DOCSLIB.ORG

The Assessment and Treatment of Severe Adult Malnutrition

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Assessment and Treatment of Severe Adult Malnutrition THE ASSESSMENT AND TREATMENT OF SEVERE ADULT MALNUTRITION Thesis submitted to the University of London in partial fulfilment of the degree of MD D f Steve Collins MB BS BSc Address for correspondence: Oleuffynon, Old Hall, Llanidloes Powys SY18 6PJ Wales, UK Tel: +44 (0) 1686 413989 E-mail: [email protected] ProQuest Number: 10016057 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest. ProQuest 10016057 Published by ProQuest LLC(2016). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. Microform Edition © ProQuest LLC. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 Abstract This thesis examines the assessment and treatment of severe adult starvation during famine. The author collected data from 573, 98 and 1059 severely malnourished adults, admitted to therapeutic feeding centres in Baidoa (Somalia) during 1992-3, Ayod (Sudan) during 1993 and Melanje (Angola) during 1993-4. The data collected are unique, recording recovery from extremes of adult starvation hitherto undocumented in the medical literature. All the centres were very rudimentary in nature, with no beds, running water, electricity or equipment for special investigations. Mortality rates in the Somalia centre were 21%; war disrupted the collection of outcome data in die centres in Sudan and Angola. The thesis assesses the relative merits of Body Mass Index, Middle Upper Arm Ciccumference and clinical signs, for screening adult admissions into therapeutic feeding centres. The analysis demonstrates that the use of Body Mass Index is inappropriate for this role and the discussion proposes a combination of clinical signs and Middle Upper Arm Circumference as an alternative. The thesis also examines the effect on rehabilitation of two diets differing primarily in their protein content (one diet with 156g protein and 16.5Mj of energy day^ , the other with Big of protein and 16.5Mj of energy day'^). Twenty five percent of oedematous patients given the lower protein diet during the initial phase of treatemnt recovered, compared with only 48% who received the higher protein diet during the initial phases of treatment. This is a three-fold decrease in mortality amongst this group of patients. The extreme levels of social disintegration, violence and death during the fieldwork prevented the execution of prospective highly controlled research. This is always true of the extreme famines where severe acute adult malnutrition is commonest and such difficulties have discouraged scientists. This is a sad state of affairs, as the extreme human suffering that occurs during famine has not received sufficient scientific attention. There is still a great need for research to assist the assessment and treatment of severe adult malnutrition. Although the conclusions of this thesis are tentative, in the absence of other data examining screening cut-offs based upon evidence gathered during famine, these are the best we have. TABLE OF CONTENTS Abstract____________________________________________________________________________ ii Table of Contents........................................................................................................................... iii List of figures................................................................................................................................ vü List of tables................................................................................................................................. viii Glossary ...........................................................................................................................................ix Acknowledgements ........................................................................................................................ xi Chapter 1 Foreword - The thesis______________________________________________________ 12 Section 1.01 Objectives -----------------------------------------------------------------------------------------------12 Section 1.02 Organisation of this thesis ------------------------------------------------------------------------------13 Section 1.03 The originality and the contribution to medicalpractice. ----------------------------------------------- 13 Chapter 2 Introduction_______________________________________________________________ 15 Section 2.01 Definitions --------------------------------------------------------------------------------------------- 15 2.01(a) “Acute and chronic” malnutrition.................................................................................... 15 2.01(b) “Primary” malnutrition..................................................................................................... 17 2.01(c) Severe adult malnutrition...................................................................................................17 2.01(d) A working definition of severe adult malnutrition.......................................................... 19 Section 2.02 The epidemiology of severe adult malnutrition ---------------------------------------------------------- 19 Section 2.03 The focus of emergency reliefprogrammes -------------------------------------------------------------- 24 Section 2.04 Research into severe adult malnutrition ---------------------------------------------------------------- 25 2.04(a) Primary acute severe adult malnutrition...........................................................................25 2.04(b) Secondary adult malnutrition ........................................................................................... 27 2.04(c) Indicators for screening: a research priority ..................................................................... 28 Chapter 3 Background to the studies and core methods __________________________________ 31 Section 3.01 Background -------------------------------------------------------------------------------------------- 31 3.01(a) Concern Worldwide ...........................................................................................................31 3.01(b) Concern adult feeding programmes where data were collected ..................................... 32 Section 3.02 Methods ------------------------------------------------------------------------------------------------ 36 3.02(a) Subjects..............................................................................................................................36 3.02(b) Measurements, equipment and precision .........................................................................36 3.02(c) Clinical data collection and coding ....................................................................................37 3.02(d) Data analysis ......................................................................................................................38 Section 3.03 Methodological issues ---------------------------------------------------------------------------------- 41 3.03(a) Constraints......................................................................................................................... 41 3.03(b) Subject selection................................................................................................................ 42 3.03(c) Controls.............................................................................................................................43 3.03(d) Measurement errors and training ......................................................................................43 Chapter 4 Study one; Is BMI a useful tool for the assessment of severe adult malnutrition during famine?_______________________________________________________________________47 Section 4.01 A im s -------------------------------------------------------------------------------------------------- 47 Section 4.02 Introduction -------------------------------------------------------------------------------------------- 47 III Section 4.03 Uterature review ---------------------------------------------------------------------------------------48 4.03(a) BMI in the assessment of chronic malnutrition in adults ................................................48 4.03(b) BMI and body composition .............................................................................................49 4.03(c) Determinants of BMI........................................................................................................50 4.03(d) The use of BMI to screen severely malnourished adults ................................................56 4.03(e) Previous investigations into the limits of human response to starvation ....................... 57 4.03(f) Triage and BMI limits of human adaptation to starvation .............................................. 64 Section 4.04 methods ------------------------------------------------------------------------------------------------ 65 4.04(a) Subjects.................................................. 65 4.04(b) Treatment in the centre .................................................................................................... 6 6 4.04(c) Discharge criteria ..............................................................................................................
Load more

Recommended publications
  • Micronutrient Need Intervention)
    Operation MINI (MIcronutrient Need Intervention) Emily Adams Walker School Marietta, Georgia Scott Braswell Garfield High School and the University of Washington Seattle, Washington In collaboration with Sarah Cusick1 and Heather Carter2 1 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention 2 National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. 1 Operation MINI (MIcronutrient Need Intervention) Emily Adams Scott Braswell Walker School Garfield High School and the Marietta, Georgia University of Washington Seattle, Washington Summary This lesson is designed for a high school biology, food science, or anatomy class and emphasizes the real-world applications of human nutrition. Student groups will play the part of aid organizations competing for funds to assist a fictitious village that has experienced a natural disaster and is now in a food crisis. They will research various aspects of micronutrient deficiencies and the logistics involved in delivering emergency rations to a village in crisis. They will then work in groups to develop and present an intervention plan. To complete these activities, students should have prior knowledge of macronutrients (carbohydrates, proteins, and fats) and how they help the body to function. Learning Outcomes • The student will be able to explain the roles vitamin A, iron, and iodine play in a healthy body. • The student will be able to describe the symptoms of vitamin A, iron, and iodine deficiencies.
    [Show full text]
  • The Use of Whey Or Skimmed Milk Powder in Fortified Blended Foods
    Supplemental Material can be found at: http://jn.nutrition.org/content/suppl/2008/07/11/138.1.145S.D C1.html The Journal of Nutrition The Use of Whey or Skimmed Milk Powder in Fortified Blended Foods for Vulnerable Groups: A Literature Review The Use of Whey or Skimmed Milk Powder in Fortified Blended Foods for Vulnerable Groups1,2 Camilla Hoppe, Gregers S. Andersen, Stine Jacobsen, Christian Mølgaard, Henrik Friis, Per T. Sangild, and Kim F. Michaelsen* Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, DK-1958 Frederiksberg, Denmark Abstract Fortified blended foods (FBF), especially corn soy blend, are used as food aid for millions of people worldwide, especially malnourished individuals and vulnerable groups. There are only a few studies evaluating the effect of FBF on health outcomes, and the potential negative effect of antinutrients has not been examined. Different lines of evidence suggest that dairy proteins have beneficial effects on vulnerable groups. Here we review the evidence on the effects of adding Downloaded from whey or skimmed milk powder to FBF used for malnourished infants and young children or people living with HIV or AIDS. Adding whey or skimmed milk powder to FBF improves the protein quality, allowing a reduction in total amount of protein, which could have potential metabolic advantages. It also allows for a reduced content of soy and cereal and thereby a reduction of potential antinutrients. It is possible that adding milk could improve weight gain, linear growth, and recovery from malnutrition, but this needs to be confirmed. Bioactive factors in whey might have beneficial effects on the immune jn.nutrition.org system and muscle synthesis, but evidence from vulnerable groups is lacking.
    [Show full text]
  • Choice of Foods and Ingredients for Moderately Malnourished Children 6 Months to 5 Years of Age
    Choice of foods and ingredients for moderately malnourished children 6 months to 5 years of age Kim F. Michaelsen, Camilla Hoppe, Nanna Roos, Pernille Kaestel, Maria Stougaard, Lotte Lauritzen, Christian Mølgaard, Tsinuel Girma, and Henrik Friis Abstract quality, especially PUFA content and ratios, in children with moderate malnutrition. There is consensus on how to treat severe malnutrition, but there is no agreement on the most cost-effective way to treat infants and young children with moderate mal- Introduction nutrition who consume cereal-dominated diets. The aim of this review is to give an overview of the nutritional Child malnutrition is a major global health problem, qualities of relevant foods and ingredients in relation leading to morbidity and mortality, impaired intellec- to the nutritional needs of children with moderate mal- tual development and working capacity, and increased nutrition and to identify research needs. The following risk of adult disease. This review will deal with the general aspects are covered: energy density, macronutri- needs of children between the ages of 6 months and ent content and quality, minerals and vitamins, bioactive 5 years with moderate malnutrition. Infants below 6 substances, antinutritional factors, and food processing. months of age should (ideally) be exclusively breastfed, The nutritional values of the main food groups—cereals, and if malnourished, will have special needs, which will legumes, pulses, roots, vegetables, fruits, and animal not be covered here. Moderate malnutrition includes all foods—are discussed. The special beneficial qualities children with moderate wasting, defined as a weight- of animal-source foods, which contain high levels of for-height between –3 and –2 z-scores of the median minerals important for growth, high-quality protein, of the new World Health Organization (WHO) child and no antinutrients or fibers, are emphasized.
    [Show full text]
  • Guidance for Approaches for Management of Acute Malnutrition
    Guidance for Approaches for Management of Acute Malnutrition (Taskforce for Management of Acute Malnutrition– Somalia Nutrition Cluster) November 2009 (Version 10) A. Introduction Somalia has experienced persistent critical levels of malnutrition over years and the challenges of widespread insecurity and the associated limited in-country capacities have compounded an already dire humanitarian situation. In an effort to enhance the humanitarian response, the Nutrition Cluster’s task force for Management of Acute Malnutrition aims to provide guidance for programming for the treatment of severe and moderate malnutrition management as well as its prevention in Somalia. Currently, there are inconsistencies in programmes implementation in terms of nutrition products used, implementation modalities and the characteristics and environmental conditions of the target population. Further with the challenge of limited funding, guidance is needed on how to prioritize the available resources to those most in need in the most effective manner. Ongoing efforts by UNICEF and WFP and others, to expand their nutrition programmes through use of blanket fortified blended food distribution and use of ready to use food (RUF) or Lipid Based Nutrient Supplements (LNS) either as complements or by changing intervention strategies, creating further demand for guidance. This paper aims to provide guidance on the use of various products, target populations and new strategies vis-à-vis the existing programmes to appropriately guide decision makers, sponsoring agencies and donor. The guidance is also intended to ensure a greater coverage of these programmes and to reduce gaps and overlaps of approaches. The paper is structured to provide background on a) Available products, b) Approaches to manage acute malnutrition, c) Nutritionally vulnerable groups, and d) Scenario’s for decision making.
    [Show full text]
  • Delivering Improved Nutrition Recommendations for Changes to U.S
    DELIVERING IMPROVED NUTRITION RECOMMENDATIONS FOR CHANGES TO U.S. FOOD AID PRODUCTS AND PROGRAMS April 2011 Food Aid Quality Review Report to the United States Agency for International Development. Prepared by Tufts University under the terms of contract AFP-C-00-09-00016-00 with USAID’s Office of Food for Peace. This report is made possible by the generous support of the American people through the support of the Office of Food for Peace (FFP) of the Bureau for Democracy, Conflict and Humanitarian Assistance (DCHA), under terms of Cooperative Agreement No. AFP-C-00-09-00016-00, managed by Tufts University. The contents are the responsibility of Tufts University and its partners in the Food Aid Quality Review (FAQR) and do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government. Recommended citation: Webb, P., B. Rogers, I. Rosenberg, N. Schlossman, C. Wanke, J. Bagriansky, K. Sadler, Q. Johnson, J. Tilahun, A. Reese Masterson, A. Narayan. 2011. Delivering Improved Nutrition: Recommendations for Changes to U.S. Food Aid Products and Programs. Boston, MA: Tufts University. This document may be reproduced without written permission by including a full citation of the source. This is the short version of a longer report to USAID. For correspondence, contact: Patrick Webb Friedman School of Nutrition Science and Policy Tufts University 150 Harrison Avenue Boston, MA 02111 E-mails: [email protected] ON THE COVER (color photo) A child in Tajikistan holds a tin of fortified vegetable oil donated by USAID. The photo was taken in Khuroson District of Tajikistan near the border with Afghanistan at a Save the Children program.
    [Show full text]
  • Evolution of Nutritional Management of Acute Malnutrition
    R E V I E W A R T I C L E Evolution of Nutritional Management of Acute Malnutrition MICHAEL H GOLDEN Emeritus Professor, University of Aberdeen, Scotland. Correspondence to: Pollgorm, Ardbane, Downings, County Donegal, Ireland. [email protected], [email protected] Wasting, kwashiorkor and stunting are not usually due to either protein or energy deficiency. Treatment based upon this concept results in high mortality rates, and failure of treated children to return physiologically to normal. They become relatively obese with insufficient lean tissue. Preventive strategies have also failed. Wasting and stunting are primarily due to deficiency of type II nutrients and kwashiorkor probably due to deficiency of several type I nutrients that confer resistance to oxidative stress. Modern dietary treatments are based upon the F75 formula whilst the child is sick without an appetite, followed by F100 for rapid gain of weight. Derivative, ready-to-use therapeutic foods (RUTF) allow treatment of large numbers of children at home, are preferred by mothers and dramatically improve coverage. Children are indentified by screening in the community and treated before complications arise, using simple protocols. Successful treatment of the sick children with severe malnutrition not only depends upon these products, but appropriate management of complications. The physiology of the malnourished child is completely different from the normal child and many drugs and treatments that are safe in children with normal physiology are fatal for the malnourished child. In particular, the diagnosis and management of diarrhea and dehydration is different in the malnourished child. Giving standard treatment frequently leads to circulatory overload and death from heart failure.
    [Show full text]
  • Management of Moderate Malnutrition in Under-5 Children by the Health Sector
    1 Management of moderate malnutrition in under-5 children by the health sector Background document for an informal technical consultation on the dietary management of moderate malnutrition - September 30 th - October 3 rd . I - BACKGROUND Introduction Moderate malnutrition (MM) is defined as a weight-for-age between -3 and -2 z-scores below the median of the WHO child growth standards. It can be due to a low weight-for- height (wasting) or a low height-for-age (stunting) or to a combination of both. Similarly, moderate wasting and stunting are defined as a weight-for-height and height-for-age, respectively, between -3 and -2 z-scores. MM affects many children in poor countries. Children with moderate malnutrition have an increased risk of mortality and MM is associated with a high number of nutrition- related deaths.1 If some of these moderately malnourished children do not receive adequate support, they may progress towards severe acute malnutrition (severe wasting and/or oedema) or severe stunting (height-for-age less than -3 z-scores), which are both life-threatening conditions. Therefore, the management of MM should be a public health priority. In contrast to severe malnutrition, programmes for the management of MM in children have remained virtually unchanged for the past 30 years, and it seems timely to review efforts to improve their efficacy and effectiveness. Scope of the meeting The meeting will focus on the dietary management of children with MM. It will aim to answer the question of "What diets should be recommended to feed moderately malnourished children?". The meeting will examine separately the management of moderately wasted and of moderately and severely stunted children.
    [Show full text]
  • Nutrition Guidelines
    FOREWORD UNHCR, UNICEF, WFP and WHO have jointly developed these guidelines as a practical tool for assessing, estimating and monitoring the food and nutrition needs of populations in emergencies. Major food shortages can be a primary feature of an emergency, as in droughts or floods that lead to famine, or they may be a consequence of war, economic disaster, or population displacement. The often serious protein-energy malnutrition and micronutrient deficiencies that inevitably follow such shortages add greatly to the burden of disease and mortality, slow - or even impede altogether - socioeconomic recovery, and make intense additional demands on scarce resources. The guidelines are aimed at field staff involved in planning and delivering a basic general food ration for emergency-affected populations. Their overall aim is to promote timely, coordinated and effective action through improved understanding of food and nutrition needs during emergencies. Graeme A. Clugston Director, Nutrition for Health and Development World Health Organization Geneva, Switzerland CONTENTS LIST OF ABBREVIATIONS . .IV PREFACE . .1 CONTEXT AND PURPOSE . .2 OVERVIEW OF APPROACH . .3 BASIC PRINCIPLES . .4 PLANNING A RATION . .6 I. THE INITIAL PLANNING FIGURE FOR ENERGY . .7 II. ADJUSTING THE INITIAL PLANNING FIGURE FOR ENERGY . .7 A. Environmental Temperature . .7 B. Health and Nutritional Status . .7 C. Demographic Characteristics . .8 D. Physical Activity Level . .8 III. CHOOSING COMMODITIES . .8 A. Macronutrient (Protein and Fat) Requirements . .8 B. Acceptable Basic Rations . .9 C. Refining the Ration: Selecting Commodities to Meet Specific Considerations . .10 1. Addressing Micronutrient (Vitamin and Mineral) Requirements . .10 a. Micronutrient Adequacy in a Ration . .11 b. Micronutrient Deficiencies . .11 c.
    [Show full text]
  • Famine and Counter-Famine Operations
    FAMINE AND COUNTER-FAMINE OPERATIONS By Frederick C. Cuny INTERTECT OUTLINE PART I: Theoretical Base 1. Famine and Its Causes 2. Consequences (To farming, livestock, health) 3. Geographic aspects 4. Societal Responses Part II: Operating strategies 5. Early Warning 6. Approaches to Famine Relief 7. Counter-Famine Operations 8. Emergency Response Part III: Programs and Projects 9. Food Relief Programs 10. Income generating projects 11. Health Programs 12. Water and Sanitation 13. Famine Logistics 14. Assessment and monitoring Part IV: Operational issues 15. Operational issues 16. Famine operations during conflicts 17. Community participation Part V: Reconstruction and prevention 18. Agricultural Reconstruction 1 19. Livestock Redistribution and Re-stocking 20. Famine Prevention Glossary Bibliography Appendices 2 -------- ---- ——- ..... — .......-— Chapter 1 FAMINE AND ITS CAUSES INTRODUCTION Famines are one of the great scourges of mankind. They kill large numbers of people, especially women and children; impoverish whole populations; encourage the spread of disease and malnutrition, dislocate families, villages, and even entire societies, and create or spread political instability. Famines and the conflicts that often create and spread^ them leave wounds in a society that may take generations to heal. There are two types of famines: those that are a result of a lack of food and those that are a result of a lack of purchasing power among the poor.1 Of the two, the latter is the most prevalent. To combat famines, there are two general approaches: provision of food and provision of economic support. The relative effectiveness of each is determined by when the assistance is applied. In most cases, food relief alone has only a limited impact and is often counterproductive.
    [Show full text]
  • Current and Potential Role Of
    Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6-23 months old and treating moderate malnutrition among 6-59 months old children Saskia de Pee1,2,a, Martin W Bloem1,2,3 1 World Food Programme, Rome, Italy 2 Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 3 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD a Author for correspondence: Saskia de Pee, Policy, Strategy and Programme Support Division, World Food Programme, Via Cesare Giulio, 68/70 Parco de'Medici, Rome 00148, Italy. E-mail: [email protected] / [email protected]. Tel. +27.31.5026718 / +27.71.6721690 (GSM) Disclaimer: This publication reflects the personal views of the authors and does not necessarily represent the decisions or the policies of the World Health Organization. This background paper was presented at the WHO, UNICEF, WFP and UNHCR Consultation on the Dietary Management of Moderate Malnutrition in Under-5 Children by the Health Sector September 30th October 3rd, 2008 - 1 - Abstract Reducing child malnutrition requires nutritious food, breastfeeding, improved hygiene, health services, and (prenatal) care. Poverty and food insecurity seriously constrain accessibility of nutritious diets, including high protein quality, adequate micronutrient content and bioavailability, macro-minerals and essential fatty acids, low anti-nutrient content, and high nutrient density. Largely plant-source-based diets with few animal source and fortified foods do not meet these requirements and need to be improved by processing (dehulling, germinating, fermenting), fortification, and adding animal source foods, e.g. milk, or other specific nutrients.
    [Show full text]
  • Improving Child Nutrition Through Quality Certification of Infant Foods
    Working paper Improving Child Nutrition through Quality Certification of Infant Foods Scoping Study for a Randomized Trial in Ghana William A. Masters John Kuwornu Daniel Sarpong February 2011 Improving Child Nutrition through Quality Certification of Infant Foods: Scoping Study for a Randomized Trial in Ghana Table of Contents 1. Introduction and summary ...............................................................................................3 2. Literature review ..............................................................................................................4 3. Status of infant feeding in Ghana .....................................................................................6 4. The market for nutrient-dense infant foods in Ghana ........................................................7 4.1 An informal survey of local infant-food makers in Accra, Kumasi and Tamale .................9 4.2 Inventory of registered infant-food makers and their products ........................................9 4.2 A formal survey of infant-food availability in Accra ........................................................11 4.3 A formal test of nutrient densities for infant food available in Accra ...............................14 4.4 Summary of findings ....................................................................................................17 5. Design of the proposed intervention and randomized trial ..............................................18 5.1 What qualities are to be certified? ................................................................................19
    [Show full text]
  • Current and Potential Role of Specially Formulated
    Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6- to 23-month-old children and for treating moderate malnutrition among 6- to 59-month-old children Saskia de Pee and Martin W. Bloem Abstract many antinutrients, no milk (important for growth), suboptimal micronutrient content, high bulk, and high Reducing child malnutrition requires nutritious food, viscosity. Thus, for feeding young or malnourished breastfeeding, improved hygiene, health services, and children, fortified blended foods need to be improved (prenatal) care. Poverty and food insecurity seriously or replaced. Based on success with ready-to-use thera- constrain the accessibility of nutritious diets that have peutic foods (RUTFs) for treating severe acute mal- high protein quality, adequate micronutrient content nutrition, modifying these recipes is also considered. and bioavailability, macrominerals and essential fatty Commodities for reducing child malnutrition should acids, low antinutrient content, and high nutrient be chosen on the basis of nutritional needs, program density. Diets based largely on plant sources with few circumstances, availability of commodities, and likeli- animal-source and fortified foods do not meet these hood of impact. Data are urgently required to compare requirements and need to be improved by processing the impact of new or modified commodities with that (dehulling, germinating, fermenting), fortification, and of current fortified blended foods and of RUTF devel- adding animal-source
    [Show full text]