CHAPTER ONE
- INTRODUCTION
1.1 NUTRITIONAL DISORDER
Nutritional disorder is a pathological state due to a relative or absolute deficiency or excess of one or more essential nutrients; clinically manifested or detected only by biochemical, anthropometric or physiological tests. Nutritional disorder which is also known as malnutrition is a condition that results from eating a diet in which nutrients are either not enough or are too much such that the diet causes health problems (Young, 2012). It may involve calories, protein, carbohydrates, vitamins or minerals. Not enough nutrients is called undernutrition or undernourishment while too much is called overnutrition (Young, 2012). Malnutrition is often used specifically to refer to undernutrition where there is not enough calories, protein, or micronutrients. If undernutrition occurs during pregnancy, or before two years of age, it may result in permanent problems with physical and mental development in a child. When a child is exposed to extreme undernourishment, known as starvation, this may have symptoms that include: a short height, thin body, very poor energy levels, and swollen legs and abdomen in child. Children also often get infections and are frequently cold. Undernutrition is an important determinant of maternal and child health, accounting for more than a third of child deaths and more than 10 percent of the total global disease burden according to previous studies (Black et al., 2008) The World Health Organization estimates that malnutrition accounts for 54 percent of child mortality worldwide, (Walker et al., 2008) about 1 million children (Jean, 2008). Another estimate also by WHO states that childhood underweight is the cause for about 35% of all deaths of children under the age of five years worldwide (FAO, 2008). As underweight children are more vulnerable to almost all infectious diseases, the indirect disease burden of malnutrition is estimated to be an order of magnitude higher than the disease burden of the direct effects of malnutrition (FAO, 2008). The combination of direct and indirect deaths from malnutrition caused by unsafe water, sanitation and hygiene (WASH) practices is estimated to lead to 860,000 deaths per year in children under five years of age.
The symptoms of micronutrient deficiencies depend on the micronutrient that is lacking. Some of the well-known classification of nutritional disorders in children are: Under-nutrition (Marasmus), Over-nutrition (Obesity, Hypervitaminoses), Protein-energy malnutrition (PEM) (Kwashiorkor, Hypovitaminoses), Mineral Deficiencies, Imbalance (Electrolyte Imbalance).
1.1.1 Malnutrition (Undernutrition and Overnutrition)
Malnutrition is most often due to not enough high-quality food being available to eat. This is often related to high food prices and poverty. A lack of breast feeding may contribute, as may a number of infectious diseases such as: gastroenteritis, pneumonia, malaria, and measles, which increase nutrient requirements (WHO, 2005). There are two main types of undernutrition: protein-energy malnutrition and dietary deficiencies. Protein-energy malnutrition has two severe forms: marasmus (a lack of protein and calories) and kwashiorkor (a lack of just protein). Common micronutrient deficiencies include: a lack of iron, iodine, and vitamin A. During pregnancy, due to the body's increased need, deficiencies may become more common. In some developing countries, overnutrition in the form of obesity is beginning to present within the same communities as undernutrition. Other causes of malnutrition include anorexia nervosa and bariatric surgery (WHO, 2005).
Nutritional disorder is caused by eating a diet in which nutrients are not enough or are too much such that it causes health problems. It is a category of diseases that includes undernutrition and overnutrition. Overnutrition can result in obesity and being overweight (Murray, 2012). In some developing countries, overnutrition in the form of obesity is beginning to present within the same communities as undernutrition. However, malnutrition is commonly used to refer to undernutrition only. Undernutrition encompasses stunted growth (stunting), wasting, and deficiencies of essential vitamins and minerals (collectively referred to as micronutrients). The term hunger, which describes a feeling of discomfort from not eating, has been used to describe undernutrition, especially in reference to food insecurity (Lim et al, 2012).
1.1.2 Protein-energy malnutrition (PEM)
Undernutrition is sometimes used as a synonym of protein–energy malnutrition (PEM). While other include both micronutrient deficiencies and protein energy malnutrition in its definition. It differs from calorie restriction in that calorie restriction may not result in negative health effects (Black et al., 2008). The term hypoalimentation means underfeeding. Severe malnutrition or Severe undernutrition is often used to refer specifically to PEM. PEM is often associated with micronutrient deficiency. Two forms of PEM are kwashiorkor and marasmus, and they commonly coexist (Stevenson and Conaway, 2011). Chronic undernutrition manifests primarily as protein-energy malnutrition (PEM), which is the most common form of malnutrition worldwide. Also known as protein-calorie malnutrition, PEM is a continuum in which people—all too often children—consume too little protein, energy, or both (WHO, 2005). At one end of the continuum is kwashiorkor, characterized by a severe protein deficiency, and at the other is marasmus, an absolute food deprivation with grossly inadequate amounts of both energy and protein. Treatment of PEM has three components. (1) Life-threatening conditions—such as fluid and electrolyte imbalances and infections—must be resolved. (2) Nutritional status should be restored as quickly and safely as possible; rapid weight gain can occur in a starving child within one or two weeks. (3) The focus of treatment then shifts to ensuring long term nutritional rehabilitation of the child. The speed and ultimate success of recovery depend upon the severity of malnutrition, the timeliness of treatment, and the adequacy of ongoing support (WHO, 2005).
Figure 1 – Showing a child in the United States with signs of Kwashiorkor, a dietary protein deficiency
Source: Wikipedia
1.1.2.1 Kwashiorkor
Kwashiorkor is mainly caused by inadequate protein intake resulting in a low concentration of amino acids. The main symptoms are edema, wasting, liver enlargement, hypoalbuminaemia, steatosis, and possibly depigmentation of skin and hair. Kwashiorkor is identified by swelling of the extremities and belly, which is deceiving of actual nutritional status (WHO, 2005). Kwashiorkor is typically seen when a child is weaned from high-protein breast milk onto a carbohydrate food source with insufficient protein. Children with this disease, which is characterized by a swollen belly due to edema (fluid retention), are weak, grow poorly, and are more susceptible to infectious diseases, which may result in fatal diarrhea. Other symptoms of kwashiorkor include apathy, hair discoloration, and dry, peeling skin with sores that fail to heal. Weight loss may be disguised because of the presence of edema, enlarged fatty liver, and intestinal parasites; moreover, there may be little wasting of muscle and body fat (WHO, 2005).
1.1.2.2 Marasmus
Marasmus is caused by an inadequate intake of protein and energy. The main symptoms are severe wasting, leaving little or no edema, minimal subcutaneous fat, severe muscle wasting, and non-normal serum albumin levels. Marasmus can result from a sustained diet of inadequate energy and protein, and the metabolism adapts to prolong survival (WHO, 2005). It is traditionally seen in famine, significant food restriction, or more severe cases of anorexia. Conditions are characterized by extreme wasting of the muscles and a gaunt expression (WHO, 2005). An infant with marasmus is extremely underweight and has lost most or all subcutaneous fat. The body has a “skin and bones” appearance, and the child is profoundly weak and highly susceptible to infections. The cause is a diet very low in calories from all sources (including protein), often from early weaning to a bottled formula prepared with unsafe water and diluted because of poverty (WHO, 2005). Poor hygiene and continued depletion lead to a vicious cycle of gastroenteritis and deterioration of the lining of the gastrointestinal tract, which interferes with absorption of nutrients from the little food available and further reduces resistance to infection. If untreated, marasmus may result in death due to starvation or heart failure.
1.2 IMPACT OF NUTRITION ON WELL-BEING
The ill effects of malnutrition on physiology, motor function, neurological and psychological function are wide ranging and may be particularly devastating during early development. Diminished muscle strength leads to impairment in motor function as well as weakness of respiratory musculature, with resultant impaired cough and predisposition to pneumonia (Kelly et al., 1984). Malnutrition results in increased circulation times and diminished cardiac work capacity, and a predisposition to congestive heart failure when under cardio-respiratory stress (Viart, 1977, 1978). Malnutrition leads to diminished immune function (Chandra and Kumari, 1994), causing increased susceptibility to infection. Neurological consequences include diminished cerebral growth, delayed cognitive development, and abnormal behavior (Engsner et al., 1974; Grantham-Mcgregor et al., 1991; Viteri, 1991; Liu et al., 2003; Smart, 1993). Further, undernourished children show lower levels of exploratory activity and attachment behavior that may affect social-emotional development (Graves, 1978). Irritability and decreased activity have been described clinically in undernourished children (Viteri, 1991) and documented in animal models of malnutrition (Graves, 1978). Malnutrition decreases the energy available for discretionary activity, which decreases social interaction, increases apathy, and negatively affects learning and quality of life (Lewis et al., 1994). These characteristics may affect a child’s ability to participate in play, school, or rehabilitation.
Efforts to improve nutrition are some of the most effective forms of development aid. Breastfeeding can reduce rates of malnutrition and death in children, and efforts to promote the practice increase the rates of breastfeeding (Bhutta et al., 2013). In young children, providing food (in addition to breastmilk) between six months and two years of age improves outcomes. There is also good evidence supporting the supplementation of a number of micronutrients to women during pregnancy and among young children in the developing world (Bhutta et al., 2013). To get food to people who need it most, both delivering food and providing money so people can buy food within local markets are effective. Simply feeding students at school is insufficient (Jonathan et al., 2011). Management of severe malnutrition within the person's home with ready-to-use therapeutic foods is possible much of the time. In those who have severe malnutrition complicated by other health problems, treatment in a hospital setting is recommended. This often involves managing low blood sugar and body temperature, addressing dehydration, and gradual feeding. Routine antibiotics are usually recommended due to the high risk of infection. Longer-term measures include: improving agricultural practices, reducing poverty, improving sanitation, and the empowerment of women (Jonathan et al., 2011).
In 2010, malnutrition was the cause of 1.4% of all disability adjusted life years. About a third of deaths in children are believed to be due to undernutrition, although the deaths are rarely labelled as such (Lazano et al., 2012). In 2010, it was estimated to have contributed to about 1.5 million deaths in women and children, though some estimate the number may be greater than 3 million. An additional 165 million children have stunted growth from malnutrition. Undernutrition is more common in developing countries. Certain groups have higher rates of undernutrition, including women—in particular while pregnant or breastfeeding—children under five years of age (Lazano et al., 2012). Physical growth is a fundamental measure of health and well-being in children, and abnormal growth may be considered a sign of disruption in a child’s nutrition, environment, or health. Even under seemingly “good” conditions (appropriate environment and regular medical attention), children with malnutrition grow more slowly than children without chronic health conditions (Samson-Fang and Stevenson, 1998), and the differences in growth increase with increasing age (Stevenson et al., 1994). Diminished body fat and overall growth in children with malnutrition have been associated with increased health care utilization and decreased societal participation (Samson-Fang et al., 2002; Stevenson et al., 2006b); thus, understanding the growth patterns in this population is important in promoting “health” in all its dimensions.
