficiency Consequences Clinical signs and symptoms: Nightblindness, blindness Weakened immune system results in significantly increased risk of contracting communicable diseases like measles. Population at Risk: Children Women of reproductive age The functions of vitamin A in the body are: to promote vision and immunity (protection) from disease Vitamin A is found in: animal sources (such as eggs and meat, milk, cheese, cream, liver and kidney) and vegetables and fruit that are red, orange and yellow in color (e.g. carrots, tomatoes, mangoes). ‘Vitamin A Deficiency’ is caused by: lack of eating vitamin A containing foods, and/ or infections such as measles and diarrhea that increase the requirement for vitamin A and destroy the vitamin A stores of the body. Consequences For children: lack of vitamin A causes blindness, and significantly increases the risk of severe illness, and even death, from such common childhood infections as diarrhea disease and measles. For pregnant women: night blindness and increases the risk of death. In Afghanistan, 10.2% of children U5 have Vitamin A Deficiency, and about 2% of women of reproductive age. Consequences

Iodine Deficiency Disorder Clinical signs and symptoms: Goiter, cretinism, reduced mental capacity Population at Risk: Unborn children from women with IDD widespread in developing countries, especially in landlocked, mountainous areas. The function of iodine in the body is: to support physical growth and mental development The signs and symptoms of Iodine Deficiency are: Visible: Large swelling on the throat or slight swelling when head is tilted back (goiter); cretinism or dwarfism Invisible: Low IQ, poor mental development Consequences In Afghanistan, 71.9% of children 7-11 years old have iodine deficiency (urinary iodine <100ug/L) , and 75% of women of reproductive age. Consequences

Vitamin C deficiency: Scurvy Clinical signs and symptoms: Bleeding easily (gums, bruises) Swollen joints Muscle weakness At risk Infants Vitamin C functions in the body to form healthy skin and connective tissue (bone, cartilage, tendons), help with iron absorption (when eaten with iron containing foods) and protection in the body (antioxidant) Vitamin C is found in these foods: oranges, lemons, limes, rhubarb, tomato, red/green peppers, potatoes (if eaten often), and other fruits and vegetables. Organ meats (liver, kidney). Deficiency is caused by lack of eating vitamin C containing foods (especially among populations dependent on food aid and non-diverse diets). The signs & symptoms of vitamin C deficiency (scurvy) are: Bleeding easily (gums, bruises) Muscular weakness Swollen or painful joints Slow-healing wounds or fractures Tooth decay Loss of appetite Infants are at particular risk to scurvy If left untreated, scurvy in any age group can lead to death. In Afghanistan, up to 10% of the population in the northwest (Southern Faryab) and west (Ghor) have had vitamin C deficiency. Consequences

Conceptual Model of Causes of Malnutrition Malnutrition Immediate Causes Inadequate Food Intake Disease Underlying Causes Poor Social and Care Environment Household Food Insecurity Poor Access to Health Care & Unhealthy Environment So why do people become malnourished? This is the conceptual model of malnutrition. What is important to notice about this picture is that malnutrition has many causes not just a lack of food. There are three levels of causes of malnutrition. Immediate causes include: inadequate food intake and disease. Inadequate food intake means not consuming foods in the quantity and quality required for health and growth. Disease can be an illness often caused by an infection. These immediate causes have underlying causes: household food insecurity, poor social and care environment, and poor access to health care and unhealthy environment. Household food insecurity is a lack of household access at all times to an adequate supply of safe and nutritious foods. Poor social and care environment is the set of attitudes, behaviors, and practices of caregivers to provide the food, health care stimulation, and emotional support necessary for children’s health, survival, growth and development. Unhealthy environment includes both clinical care (eg vaccinations, basic health care) and public health issues- like adequate access to clean safe water, appropriate personal hygiene, etc Basic causes of malnutrition at the bottom of the diagram include: the larger societal structures like the education system, national infrastructure (access to markets), political ideologies, and natural resources available to the population. Many of the sessions we will cover today will address parts of this diagram. Any questions? (take 2-3 short questions) Basic Causes Formal & Informal Infrastructure Political Ideology Resources Adapted from UNICEF

The causes of malnutrition are complex and interconnected requires people to work together for Adequate CARE for mothers and children, and support for mothers on appropriate child feeding practices Sufficient availability of, or access to, affordable, safe and nutritious FOOD throughout the year Easy and sustained access to HEALTH sanitation and clean water services The causes of under nutrition are many and interconnected. Globally, nutrition is now viewed in terms of three main themes, food, health and care practices and behaviours. As shown in this slide All are rooted in contextual determinants poverty, position of women , the socio political environment and culture. In order to address problems in nutrition, all these factors have to be addressed All these are influenced by social, cultural and political determinants, including the level of women’s empowerment

Malnutrition and Infection Cycle Inadequate dietary intake Appetite loss Nutrient loss Malabsorption Altered metabolism Weight loss Growth faltering Lowered immunity Mucosal damage When we say that malnutrition can be the result of the two direct causes, we mean that they become malnourished (where illness makes it harder for the body to absorb the nutrients that it receives, and that in adequate dietary intake makes it more likely for someone to become ill. ) The relationship between the two can make the other one worse. This is called the Malnutrition and Infection Cycle Disease: Incidence duration - severity Source: Helen Young, WFP Food and Nutrition Training, Tufts University

RISKS of being malnourished... Lowered resistance to disease Increased risk of mortality As nutritional status declines the risk of death increases, there is a lowered resistance to disease, in the care of MDDs, there is quite a bit of “invisible” impacts, such as lowered learning ability, and overall reduction of physical activity Learning difficulties Reduced physical activity

Inter-generation cycle of malnutrition The high prevalence of chronic malnutrition is explained by extremely poor maternal nutritional status. Poor maternal nutritional status will contribute to poor intrauterine growth and low birth weight. Poor complementary feeding practices and micronutrient deficiencies coupled with a high incidence of diarrhea and subsequent inadequate quality of food will likely lead to another generation of malnourished mothers - and who will replicate this cycle.

Main messages Malnutrition : broad range of conditions Undernutrition = PEM and MDDs Visible and invisible consequences Many challenges Take into account underlying causes, seasonality and the intergenerational cycle of malnutrition Nutrition is everyone’s business In summary: Malnutrition covers a broad range of conditions Undernutrition includes PEM and MDDs There are visible and invisible consequences of PEM and MDDs The nutrition situation in Afghanistan has many challenges, and much of the population is currently negatively affected or at risk. Addressing malnutrition needs to take into account the underlying causes of malnutrition, as well as seasonality and the intergenerational cycle of malnutrition There are a broad array of interventions to address malnutrition- and these involve many different sectors Nutrition is about more than just food, and everyone in each sector has a role to play in promoting the health of Afghanistan’s people (Leave time for questions and clarifications)