Malnutrition and micronutrient deficiencies among Bhutanese refugee children--Nepal, 2007

Acute and chronic malnutrition and micronutrient deficiencies have been found in refugee camp populations. In southeastern Nepal, despite consistent access by refugees to general rations, certain micronutrient deficiencies have posed a substantial health burden to the approximately 100,000 Bhutanese residing in seven refugee camps. Limited food diversity, frequent illness, and poor feeding practices have been cited as underlying causes of poor nutritional status in this population. Annual surveys to assess levels of acute malnutrition (i.e., wasting) and chronic malnutrition (i.e., stunting) have been conducted in these camps by the Association of Medical Doctors of Asia (AMDA) and United Nations High Commissioner for Refugees (UNHCR); however, the capacity to reliably evaluate micronutrient deficiencies has not existed locally in the camps. In January 2007, AMDA and CDC, at the request of UNHCR and the World Food Programme (WFP), conducted a nutritional survey of children aged 6-59 months, assessing 1) the prevalence of acute malnutrition, chronic malnutrition, underweight, anemia, and angular stomatitis (i.e., riboflavin deficiency); 2) the cumulative incidence of diarrhea and acute respiratory illness (ARI); and 3) the feeding practices of the children's mothers. This report describes the results of that survey, which indicated that, although acute malnutrition was found in only 4.2% of the children, chronic malnutrition was found in 26.9% and anemia in 43.3%. These findings underscore the importance of monitoring both malnutrition and micronutrient deficiencies and addressing the underlying causes of nutritional deficits.     

Addressing Malnutrition in Hospitalized Adults

Established guidelines and standardized protocols exist to assist clinicians in effectively addressing disease‐related malnutrition in hospitalized adults. The goals of this treatment vary according to the disease state and the severity of the malnutrition. In starvation‐related malnutrition, the goal of nutrition therapy is to restore healthy levels of lean body mass and body fat. For chronic disease‐related malnutrition, the goals of treatment are to maintain and improve lean body mass and body fat. In acute‐disease‐related malnutrition, the goals of nutrition therapy are to support vital organ function and preserve the host response through the acute episode. The success of addressing malnutrition in hospitalized patients depends not just on the nutrition therapy selected, but also on the timely and appropriate application of guidelines and protocols by the clinicians dedicated to caring for malnourished patients. Coordination of nutrition care among providers is highly desirable, and usually includes a multidisciplinary team of clinicians typically comprising a physician, nurse, dietitian, and pharmacist. For greatest success, this attention to recognizing and addressing malnutrition begins at admission and continues beyond discharge to the community. When addressing malnutrition in hospitalized patients, oral feeding through diet enrichment or oral nutrition supplementation (ONS) is the first line of defense. ONS has consistently been demonstrated to provide nutrition, clinical, functional, and economic benefits to malnourished patients in both individual trials and meta‐analyses. In an era when the cost of healthcare is rising as the population ages, addressing malnutrition in hospitalized patients is an important priority.     

Prognostic impact of disease-related malnutrition

This review focuses on the studies investigating the prognostic implications of disease-related malnutrition. Malnutrition is a common problem in patients with chronic or severe diseases. Prevalence of hospital malnutrition ranges between 20% and 50% depending on the criteria used in order to determine malnutrition and the patient's characteristics. Furthermore, nutritional status is known to worsen during hospital stay which is partly due to the poor recognition by the medical staff and adverse clinical routines. Studies have repeatedly shown that clinical malnutrition however has serious implications for recovery from disease, trauma and surgery and is generally associated with increased morbidity and mortality both in acute and chronic diseases. Length of hospital stay is significantly longer in malnourished patients and higher treatment costs are reported in malnutrition. Since it has been demonstrated that proper nutritional care can reduce the prevalence of hospital malnutrition and costs, nutritional assessment is mandatory in order to recognise malnutrition early and initiate timely nutritional therapy.     

Nutritional status of Naporuna children under five in the Amazon region of Ecuador]

OBJECTIVES: To assess the nutritional status of Naporuna children under five years of age from the Amazon region of Ecuador, and to identify risk factors for developing malnutrition in this population group. METHODS: A survey-based cross-sectional study was carried out in Orellana, a province in northeastern Ecuador, between June 2001 and February 2002. Household interviews were conducted in 30 communities chosen at random, and a questionnaire was used to record the following: the social and demographic characteristics and parity of mothers having children under five years of age, and the children's demographic and anthropometric characteristics, history of breastfeeding, and medical conditions suffered over the two-week period just prior to the survey. Each child was also subjected to a physical examination. Anemia was diagnosed clinically by conjunctival exam. The statistical association among variables was determined by means of the chi-square test, with use of Yates' correction and Fisher's exact test (two-tailed) when there were 5 observations or less. Risk factors for chronic malnutrition and underweight were determined by means of logistic regression. RESULTS: Overall, 189 mothers of 347 children under five were interviewed. Of these 347 children, 307 (88.5%) participated in the study. Chronic malnutrition was found in 22.8% of the children; 26.4% were underweight, and 9.8% had acute malnutrition. Moreover, 7.5% had severe chronic malnutrition; 4.9% were severely underweight, and 1.6% had severe acute malnutrition. A total of 5 children (1.6%) showed signs of both chronic and acute malnutrition. The largest prevalence of chronic malnutrition was found in the 12-23 month age group. Risk factors for chronic malnutrition that were statistically significant included living in an area without access to a road, the total number of children in the family (> or =7), and the presence of an acute respiratory infection or abdominal distension on the day the physical examination was performed. Abdominal distension and pale conjunctiva on physical examination were predictive for underweight. CONCLUSIONS: Among the Naporuna children under 5 years of age included in this study, the prevalences of acute malnutrition and underweight appeared to be higher than had been previously detected among other populations in the Amazon region. More studies on the prevalence of parasitic infections and anemia and on the feeding practices and dietary habits of indigenous communities are needed in order to better understand their nutritional intake. A program for monitoring the diet of indigenous peoples is necessary and should be established.     

Nutrition and dietetics in aged care

Aim: The global trends of rapid population ageing and increased risk of malnutrition among older people have a tremendous impact on nutrition care for the elderly. The present paper offers an overview of the challenging nutritional needs and problems of the elderly and explores strategies related to nutrition and dietetics to improve care for this particular segment of the population. Methods: A narrative review on monitoring malnutrition and improving food services was undertaken with reference to the literature and drawing on the experience of the author. Results: There is a wide range of problems associated with malnutrition in the elderly that have implications on strategies of intervention for addressing these problems. Conclusions: The current challenges for dietitians include identifying and monitoring the nutritional needs and malnutrition problems of the elderly, improving the quality of food services in health‐care facilities, and initiating innovative approaches to nutrition and dietetic services in the community.     

Baseline data from the Nyando Integrated Child Health and Education Project--Kenya, 2007

Approximately 10 million children aged <5 years die each year in developing countries. The leading infectious causes of these deaths include acute respiratory infections, diarrhea, measles, and malaria; malnutrition contributes to approximately 50% of these deaths. To address multiple conditions that contribute to mortality, child-survival programs require effective interventions and implementation strategies. To assess the effectiveness of multiple interventions, CDC has joined with partners to create the Nyando Integrated Child Health and Education (NICHE) project to combine several proven approaches to child survival in an impoverished rural district of western Kenya. During March-April 2007, CDC began the NICHE project with a baseline survey. This report summarizes preliminary data from that survey, which determined that 1) 86.1% of surveyed households were in the poorest Kenya socioeconomic quintile and 2) among children aged 6-35 months, 21.5% had experienced an acute respiratory infection and 9.1% had experienced diarrhea in the preceding 24 hours, 28.0% had chronic malnutrition, 66.2% had anemia, and 19.8% had a positive malaria smear. Comprehensive interventions will be needed to improve living conditions and reduce the risk for death before age 5 years among children in this population.     

The Multidimension of Malnutrition among School Children in a Rural Area,South Africa: A Mixed Methods Approach

To address childhood malnutrition, the use of multifaceted methodologies, such as mixed methods research, is required to inform effective and contextual interventions. However, this remains limited in studying malnutrition among school children in a South African context, notwithstanding its persistence. We adopted a convergent parallel mixed methods design to best understand the magnitude of malnutrition through multilevel influences in a rural area. A quantitative survey determined the magnitude of malnutrition and associated factors among school children and their mothers (n = 508), parallel to a qualitative study, which explored mothers’ insights into the influences of child growth and nutrition in interviews using seven focus group discussions. Mixed methods integration was achieved through convergence of the quantitative constructs developed from measured variables for malnutrition and related factors with ten emergent qualitative themes using a joint display analysis to compare the findings and generate meta-inferences. Qualitative themes on food unavailability and affordability, poor feeding beliefs and practices, and decision to purchase foods were consistent with the quantified poor socio-demographic status of mothers. Furthermore, the qualitative data explained the high prevalence of undernutrition among children but did not corroborate the high estimated households’ food security in the quantitative survey. The misperceptions of mothers on child growth agreed with limited food knowledge as well as lack of knowledge on child growth gathered during the survey. Moreover, mothers believed that their children were growing well despite the high presence of childhood undernutrition. Mothers further overrated the effectiveness of school feeding programmes in providing healthy food to children as compared to their household food. They reported high incidence of food allergies, diarrhea, and vomiting caused by food consumed at school which resulted in children not eating certain foods. This might have impacted on the nutritional status of children since mothers depended on the school feeding program to provide food for their children. The ambiguity of cultural influences in relation to child growth was evident and substantiated during qualitative interview. Mixed methods integration offered a better understanding of malnutrition from empirical findings on interrelated factors at child, maternal, household, and school levels. This study points to a need for multilevel, informed, and contextual multidimensional interventions to contribute towards addressing childhood malnutrition in South Africa.     

Association between nutritional status and subjective health status in chronically ill children attending special schools

Purpose

In hospitalized children with a chronic disease, malnutrition was associated with a lower subjective health status. In outpatient children with a chronic disease attending special schools, this association has never been studied. The aim of this study was to assess the association between nutritional status and subjective health status in chronically ill children attending special schools.

Methods

Overall, 642 children, median age 9.8 years (IQR 7.7–11.5), 60 % male, 72 % Caucasian, were included in this prospective study in nine special schools for chronically ill children in the Netherlands. Overall malnutrition was assessed as: acute malnutrition (<?2 SDS for weight for height (WFH)) and chronic malnutrition (<?2 SDS for height for age). The malnutrition risk was assessed with the nutritional risk-screening tool STRONG_kids. Subjective health status was assessed with EQ-5D.

Results

Overall, 16 % of the children had overall malnutrition: 3 % acute and 13 % chronic malnutrition. Nurses reported ‘some/severe problems’ on the health status dimensions mobility (15 %), self-care (17 %), usual activities (19 %), pain/discomfort (22 %), and anxiety/depression (22 %) in chronically ill children. Their mean visual analogue scale score (VAS) was 73.0 (SD 11.1). Malnutrition, medication usage, and younger age explained 38 % of the variance of the VAS score.

Conclusions

The presence of overall malnutrition in chronically ill children attending special schools was associated with lower subjective health status, especially in younger children and in those with chronic medication usage. Therefore, it is important to develop and use profile-screening tools to identify these children.

     

Malnutrition in Older Adults—Recent Advances and Remaining Challenges

Malnutrition in older adults has been recognised as a challenging health concern associated with not only increased mortality and morbidity, but also with physical decline, which has wide ranging acute implications for activities of daily living and quality of life in general. Malnutrition is common and may also contribute to the development of the geriatric syndromes in older adults. Malnutrition in the old is reflected by either involuntary weight loss or low body mass index, but hidden deficiencies such as micronutrient deficiencies are more difficult to assess and therefore frequently overlooked in the community-dwelling old. In developed countries, the most cited cause of malnutrition is disease, as both acute and chronic disorders have the potential to result in or aggravate malnutrition. Therefore, as higher age is one risk factor for developing disease, older adults have the highest risk of being at nutritional risk or becoming malnourished. However, the aetiology of malnutrition is complex and multifactorial, and the development of malnutrition in the old is most likely also facilitated by ageing processes. This comprehensive narrative review summarizes current evidence on the prevalence and determinants of malnutrition in old adults spanning from age-related changes to disease-associated risk factors, and outlines remaining challenges in the understanding, identification as well as treatment of malnutrition, which in some cases may include targeted supplementation of macro- and/or micronutrients, when diet alone is not sufficient to meet age-specific requirements.     

Malnutrition in pediatric hospital patients: Current issues

Malnutrition in hospitalized children is still very prevalent, especially in children with underlying disease and clinical conditions. The purpose of this review is to describe current issues that have to be taken into account when interpreting prevalence data. Weight-for-height and height-for-age standard deviation scores are used for classification for acute and chronic malnutrition, respectively. Body mass index for age can also be used for the definition of acute malnutrition but has a few advantages in the general pediatric population. The new World Health Organization child-growth charts can be used as reference but there is a risk of over- and underestimation of malnutrition rates compared with country-specific growth references. For children with specific medical conditions and syndromes, specific growth references should be used for appropriate interpretation of nutritional status. New screening tools are available to identify children at risk for developing malnutrition during admission. Because of the diversity of medical conditions and syndromes in hospitalized children, assessment of nutritional status and interpretation of anthropometric data need a tailored approach.     

Child malnutrition and development processes in two Tanzanian villages

Despite drastic changes in the agricultural, educational andhealth sectors, Tanzania still has a high rate of child malnutrition.The differences in malnutrition rates between nearby villagesare often very large - in fact larger than between regions. This study of child malnutrition in two villages in the Rukwaregion, is an attempt to explain some of the underlying factorsand processes leading to differences in the malnutrition rate.An attempt has also been made to link this to developmentalprocesses. The villages had undergone development in the same areas: agriculturalmodernization, market integration, mass education and the expansionof the health service. However, the data from this study indicatesthat the balance in emphasis between the various parts of thedevelopment package was different in the two villages, and thatthis had implications for the food and nutritional situationin the households.     

Malnutrition and Inflammation—“Burning Down the House”

A summary of my 2014 Rhoads Lecture is presented that explores our progress in understanding the complex interplay of malnutrition and inflammation. A historical perspective is provided that highlights the contributions of some of the key pioneers in the nutrition assessment field. Advances in agriculture, education, public health, healthcare, and living standards have affected traditional settings for malnutrition. The chronic disease, surgery, and injury conditions that are associated with modern healthcare are becoming prevalent settings for malnutrition. One consequence has been a growing appreciation for the contributions of inflammation to malnutrition in these clinical conditions. This recognition has driven a fresh look at how we define and think about malnutrition syndromes. An inflammatory component is included in the definitions suggested by the recent Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition consensus report that also describes characteristics recommended for the identification and documentation of malnutrition. Efforts are currently underway to evaluate the feasibility and validity of this approach. Recent advances in research highlight the profound impact of inflammation‐mediated erosion of muscle mass on clinical outcomes. Research to identify better biomarkers of inflammation and malnutrition must be a leading priority. New “omics” approaches are an especially promising avenue of biomarker investigation. Inflammation can be a good thing; let's try to keep it that way.     

Malnutrition, nutritional indices, and early enteral feeding in critically ill children.

We measured the incidences of protein and fat depletions and the frequencies of acute and chronic protein-energy malnutrition during stress states in children and investigated the influence of early enteral feeding on nutrition indices and acute-phase proteins. Seventy-one, consecutively enrolled, critically ill children received early enteral feeding (energy intakes equal to 0.50, 1, 1.25, 1.5, and 1.5 of the predicted basal metabolic rates on days 1 through 5, respectively) through nasogastric tubes. On the first day of the study, 16.7% of the patients already were depleted of protein and 31% of fat stores. Overall, 16.9% were at risk for chronic protein-energy malnutrition and 21.1% for acute protein-energy malnutrition, whereas 4.2% and 5.6% already had chronic and acute, respectively protein-energy malnutrition. Only 22.7% of patients without protein deficiencies versus 37% of those at risk or already deficient developed multiple-organ system failure. Transferrin and prealbumin levels improved at the end of the period of early enteral feeding (187 +/- 6.6 versus 233 +/- 7 mg/dL, P < 0.0001; 15.1 +/- 2 versus 21.9 +/- 2.9 mg/dL, P < 0.0001; respectively); survivors had higher prealbumin levels than non-survivors (22.3 versus 15.5 mg/dL). With logistic regression analysis, only repleted energy, not anthropometric or nutrition indices, was independently associated with survival (P = 0.05). These results reinforce the observation that critically ill children are at risk for fat or protein depletion and development of malnutrition, which is associated with increased morbidity and mortality. We conclude that early enteral nutrition improves nutrition indices and outcomes.     

The Role of Nutritional Status in Elderly Patients with Heart Failure

Evidence indicates that malnutrition very frequently co-occurs with chronic heart failure (HF) and leads to a range of negative consequences. Studies show associations between malnutrition and wound healing disorders, an increased rate of postoperative complications, and mortality. In addition, considering the increasing age of patients with HF, a specific approach to their treatment is required. Guidelines proposed by the European Society of Cardiology (ESC) for treating acute and chronic HF refer to the need to monitor and prevent malnutrition in HF patients. However, the guidelines feature no strict nutritional recommendations for HF patients, who are at high nutritional risk as a group, nor do they offer any such recommendations for the poor nutritional status subgroup, for which high morbidity and mortality rates have been observed. In the context of multidisciplinary healthcare, recommended by the ESC and proven by research to offer multifaceted benefits, nutritional status should be systematically assessed in HF patients. Malnutrition has become a challenge within healthcare systems and day-to-day clinical practice, especially in developed countries, where it affects the course of disease and patients’ prognosis.     

Body Composition Tools for Assessment of Adult Malnutrition at the Bedside

Because of the key role played by the body's lean tissue reserves (of which skeletal muscle is a major component) in the response to injury and illness, its maintenance is of central importance to nutrition status. With the recent development of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition diagnostic framework for malnutrition, the loss of muscle mass has been recognized as one of the defining criteria. Objective methods to evaluate muscle loss in individuals with acute and chronic illness are needed. Bioimpedance and ultrasound techniques are currently the best options for the clinical setting; however, additional research is needed to investigate how best to optimize measurements and minimize error and to establish if these techniques (and which specific approaches) can uniquely contribute to the assessment of malnutrition, beyond more subjective evaluation methods. In this tutorial, key concepts and statistical methods used in the validation of bedside methods to assess lean tissue compartments are discussed. Body composition assessment methods that are most widely available for practice and research in the clinical setting are presented, and clinical cases are used to illustrate how the clinician might use bioimpedance and/or ultrasound as a tool to assess nutrition status at the bedside. Future research needs regarding malnutrition assessment are identified.     

The changing elderly population and future health care needs

The impending growth of the elderly population requires both fiscal and substantive changes in Medicare and Medicaid that are responsive to cost issues and to changing patterns of need. More emphasis is required on chronic disease management, on meaningful integration between acute and long-term case services, and on improved coordination between Medicare and Medicaid initiatives. This paper reviews various trends, including the growth in managed-care approaches, experience with social health maintenance organizations and Program of All-Inclusive Care for the Elderly demonstrations, and the need for a coherent long-term care policy. Such policies, however, transcend health care and require a broad range of community initiatives.     

云南德宏州傣族、景颇族、阿昌族、德昂族0～6岁儿童营养不良等常见病的调查

目的:了解云南德宏州傣族、景颇族、阿昌族、德昂族0～6岁儿童营养不良现状,为防治疾病提供科学依据。方法:采用典型调查对云南德宏州傣族、景颇族、阿昌族、德昂族0～6岁儿童进行体格发育测量;调查急性呼吸道感染(ARI)、反复呼吸道感染(RRI)、腹泻(CDD)、贫血、营养不良等情况;血红蛋白Hb测定运用血细胞分析仪(迈瑞BC-2008),6月～6岁Hb<110 g/L为贫血;体格发育形态指标按全国九市儿童体格发育调查方案;统计处理和分析采用SPSS 15.0软件进行。结果:消瘦率、ARI、急性腹泻、慢性腹泻及贫血随年龄增加而降低;低体重率和发育迟缓率与年龄之间差异无统计学意义;RRI随年龄增加而增加;呼吸道感染(ARI、RRI)、慢性腹泻、贫血民族之间差异有统计学意义,其中景颇族贫血发病居4个民族之首,阿昌族以RRI、急性腹泻、慢性腹泻居4个民族之首;结论:营养不良有明显下降趋势;贫血发生率还很高,主要原因是地中海贫血占的比例大。     

Nutritional depletions in critically ill children: associations with physiologic instability and increased quantity of care

The association of nutritional depletions with physiologic instability and quantity of care was examined in 60 critically ill children. Nutritional status was evaluated by anthropometric techniques. Physiologic stability was measured by the Physiologic Stability Index and quantity of care was measured by the Therapeutic Intervention Scoring System. Acute protein-energy malnutrition was significantly associated with increased physiologic instability and increased quantity of care (p less than 0.01). This association was present for the total group, children less than 24 months of age, and for these two groups with nonsurvivors excluded. Mortality was also significantly associated with acute protein-energy malnutrition (p less than 0.001). Physiologic instability and increased quantity of care were not associated with chronic protein-energy malnutrition, fat store depletion, or somatic protein store depletion. We conclude that acute protein-energy malnutrition in critically ill children is associated with increased physiologic instability and increased quantity of care.     

Nutrition and alcoholic liver disease

While the rate of malnutrition is relatively modest in alcoholic patients without alcoholic liver disease, the rate of malnutrition is virtually 100% in patients with alcoholic hepatitis and/or alcoholic cirrhosis. The reasons for malnutrition in the alcoholic hepatitis patient include various factors such as anorexia, poor diet, malabsorption, and altered metabolic state. When the patient is hospitalized, the malnutrition frequently worsens because of fasting for tests, continued anorexia, and complications such as gastrointestinal bleeding. Patients with severe acute hepatitis appear to be both hypermetabolic and hypercatabolic, whereas data are much more conflicting concerning patients with more stable liver disease. Most studies suggest that patients with alcoholic liver disease require at least 60 g of protein per day to maintain positive nitrogen balance. Consistent alterations in plasma amino acid profiles occur in alcoholic liver disease, and specialized nutritional formulations have been devised to correct this amino acid profile with the intent of improving overall nutritional status, hepatic encephalopathy, and mortality. The effects of nutritional support (including use of specialized products) on outcome, on acute hepatic encephalopathy, and on chronic or latent portal systemic encephalopathy are reviewed.     

Understanding chronic malnutrition in childhood and old age: role of energy balance research

Undernutrition is commonly associated with chronic disease in children and the elderly. Overnutrition is also, but less commonly, associated with chronic illness. In most diseases malnutrition arises because energy intake does not match energy output. Traditionally, the focus of research has been on abnormalities in energy expenditure, in the belief that these factors were the main determinants of energy imbalance. Recent studies using the doubly-labelled-water method to measure total energy expenditure, combined with more complex study design, have suggested an alternative conclusion. In many chronic diseases patient behaviour, and particularly energy intake, is responsible for energy imbalance and malnutrition. Energy balance studies have therefore provided a useful foundation for the design of strategies aimed at preventing or managing chronic malnutrition. However, modifying patient behaviour is an ambitious undertaking which may not be within the scope of existing clinical nutrition services. A number of non-traditional models of managing chronic malnutrition in children and the elderly are promising. Increasing recognition of the value of systematic review will also provide improved strategies for prevention and management of chronic malnutrition.