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 ..............................................................................................................