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MALNUTRITION AND UNDERNUTRION

Presented byPaul N.

TOLEFAC, MDIntern,

FMBS/UY1 Supervised by

Innocent Takougang, MD

Associate Professor, FMBS

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Objectives At the end of the presentation we should understand:

Understand the difference between malnutrition and undernutrition

Classification of malnutrition The 3 phase approach in the management of severe

acute malnutrition

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Outline Definitions epidemiology Pathophysiology Clinical features management

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Definitions Malnutrition: An abnormal physiological condition caused by

inadequate, unbalanced or excessive consumption of macronutrients and/or micronutrients. It includes undernutrition and over-nutrition and obesity.

Undernutrition: it is a subset of malnutrition that results from undernourishment, and/or poor absorption. It includes: Underweight: a child has low weight for age. Composite measure includes

chronic and acute malnutrition. Stunting: child short for their age as a result of chronic under nutrition during

the most critical periods of growth and development in early life (< -2 SD HFA). Wasting: child’s weight is too low for their height as a result of acute under

nutrition (< -2SD WFH).

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Definitions Hunger: A state, lasting for at least one year, of inability to acquire

enough food, defined as a level of food intake insuffiecient to meet dietary energy requirements.

Famine is the state in which significant proportion (at least 20%) of a defined population lacks access to food in sufficient quantity and quality, such that epidemics of infectious disease become more frequent, acute malnutrition rates in children under 5 are above 30% and death rates rise.

Starvation occurs when the individual’ nutrient intake drops below the minimum needed to maintain body mass leading to consumption of muscles and lean body tissue for energy production.

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Definitions Protein – Energy Malnutrition (PEM): This is

the manifestation of inadequate dietary intakes of protein and or energy. Most common forms are marasmus and kwashiorkor.

Primary malnutrition: Malnutrition resulting from an inadequate food intake such as in starvation and famine.

Secondary malnutrition: Malnutrition resulting from increased nutrient needs, decreased nutrient absorption, and/or increased nutrient losses

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Epidemiology In 2000, 26.7% of preschoolers in the developing world

were estimated to be underweight, as reflected by a low weight for age, and 32.5% were estimated to be stunted based on a low height for age.

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Epidemiology: World & Africa

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Epidemiology: world

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Epidemiology: Stunting worldwideGlobally, about 1 in 5 (26% in 2011) children are stunted of whom 80% live in 40 countries.

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Epidemiology: World and Africa

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Epidemiology: Cameroon Author , Year Journal Objective Results Jesson J et al, 2015

BMC infectious diseases

Prevalence of malnutrition amongst HIV infected children in central & west Africa

Prevalence was 42% (n = 1350) with acute chronic and mixed malnutrition 9%, 7% and 26%.

Georges Nguefack-Tsague et al, 2014

Pan African Medical journal

Using underweight to predict wasting

Wasting in 5.5% and underweight in 12,9%

Sobze SM et al, 2014

Pan African Medical journal

assess the nutritional status of infants from mothers tested positive to HIV in the Dschang HD

SD was noticed in height-for-age z-score of girls between 1 to 2 years compared to 1-year old girls as well as to boys of all ages, defining them as stunted.

Sumbele IU et al, 2015

BMC public health

examines the prevalence, severity and predictors of malnutrition on malaria parasitaemia.

The overall prevalence of malnutrition was 22.8 %, with stunting being the most common form (17.1 %), followed by underweight (8.2 %) and wasting (5.5 %

Mbuh JV et al, 2013

Journal of helminthology

The prevalence of intestinal helminth infection was 47.2% (n = 265) The prevalence of malnutrition was 30.2%

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Causes of malnutrition Primary: Starvation, famine

aand hunger resulting from food scarcity, poverty and unemployment and natural disasters

Secondary: GI disorders Malabsorption syndromes Hyper-catabolic state

such as hyperthyroidism

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Pathophysiology

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Clinical Features• Oedema• Loss of muscle & fat often

masked by the oedema• Anorexia• Abdominal distention• Hair losing color• Apatic/irritable, miserable• Skin cracks/fragile, prone to

infections• Acutely sick

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Clinical features•Severe Wasting, very thin•Loss of Muscle Bulk,•No subcutaneous Fat

• Loose skin folds, floppy buttocks

• Often reasonable appetite when no med complication•Miserable, restless•Apathy

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Classification of Malnutrition Classification Definition classes Class definitionGomez Weight below % median WFA Mild 75%-90% WFA

Moderate 60%–74% WFASevere <60% WFA

waterlow z score below median WFH Mild 80%–90% WFHModerate 70%-80% WFHSevere <70% WFH

WHO (wasting)

z score below median WFH Moderate -3%</= z-score < -2Severe z-score < -3

WHO (wasting)

z score below median HFA   -3%</= z-score < -2  z-score < -3

Kanawati MUAC/OFC Mild <0.31Moderate <0.28Severe <0.25

cole z score of BMI for age Grade 1 BMI for age z-score < -1Grade 2 BMI for age z-score < -2Grade 3 BMI for age z-score < -3

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Classification of malnutrition

Classification Mild Moderate Severe

Albumin (g/dL) 2.8-3.4 2.1-2.7 < 2.1

Transferrin (mg/dL) 150 - 200 100 - 149 < 100

Total Lymphocyte Count (per µL)

1200 - 2000 800 - 1199 < 800

Wellcamb Classification

Weight for Age (Gomez)

With Edema

Without Edema

60-80% kwashiorkor

undernutrition

< 60%marasmic-kwashiorkor

marasmus

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Management SAM Severe acute malnutrition is defined as the presence of

oedema of both feet or severe wasting (WFH <-3SD or MUAC < 11.5 cm).

The patient should be evaluated clinically for the presence of other conditions. Criteria for admission in children 6-59 months include: MUAC < 11.5cm Z score < -3SD Presence of oedema Lack of appetite

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Management: 3 Phases

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managementReSoMal• 2 litres water• WHO ORS 1 sachet• Sugar 50g• KCl 40mlOthers• Vitamin A: Give vitamin A

orally on days 1, 2 and 14 (age < 6 months, 50 000 IU; age 6–12 months, 100 000 IU; older children, 200 000 IU).

• Severe Anaemia: Blood transfusion should be given in the first 24 h only if: Hb is < 4 g/dl or Hb is 4–6 g/dl and the child has respiratory distress.

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Management

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ConclusionChild 6-

59months

SAM

Criteria for admission

present

Hospitalised and treat

Absent

Administer specific outpatient treatment

No SAM

Specific assessment & treatment

Back to objectives Understand the

difference between malnutrition and undernutrition

Classification of malnutrition

The 3 phase approach in the management of severe acute malnutrion

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The hidden truth about success