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Malnutrition in the Philippines - Perhaps a Double Burden?

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Malnutrition in the Philippines - Perhaps a Double Burden? Kreißl A Malnutrition in the Philippines - perhaps a Double Burden? Journal für Ernährungsmedizin 2009; 11 (1), 24 For personal use only. Not to be reproduced without permission of Verlagshaus der Ärzte GmbH. Wissenschaftliche Arbeiten Malnutrition in the Philippines – perhaps a Double Burden? Adequate nutrition and freedom from hunger are basic human rights for all, but malnutrition, especially among children, represents a major global human development problem. Kreißl Alexandra* Abstracts Viel zu viele Filipinos leiden unter einer oder mehreren Formen Far too many Filipinos suffer from one or more forms of malnu- der Mangelernährung, verursacht durch verschiedene Faktoren trition and it is caused by various reasons like poverty, popula- wie Armut, Bevölkerung, Politik, Pathologie, Lebensmittelher- tion, politics, pathology and production of food and preserva- stellung und Bewahrung der Nahrungsmittel vor Verschwen- tion of food from wastage and loss. The four major deficiency dung und Verlust. Die vier Hauptmangelerkrankungen bei phi- disorders among Filipino children are protein-energy malnutri- lippinischen Kindern sind Protein-Energie-Mangelernährung tion (PEM), Vitamin A Deficiency (VAD), Iron Deficiency Anae- (PEM), Vitamin-A-Mangel (VAD), Eisenmangelanämie (IDA) mia (IDA) and Iodine Deficiency Disorder (IDD). High fatality und Jodmangel (IDD). Die Ursache der hohen Sterberaten bei rates among infants and children are caused by PEM, especially Säuglingen und Kindern ist PEM, wobei es sich vor allem um by kwashiorkor, marasmus or marasmic kwashiorkor. Rural ar- Kwashiorkor, Marasmus und marasmischer Kwashiorkor han- eas, poor medical care and poverty make treatment more dif- delt. Ländlicher Wohnsitz, schlechte medizinische Versorgung ficult. However, the best way to treat malnutrition should be und Armut erschweren zusätzlich die notwendige Behandlung. in hospital, including a stabilization phase and a rehabilitation Aber der beste Weg, um Mangelernährung zu behandeln, ist phase. der Aufenthalt im Krankenhaus, wobei die Stabilisationsphase Vitamin A Deficiency is related to low-socio-economic status und Rehabilitationsphase mit eingeschlossen ist. and is a major health problem among Filipino children, aged 6 Vitamin-A-Mangel steht in Zusammenhang mit niedrigem so- months to 5 years, with the highest prevalence in Western Min- zioökonomischem Status und stellt ein sehr großes Gesund- danao. Iron Deficiency Anaemia is the most prevalent micronu- heitsproblem unter den philippinischen Kindern dar, im Alter trient deficiency problem in the Philippines. The most vulnera- von 6 Monaten bis 5 Jahren, und mit der höchsten Prävalenz ble group is infants, aged 6 to 11 months and with the highest in West-Mindanao. Eisenmangelanämie ist das meist verbrei- prevalence rate in the Autonomous Region of Muslim Mindan- tete Mikronährstoffmangel-Problem auf den Philippinen. Eine ao (ARMM). As opposed to VAD and IDA, Iodine Deficiency besonders gefährdete Personengruppe sind Säuglinge, im Al- Disorder is the easiest deficiency to control with simple iodiza- ter von 6 bis 11 Monaten, mit der höchsten Prävalenzrate im tion of salt. Central Luzon and ARMM show a higher preva- Gebiet Autonomous Region of Muslim Mindanao (ARMM). Im lence of IDD among children, 6 to 12 years, in comparison to Gegensatz zu VAD und IDA ist Jodmangel der Mangelzustand, other regions of the Philippines. den man am leichtesten kontrollieren kann, und zwar mittels Io- This Asian country is on the way to recover with effective meth- dierung des Salzes. Im Vergleich zu anderen philippinischen Re- ods to fight for infant and child survival: In 1993-1998, the gionen weist Zentral-Luzon und ARMM eine höhere IDD-Prä- Philippine Plan of Action for Nutrition (PPAN) was an exem- valenz unter Kindern, im Alter von 6 bis 12 Jahren, auf. plary project to improve the nutritional status of Filipinos with Im Moment befindet sich dieses asiatische Land auf dem Weg five impact programmes: Home, School and Food Produc- der Besserung, mittels wirksamer Methoden, um für das Über- tion, Micronutrient Supplementation, Food Fortification, Nu- leben von Säuglingen und Kindern zu kämpfen: 1993 bis 1998 trition Education and Food Assistance. In 1999-2004, the Me- fand das vorbildliche Projekt Philippine Plan of Action for Nu- dium-Term Philippine Plan of Action for Nutrition (MTPPAN) trition (PPAN) statt, zur Verbesserung des Ernährungsstatus was an appreciate successor and achieved more objectives and von Filipinos mit folgenden fünf sehr einflussreichen Program- improvements. men: Haus-, Schul- und Lebensmittelproduktion, Supplementa- tion von Mikronährstoffen, Fortifikation von Nahrungsmitteln, Bildung in Bezug auf Ernährungslehre und Nahrungsmittelhil- Keywords: malnutrition, protein-energy malnutrition, kwashior- fe. Von 1999 bis 2004 war das Projekt Medium-Term Philippi- kor, marasmus, deficiency, obesity ne Plan of Action for Nutrition (MTPPAN) ein würdiger Nach- folger und hat noch mehr Ziele und Verbesserungen erreichen können. Die vorliegende Arbeit finden Sie in der Online-Version des Stichwörter: Mangelernährung, Protein-Energie-Mangelernährung, Journals für Ernährungsmedizin unter www.aerzteverlagshaus.at Kwashiorkor, Marasmus, Defizienz, Adipositas Korrespondenz * Mag. Alexandra Kreißl, Abteilung für Ernährungsmedizin, Telefon und Fax: +43 01 40400 - 2338 Universitätsklinik für Kinder und Jugendheilkunde, Email: [email protected] Währinger Gürtel 18-20, 1090 Wien, Österreich 24 JEM Juni 2009 Wissenschaftliche Arbeiten DEFINITION: MALNUTRITION In 1959, Jelliffe introduced the term ”protein-calorie-malnutri- Table 1: Different Types of Classification3 tion” which has been largely replaced by “protein-energy-mal- nutrition”. Protein-energy malnutrition (PEM), or simply “mal- Type % reference Nutritional class nutrition”, is characterized by growth failure and continues to be a severe health problem in children in developing countries. Gomez 90-109 “Normal” The greatest problem regarding malnutrition is in South and Weight-for-age 75-89 Grade I or mild malnutrition Southeast Asia, due the enormous population and the pre- 60-74 Grade II or moderate valence of underweight children, which is two or three times malnutrition <60 Grade III or severe mal- higher than elsewhere all over the world. However, another nutrition major problem in the Philippines is poverty. Particularly prima- ry protein-energy malnutrition is associated with poverty and represents the “iceberg phenomenon”. The majority of children Wellcome 60-79 No oedema-Oedematous have mild malnutrition and form the basis of the iceberg. Far Weight-for-age Undernourished-Kwash- fewer have moderate malnutrition and only few, the top of the iorkor iceberg, have severe malnutrition. PEM leads to both, macro- <60 Marasmus-Marasmic- nutrient deficiency and micronutrient deficiency, the so-called Kwashiorkor “Global Malnutrition”. 3 The severe forms of protein-energy malnutrition are relatively Waterlow “Stunting” easy to diagnose from their clinical manifestations. Filipino chil- Height-for-age 90-94 Mild dren are usually found in mild or moderate malnutrition cate- 85-89 Moderate gory. The diagnose of mild and moderate forms is mainly based <85 Severe on anthropometry. The prevention and reduction of mild and Weight-for-height moderate PEM will automatically reduce severe PEM. 1 “Wasting” 80-89 Mild 1 70-79 Moderate Figure 1: PEM Iceberg <70 Severe Nutritional Kwashiorkor Prevalence (%) marasmus COmmON FORMS OF MALNUTRITION Severe PEM 1-5 Protein-energy-malnutrition is subdivided into kwashiorkor, marasmus and marasmic kwashiorkor. Children with PEM are at a higher risk for problems like hypothermia, hypoglycaemia, Moderate PEM 10-25 electrolyte disturbances and serious infection. No clear distinc- tion has been made between growth failure (marasmus and undernutrition) and oedematous malnutrition (kwashiorkor and marasmic kwashiorkor) in terms of clinical conditions and Mild PEM 20-40 pathology. Even if their treatment is very similar, there are some major hypotheses to explain the different forms of PEM. Table 2: Differences between Kwashiorkor and Marasmus1 No evidence of PEM 15-50 Feature Kwashiorkor Marasmus CLASSIFICATION OF PEM Growth failure Present Present The classification of protein-energy malnutrition is based on ex- Wasting Present Present, marked amination and anthropometric measurements such as weight- Oedema Present (sometimes Absent for-age, height-for-age, weight-for-height and measurements mild) include mid-upper arm circumference (MUAC). The problems Hair changes Common Less common with these measurements are the differences between observ- Mental changes Very common Uncommon ers in their techniques and they do not show the same range of graded differences like the weight of the whole body does. Dermatosis Common Does not occur Fundamental for classification of PEM are the definition of flaky-paint “normal” as any value between the 2.5th and the 97.5th per- Appetite Poor Good centile, approximately +2 SD of mean values and last but not Anaemia Severe (sometimes) Present, less severe least reference values. The term “reference” value is especial- Subcutaneous fat Reduced by present Absent ly hard to define. Most of the scientists do not have the same opinion referring to “ideal” height or weight. 1 The following reference values are used: “Harvard Standard” (growth Face May be oedematous Drawn in, monkey-like dates from 1930–1950, USA) “Tanner-Whitehouse Standard” (growth dates from 1950–1960,
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