2. MALNUTRITION
OBJECTIVES:
At the end of the lecture students should be able to:
• Define and classify malnutrition
• Why public health problem
• Identify impact of malnutrition
• Public health interventions
• Take Home message
2
3. Definition
Malnutrition is defined as a state in which the physical
function of an individual is impaired to the point where
he or she can no longer maintain natural bodily capacities
such as growth, pregnancy, lactation, learning abilities,
physical work and resisting and recovering from disease .
6. Malnutrition
Derived from malus (bad) and nutrire (to nourish)
Includes both
Under nutrition (deficiency of one or more
essential nutrients)
Over nutrition (an excess of a nutrient or
nutrients)
7. Types of
Malnutrition
(under nutrition)
• Under nutrition is depletion of energy (calories) resulting form
insufficient food intake over an extended period of time.
• In extreme cases under-nutrition is called Starvation.
Specific Deficiency is the pathological state resulting form a
deficiency of an individual nutrient such as vitamin A deficiency,
iodine deficiency.
7
8. Types of
Malnutrition
(Over nutrition)
Over nutrition:
• “Over nutrition is the pathological state resulting from the
consumption of excessive quantity of food over an extended
period of time”.
• Overweight and obesity are very common conditions in
developed society and are becoming more common in developing
societies and those in transition.
8
18. Public health
importance
For a health problem or condition to be considered a public health issue,
four criteria must be met:
1) the health condition must place a large burden on society, a
burden that is getting larger despite existing control efforts;
2) the burden must be distributed unfairly (i.e., certain segments
of the population are unequally affected);
3) there must be evidence that upstream preventive
strategies could substantially reduce the burden of the condition;
and
4) such preventive strategies are not yet in place.
19. Public health
importance
1) the health condition must place a large burden on
society, a burden that is getting larger despite existing
control efforts;
20. Global
Situation
Globally, around 162 million, or a quarter of the
world's children, suffer from stunting,
Around 99 million are underweight,
In addition, around 51 million (8%) of the world's
under-five children are wasted, with the greatest
numbers are also found in Asia and in Africa.
21. Global
situation
• At the same time, around 44 million of the world’s
under-five children are overweight that is quickly
establishing itself globally, affecting both poor and
rich populations.
22. Global
situation
• 2 billion people are deficient in key vitamins &
minerals
• Globally, 10% of deaths and disability- adjusted- life-
years (DALYs) among children below five years are
caused by micronutrient deficiencies. Iron and
Vitamin A and zinc deficiency represent the highest
health
23. Situation in
Egypt
A reduction in the percentage of stunted children compared to the
levels observed in the earlier EDHS surveys, particularly the 2008
Egypt DHS.? However, the proportion of children who are wasted
has increased gradually over time, from 3 percent in 2000 to 8
percent in 2014. Six percent of children under age of five are
underweight for their age (El Zanaty and Way, 2014).
25. Situation in
Egypt
The HIECS similarly estimates a high stunting rate for
children aged 6-59 months of 31 percent in 2011 (where 30-39
percent is considered “high” by the WHO). In 9 governorates
across all regions, HIECS data found anemia amongst children
aged 6-59 months to be an estimated 50.2 percent in 2011.
26. The Ugly Face of
“Hidden Hunger”
Zinc DeficiencyVitamin A Deficiency Iodine Deficiency
Iron Deficiency
Folic Acid Deficiency
27. Situation in
Egypt
Micronutrient malnutrition often called "hidden hunger" because
clinical manifestations of vitamin and mineral deficiencies usually
only begin to show when the condition is severe and has already
led to serious health burdens. Without proper technology, human
resources, or laboratory facilities, it is difficult to assess true
population deficiencies, and it is usually determined based on the
prevalence of resulting illness (Bhutta et al., 2008).
28. Situation in
Egypt
In Egypt, Overall, more than one in four children in
Egypt suffers from some degree of anemia. Ten percent
were found to be moderately anemic, with the remainder
classified as mildly anemic .
Additionally 40% of women are suffering from anemia
caused by iron deficiency. In 22% of pregnant women
are deficient in vitamin A
29. Situation in
Egypt
Vitamin and mineral deficiencies also affects the well-being of
children in Egypt. Only 79% of households consume iodized salt,
leaving more than 429,000 newborns every year unprotected from
iodine deficiency disorders, adversely affecting their learning
abilities and future development .
In Egypt, the coexistence of high stunting rates, anemia and
obesity highlights the presence of a ‘Triple burden of
malnutrition’
34. Folic Acid Deficiency
Neural tube defects, Megaloblastic Anemia
Mothers and children were slightly more vulnerable for folate
deficiency (14.7-14.9%) than adolescents (12.6%) Dr Hanaa Zagloul
35. Situation in
Egypt
(Feeding
practices)
Although most infants are breastfed, exclusive breastfeeding
is not widely practiced. Only alittle more than half of
children age 0-3 months are exclusively breastfed.
Supplements are introduced
Breastfed remains high into the second year of life; more
than seven in ten children age 12-17 monthsare being
breastfed.
Bottle-feeding is not common in Egypt.
Nevertheless, 30 percent of children 0-5 months of age were
fed with a bottle with a nipple (El Zanaty and way ,2014).
36. Public health
importance
2) the burden must be distributed unfairly (i.e., certain
segments of the population are unequally affected);
37. The greatest numbers are also found in Asia and in Africa
(WHO,2013)
Stunting ,Underweight,
Wasting (globally)
Africa Asia
38. Around one in five children under age five are stunted,
and one in ten children is severely stunted
(EDHS,2014).
Stunting in Children
(under 5 yrs)(Egypt)
Urban
(23) %
Age
18-23
months
(25) %
Rural
21%
39. Reflecting the effects of both chronic and short-term malnutrition, 6
percent of children under
age five are underweight for their age (EDHS,2014).
.
Underweight in
children
(Egypt)
Upper Egypt and in the Frontier
Governorates
(More)
Urban Governorates
and Lower Egypt.
41. The proportion of children with any anemia in the 2014 EDHS is similar
to the level at the time of the 2000 EDHS (30 percent) and considerably
lower than the level reported in the 2005 EDHS (49 percent).
Anemia in Children
(under 5 yrs)
Urban
(23) %
Rural
29%
42. Mothers and children were slightly more vulnerable for folate
deficiency (14.7-14.9%) than adolescents (12.6%) (TawfiK et al., 2013)
Dr Hanaa Zagloul
Folate in Children
(under 5 yrs)
Upper and lower
(Higher) folate
deficiency
Metropolitan and
Costal region
7.4% and 3.9%,
respectively
45. Each day over 20,000 children will die from malnutrition.
Over 1/3 of the developing nations children will die due to
malnutrition, while 1/4 of developed nations children are
diagnosed with obesity.
65% of the worlds population lives in countries where obesity
and overnutrition kills more people than undernutrition
47. Impact of
Malnutrition
A) The intergenerational cycle of growth failure
There is an inter-generational component of malnutrition, which means that
poor growth can be transmitted from one generation to the next. This is known
as the cycle of malnutrition. At each stage in the life cycle, malnutrition has
consequences for each successive stage and/or the next generation, particularly
among low-income households in developing countries (Black et al., 2013).
48. HSERV 544 - Nutrition in Children 48
Intergenerational Cycle of Undernutrition
Childhood: Child growth
failure, impaired mental
development
Adolescents: Low
weight and height
Pregnancy
Compromised
nutritional status
Adult: Small adult
woman, lowered
productivity
Fetal and Infant
stages: Low
birthweight baby
49. WHO/UNICEF 20-hour Course as adapted
by Healthy Children Project for use in Egypt
2009
49
3/1
OriginalillustrationbyJennyCorkery
Fatima & Miriam meet at the antenatal clinic
50. Impact of
Malnutrition
Mothers who suffer chronic caloric or micronutrient
deficiencies are more likely to have low birth weight babies: in
effect, they pass their malnutrition on to the next generation.
These mothers also face increased risk of death in childbirth.
Low birth weight babies face higher mortality rates, impaired
mental and physical development and increased risk of adult
chronic diseases.
Stunted children living with inadequate food, health and care
remain stunted as adolescents .
51. Impact of
Malnutrition
• The girls among them grow up too often as another
generation of malnourished mothers who have low
birth weight babies of their own.
• Adults affected by malnutrition may have a low body
mass index or nutritional edema (retention of fluid).
• If malnourished adults continue to have inadequate
food, health and care into old age, they will remain
malnourished .
52. Impact of
Malnutrition
B) Costs of Malnutrition
B.1 Non Financial Cost
Taken together, stunting, severe wasting, low birth weights due to
intrauterine growth restriction, sub-optimal breastfeeding (non-exclusive for six
months and discontinued before one to two years) and deficiencies of vitamin A,
zinc and iron lead to the deaths of 3.6 million children under five years of age
each year. Moreover, these forms of malnutrition together account for 35 percent
of all preschooler deaths and 11 percent of the global burden of disease .
54. Time Magazine, August, 2008
1. Hypoglycemia
2. Hypothermia
3. Dehydration
4. Infection
5. Severe anemia
Direct causes of death:
55. Impact of
Malnutrition
B) Costs of Malnutrition
B.1 Financial Cost
In Addition, Malnutrition put heavy charges on the economies of
developing countries. Difficult pregnancies and the illnesses that
malnourished mothers and their children experience cost an
estimated $30 billion annually. Lost productivity and income due
to early deaths, poor school performance, disability and
absenteeism likely raise the yearly total into the hundreds of
billions of dollars .
56. Impact of
Malnutrition
The Cost of Hunger Study in Egypt estimated the economic and
social cost of child undernutrition at 20.3 billion EGP. Without
measures to combat and eliminate undernutrition, this cost is
expected to increase by about 32% by 2025 to reach to 26.8 billion
EGP.
That is an additional cost of an estimated 6.5 billion EGP of not
taking any steps to address undernutrition among children under
five.
57. Impact of
Malnutrition
C. Effects of Fetal and Early Childhood Malnutrition on Adult Health and
Human Capital
It is concluded that small size at birth and at 2 years of age (particularly height)
were associated with reduced human capital: shorter adult height, less schooling,
reduced economic productivity, and for women, lower offspring birth weight. On
the other hand, larger child size at 24 months of age was alsoa risk factor.
58. Impact of
Malnutrition
1) Achieved schooling and educational performance
Undernutrition can affect cognitive development by causing
direct structural damage to the brain and by impairing infant
motor development .
Substantial evidence suggests an association between stunting
and present or later cognitive ability or school performance in
children from low-income and middle-income countries. Four of
five longitudinal studies report that height-for-age predicts school
or cognitive test performance in later life .
59. Impact of
Malnutrition
2)Body-mass index, body composition, and obesity
Maternal nutritional status during pregnancy can affect offspring
body size and composition by production of long-term deficits in
fetal lean body mass altering sensitivity of the hypothalamic-
pituitary-adrenal axis which affects appetite and physical activity
or through the action of specific components of the maternal diet
on gene expression .
60. Impact of
Malnutrition
3)Insulin resistance and type 2 diabetes
Type 2 diabetes results from a combination of insulin resistance and
insulin secretary failure. The so-called thrifty phenotype hypothesis
proposed that undernourished fetuses and infants make changes
(reduced lean-tissue growth and insulin sensitivity).
There is an increased risk of diabetes associated with very high
birth weight .Three studies from low-income and middle-income
countries (all adjusting for adult weight) showed higher glucose
concentrations in people with lower birth weight
61. Impact of
Malnutrition
4)Blood pressure
Animal studies provide strong evidence that blood pressure is
raised in offspring of mothers who are exposed to diet restriction
during pregnancy. Inadequate nutrition is postulated to reduce the
size and number of nephrons, thereby restricting adult renal
functional capacity .
Early nutrition can also affect the rennin-angiotensin system .
exposure to glucocorticoids and arterial distensibility and it has
indirect effects on blood pressure through body composition .
62. Impact of
Malnutrition
5) Cardiovascular disease
Several studies in high-income countries have shown that birth
weight is inversely associated with the risk of coronary heart
disease and stroke. The hazard ratio for coronary heart disease in
the Helsinki cohort study was higher in men who weighed less than
2.5 kg at birth compared with those weighing more than 4.0 kg.
Lower birth weight has also been associated with increased carotid
intima media thickness, reduced arterial compliance, and impaired
endothelial function, which are all considered to be precursors of
cardiovascular disease .
63. Impact of
Malnutrition
6) Immune function
In Filipino adolescents and Pakistani adults antibody response to
selected vaccines was lower in people who were small at birth than
in those with a birth weight of 2500 g or more.
64. Impact of
Malnutrition
7.Lung function
Lung architecture develops in utero and during the first 2-3 years
of life .Early impairment of nutrition or oxygen availability can
permanently damage lung structure and function .Forced expiratory
volume in 1 second (FEV1) and forced vital capacity show
pulmonary development and have been used as outcomes in several
studies of early determinants .
65. Impact of
Malnutrition
8) Cancers
Unlike other outcomes considered here, cancers are associated with
larger size in early life, possibly reflecting increased exposure to
growth factors before or after birth, or both .
In high-income countries, studies have shown consistent positive
association between birth weight and premenopausal breast cancer
Much the same associations were reported for prostate,
haemopoietic, and colorectal cancers .
66. Impact of
Malnutrition
9)Bone mass, fracture risk, and osteoporosis
Short birth length is associated with an increased risk of bone
fractures in adults .Positive correlations between birth weight
or weight in infancy and adult bone-mineral content or density
suggest that fetal and infant growth make important
contributions to adult bone mass .
67. Impact of
Malnutrition
10)Mental illness
Specific forms of mental illness are thought to be affected by
adverse intrauterine experience, including maternal undernutrition.
Alterations in brain development, occurring sometime in mid-
gestation, can precipitate evolving malfunction that manifests in
early adulthood. The neurodevelopmental hypothesis is supported
by significant changes in the size and structure of features of the
brain in some adults diagnosed with schizophrenia. Other effects of
prenatal undernutrition, such as changes in arousal and sleep
waves, are consistent with schizophrenia .
68. Impact of
Malnutrition
11) Blood lipids
Intrauterine malnutrition and early life growth patterns can result in metabolic
and physiological programming, with lifelong effects on the risk of
cardiovascular disease. Unhealthy lipid profiles can be a potential mechanism
underlying these associations and animal studies have supported this notion
In people aged 45 years from Beijing, low birth weight was related to raised
triglycerides and reduced HDL cholesterol, after adjustment for sex and adult
body-mass index .
70. MDG 1:
Eradicate extreme poverty and hunger
Reducing prevalence of underweight children under five
years of age is an agreed target for MDG 1. Reducing
malnutrition increases economic growth.
MDG 2:
Achieve universal primary education
Reducing malnutrition increases cognitive development and
contributes to learning and school completion rates.
MDG 3:
Promote gender equality
Promoting better nutrition practices contributes to
empowering women and to reducing discrimination against
girls in family feeding practices.
MDG 4:
Reduce child mortality
Malnutrition remains the underlying cause in one in three of all
deaths of children under five.
MDG 5:
Improve maternal health
Improved maternal nutrition and reduced maternal mortality
through iron-folic acid, calcium and other micronutrient
supplements.
MDG 6:
Combat HIV/AIDS, malaria and other diseases
Reduces maternal and child mortality caused by the interaction
of malnutrition with HIV/AIDS and other infectious diseases.
MDG 7:
Ensure environment sustainability
Better nutritional practices mean more effective use of
available food and so better adaptation to environmental stress
75. Millennium
Development Goals
(MDG) 2000
United Nations
1. Eradicate extreme poverty & hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria, other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
76. New Public
Health
Initiative
THE 1,000 DAY WINDOW OF OPPORTUNITY
The 1,000 days from pregnancy to a child s second birthday is the
most critical time for positive impact on a child s cognitive,
intellectual, and physical development. Good nutrition in the first
1,000 days lays the foundation for health, development, and even
prosperity for the next generation.
77. Sustainable
development
goals
SDG 2015-
2030
Goal 2. End hunger, achieve food security and improved nutrition, and
promote sustainable agriculture
2.1 by 2030 end hunger and ensure access by all people, in particular the poor
and people in vulnerable situations including infants, to safe, nutritious and
sufficient food all year round
2.2 by 2030 end all forms of malnutrition, including achieving by 2025 the
internationally agreed targets on stunting and wasting in children under five
years of age, and address the nutritional needs of adolescent girls, pregnant
and lactating women, and older persons
2.3 by 2030 double the agricultural productivity and the incomes of small-
scale food producers, particularly women, indigenous peoples, family
farmers, pastoralists and fishers, including through secure and equal access to
land, other productive resources and inputs, knowledge, financial services,
markets, and opportunities for value addition and non-farm employment
78. Sustainable
development
goals
SDG 2015-
2030
2.4 by 2030 ensure sustainable food production systems and implement
resilient agricultural practices that increase productivity and production, that
help maintain ecosystems, that strengthen capacity for adaptation to climate
change, extreme weather, drought, flooding and other disasters, and that
progressively improve land and soil quality
2.5 by 2020 maintain genetic diversity of seeds, cultivated plants, farmed and
domesticated animals and their related wild species, including through soundly
managed and diversified seed and plant banks at national, regional and
international levels, and ensure access to and fair and equitable sharing of
benefits arising from the utilization of genetic resources and associated
traditional knowledge as internationally agreed
2.a increase investment, including through enhanced international cooperation,
in rural infrastructure, agricultural research and extension services, technology
development, and plant and livestock gene banks to enhance agricultural
productive capacity in developing countries, in particular in least developed
countries
79. USAID
NUTRITION
STRATEGY
2014-2025
2025 NUTRITION TARGETS ADOPTED AT THE WORLD
HEALTH ASSEMBLY IN 2012:
• 40 percent reduction of the global number of
children under five who are stunted;
50 percent reduction of anemia in women of reproductive age;
30 percent reduction of low birth weight;
No increase in childhood overweight;
Increase the rate of exclusive breastfeeding in the
first six months up to at least 50 percent; and
• Reduce and maintain childhood wasting to less than 5 percent.
81. Situation of
nutrition
intervention
in Egypt
The Egyptian government in partnership with the World Food
Programme (WFP) and Global Alliance for Improved Nutrition
(GAIN) fortified the flour used for making baladi bread with iron
and folic acid. In 2010, the Egyptian government announced a
five-year national project that targets 60 million Egyptians ; this
project will fortify subsidized vegetable oil with Vitamin A and D
as revealed below(MOHP,NNI, UNICEF and WHO, 2012).
82. Situation of
Nutrition
intervention in
Egypt
Macro level interventions by the Egyptian
government and partners:
A-Wheat policy which include; reforms in pricings, production levels and a
subsidy on bread.
B- Large-scale food fortification
∘ In 1996 fortification of table salt with Iodine.
∘ In 2008, fortified flour used for making baladi bread with iron and folic acid.
∘ In 2010, fortified subsidized vegetable oil with Vitamin A and D (WFP and
GAIN, 2010).
83. Situation of
Nutrition
Intervention
in Egypt
C- Supplementation programs
∘ Vitamin A supplementation for delivered women (for free)
∘ Iron and folic a tabs supplementation for all pregnant women (for
free)
∘ Vitamin A supplementation for all infants 9 and 18 months( for
free).
∘ Iron supplementation for infants 6 months to 30 months (weekly
dose)
∘ Zn supplementation for infants (with diarrheal treatment)
(MOHP,NNI, UNICEF and WHO, 2012).
84. Situation of
Nutrition
intervention in
Egypt
D)Policies
Policy Area (1): promotion of intersectoral collaboration that lead to
Universal Access toadequate food and nutrition
Policy Area (2): Incorporation of Nutrition Objectives (which fall under
the policy areas) into National Development Policies, Plans, Strategies,
Programmes, or activities to achieveMillennium Development Goals
Policy Area (3): Improving Household Food Security
Policy Area (4): Monitoring the food and nutrition situation
Policy Area (5): Improving the Quality and Safety of Food related
Services to protect
consumer health
85. Situation of
Nutrition
intervention
inEgypt
Policy Area (8):Capacity building and development at community, institutional and
authority levels
Policy Area (9): Prevention and Control of non-communicable/chronic diet-related
diseases (NCDs)
Policy Area (10):Promotion of infant and young child feeding and protection of
breastfeeding
Policy Area (11):Prevention and control of micronutrients deficiency
Policy Area (12):Promotion of healthy dietary practices and life styles focusing on school
aged children and adolescents
87. The SUN approach
The multi-stakeholder
platform
Works to align and
coordinate action
across sectors.
Women’s
Empowerment
Health
Development
& Poverty
Reduction
Agriculture
Education
Social
Protection
88. “The doctor of the future will no longer treat the human frame with
drugs, but rather will cure and prevent disease with nutrition.”
- Thomas Edison (1847 – 1931), American Inventor, Scientist & Businessman
89. WHO/UNICEF 20-hour Course as adapted
by Healthy Children Project for use in Egypt
2009
89FirstSkin toSkinContact
5/3
DrNilsBergman,Cape
Town,SouthAfrica
90. WHO/UNICEF 20-hour Course as adapted
by Healthy Children Project for use in Egypt
2009
90
Skin toSkinContact & Early Breastfeeding
5/2
UNICEF/HQ92-0369/RogerLemoyne,Thailand
