Public Health: Strategies, Documents and Reports
On the above regime, a child with serious kwashiorkor would usually begin to lose oedema during the first three to seven days, with consequent loss in weight. The Nairobi Hospital Oncology seminar room Period: In recent decades xerophthalmia has been especially prevalent in children of poor rice-eating families in South and Southeast Asia e. This indicator is a description of the strengths and weaknesses of various aspects of nutrition governance in countries. Th Nairobi Hospital, Oncology seminar room Period: The matrix lists the high-level expected results 'the UNDAF outcomes' , the outcomes to be reached by agencies working alone or together and agency outputs.
Even within these regions, the IFAD reports that some countries and sub-regions fared better than others. In other words, inequality is high even while absolute poverty is slowly being reduced. In addition, in terms of raw numbers of people, South Asia and sub-Saharan Africa are where most rural poor live:.
Although the graphs seem to show progress, the report warns of complacency as further efforts to reduce rural poverty will be complicated by. IFAD also notes that women tend to do more work for less pay and are the primary care givers in virtually all rural societies, yet barely feature in recognition or policy.
IFAD also adds that The general implication of these findings is that achieving gender equality requires challenging social institutions, and that doing so is crucial to address interlocking deprivations which result in poverty — not only for women, but poverty more broadly.
A Canadian study in suggested that the wealthiest nations do not have the healthiest people ; instead, it is countries with the smallest economic gap between the rich and poor. For many years, poverty has also been described as the number one health problem for many poor nations as they do not have the resources to meet the growing needs. Yet, it is not beyond humanity:. Health equity through action on the social determinants of health. The report noted that health inequalities were to be found all around the world, not just the poorest countries:.
The poorest of the poor, around the world, have the worst health. Those at the bottom of the distribution of global and national wealth, those marginalized and excluded within countries, and countries themselves disadvantaged by historical exploitation and persistent inequity in global institutions of power and policy-making present an urgent moral and practical focus for action.
These all apply to the socially disadvantaged in low-income countries in addition to the considerable burden of material deprivation and vulnerability to natural disasters. So these dimensions of social disadvantage — that the health of the worst off in high-income countries is, in a few dramatic cases, worse than average health in some lower-income countries … — are important for health.
Sir Michael Marmot, chair of the Commission, noted in an interview that most health problems are due to social, political and economic factors. The key determinants of health of individuals and populations are the circumstances in which people are born, grow, live, work and age, he says.
And those circumstances are affected by the social and economic environment. Marmot expands on this further in the video clip. Even within a country such as the UK, then, the report finds that the average life-span can differ by some 28 years, depending on whether you are in the poorer or wealthier strata of society. This is discussed in more detail on this web site on this page: Various things can create inequality.
Most common generalizations will be things like greed, power, money. But even in societies where governments are well-intentioned, policy choices and individual actions or inactions can all contribute to inequality.
In wealthier nations, the political left usually argue for addressing inequality as a matter of moral obligation or social justice, to help avoid worsening social cohesion and a weakening society. The political right in the wealthier nations generally argue that in most cases, western nations have overcome the important challenge of inequality of opportunity, and so more emphasis and responsibility should be placed on the individual to help themselves get out of their predicament.
Both views have their merits; being lazy or trying to live off the system is as abhorrent as inequalities structured into the system by those with wealth, power and influence. In poorer countries, those same dynamics may be present too, sometimes in much more extremes, but there are also additional factors that have a larger impact than they would on most wealthier countries, which is sometimes overlooked by political commentators in wealthy countries when talking about inequality in poorer countries.
Indonesia is another example as part of this Noam Chomsky interview by The Nation magazine reveals. Latin America on the whole is another. Latin America has the highest disparity rate in the world between the rich and the poor: Internal, regional and external geopolitics, various international economic factors and more, have all contributed to problems. For example, the foreign policy of the US in that region has often been criticized for failing to help tackle the various issues and only being involved to enhance US national interests and even interfering, affecting the course and direction of the nations in the region through overt and covert destabilization.
This, combined with factors such as corruption, foreign debt, concentrated wealth and so on, has contributed to poverty there. Much of the above was written around early Unfortunately, well into , the World Bank reported that the Latin American rich-poor gap is widening.
There has been progress in closing the gender gap in income, and girls and young women had overtaken their male counterparts in education. However, inequality is very high. The UK and US are often two of the more dynamic nations, economically and opportunities to make a very successful life is well within the realms of possibility. Yet, these two tend to have the worst levels of inequality amongst industrialized nations. Such levels of inequality implies that it is overly simplistic to blame it all on each individual or solely on government policy and white-collar corruption.
While ideological debates will always continue on the causes of inequality, both the political left and right agree that social cohesion social justice or family values, etc is suffering, risking the very fabric of society if it gets out of control. He suggests that as well as a minimum wage, for the sake of social cohesion there should perhaps be a maximum wage , too.
Crime and unhappiness stalk unequal societies. Inequality leads to instability, the last thing the country or world needs right now. Even the former hardline conservative head of the International Monetary Fund, Michel Camdessus, has come to the conclusion that the widening gaps between rich and poor within nations is morally outrageous, economically wasteful and potentially socially explosive. Above subsistence levels, what undermines our sense of well-being most is not our absolute income levels, but how big the gaps are between us and our peers.
Allowing the super-rich to live apart from society is as damaging in its own way as the exclusion of the poorest. It seems, however, that neoliberal economic ideology may lead many to think inequality is not important. It looked into a scenario of what would happen in a few years if the growing inequality in the United Kingdom continued to widen. While the predictions of what would happen are always tough to make, the documentary noted some important issues that are already present, and that also parallel many parts of the world today.
In summary, the documentary noted the increasing alienation and exclusion of people in society where inequality was high, but if government tried to do something about it, they would face a powerful obstacle: The remainder of this subsection provides more details:. Gated communities , while providing an opportunity to develop otherwise derelict areas, also represents a sign of growing inequality, whereby those who can afford to do so live in areas where security is paid for and managed to ensure undesirables are kept out.
While individuals are making understandable decisions regarding their security, there is the additional effect of cutting off from the rest of society, leading to consequences such as:.
While this phenomenon is rarely discussed in the U. These are times when the welfare state is failing people because it gives people a false sense of security and uses an element of coercion payment of taxes to pay for the services. Yet, at the same time, the documentary noted, what is making this situation more complicated is that the super rich are taking advantage of globalization and all the loop holes it provides, such as off-shore tax havens. As a result, there is less the state is able to do, leading to further frustrations.
At the same time, in U. This is in response to the increase in crime, an effect of inequality. But this has important implications. However, policing is meant to be more than protecting things of material value; the police are supposed to have social and human concerns for society as well, something a private security firm neither is mandated to have, nor is usually created for.
Due to the different roles, the costs, structures and accountability are also different. If crime is perceived to be increasing and the police are not seen as trusted, people can, and do take actions into their own hands. Wealthier people of course can afford to take more measures. In theory then, one of the many things that makes up a functioning, stable and democratic society is an uncorrupted judicial system and law enforcement.
Addressing the root causes of inequality would therefore seem to be where the challenge lies. The political costs of inequality are recognized and accepted as being too high.
The economic costs of fighting effects are also high. Citing some research, the BBC also noted that for each dollar spent on poverty causes, seven dollars was saved on consequences. Unfortunately, governments are in a difficult situation, because they can try to address inequality, but they will anger the rich.
In May , the BBC aired another documentary related to inequality, called The Experiment , where they showed in detail how inequality can turn good people to evil.
Inequality is also characterized by a concentration of wealth, which means a concentration of political power. Historically, one of the main reasons for continued poverty has been in order to maintain this power. In the developing world, there is a pattern of inequality caused by the powerful subjugating the poor and keeping them dependent. Outside influence is often a large factor and access to trade and resources is the usual cause. It is often asked why the people of these countries do not stand up for themselves.
In most cases when they do, they face incredible and often violent oppression from their ruling elites and from outsiders who see their national interests threatened.
Everyone has the right to work, to just and favourable conditions of work and to protection for himself and his family [and] an existence worthy of human dignity … Everyone has the right to a standard of living adequate for the health and well being of himself and his family, including food, clothing, housing and medical care.
And contrast that with the following around the same time, from a key superpower that helped create the United Nations. Our real task in the coming period is to devise a pattern of relationships which will permit us to maintain this position of disparity. The day is not far off when we are going to have to deal in straight power concepts.
The less we are then hampered by idealistic slogans, the better. We should make a careful study to see what parts of the Pacific and Far Eastern world are absolutely vital to our security, and we should concentrate our policy on seeing to it that those areas remain in hands which we can control or rely on.
While it is recognized that strong institutions, a functioning and non-corrupt democracy, an impartial media, equitable distribution of land and a well structured judicial system and other such factors , etc.
Often, it can be a very large sector. For example, those likely to lose out in such an equalizing effect are the rich, elite power holders. This is a pattern seen throughout history. Take for example the medieval days of Europe where the wealthy of the time controlled land via a feudal ruling system and hence impoverished the common people intentionally. Trading superiority was maintained by raiding and plundering areas deemed as a threat. Summarizing from the works of the Institute for Economic Democracy:.
The discovery of the Americas, expansion of trade routes etc brought much wealth to these centers of empire which helped fuel the industrial revolution, which required even more resources and wealth to be appropriated, to continue this growth.
Mass luxury consumption in Europe expanded as well as a result of the increased production from the industrial revolution. But this had a further negative impact on the colonized nations, the country side , or the resource-providers.
For example, to keep profits up and costs down, they used slavery where they could, sometimes transferring people across continents, introducing others when indigenous populations had either been wiped out, decimated, or proved too resistant in some way. Europeans also carved out artificial borders to reflect their territorial acquisitions, sometimes bringing different groups of people into the same borders that had never been forced to live together in such short times.
Some poorer countries today still suffer the effects of this. Many Europeans and their descendants around the world have tried to look back at history and ask how it was that Europe and the West prospered and rose to such prominence. The late Professor J.
Race and Christianity in particular, Protestantism were often claimed to be a factor, too. Blaut Guilford Press, Except for religious conflicts and the petty wars of feudal lords, wars are primarily fought over resources and trade. Is there any man, is there any woman, let me say any child here that does not know that the seed of war in the modern world is industrial and commercial rivalry?
Plundering the countryside to maintain dominance and control of the wealth-producing process has been an age-old process. These mercantilist processes continue today. Those policies of plunder by raid have continued, but include a more sophisticated plunder by trade:. The powerful and cunning had learned to plunder by trade centuries ago and societies ever since have been caught in the trap of those unequal trades.
Once unequal trades were in place, restructuring to equal trade would mean the severing of arteries of commerce which provide the higher standard of living for the dominant society and collapse of those living standards would almost certainly trigger open revolt. The world is trapped in that pattern of unequal trades yet today. The geopolitical events of the post World War II era have been crucial for their impacts on poverty and most other issues.
Virtually the entire colonial world was breaking free, its resources would be turned to the care of its own people, and those resources could no longer be siphoned to the old imperial-centers-of-capital for a fraction of their value.
What Western nations were observing, of course, was the same potential loss of the resources and markets of their countryside as the cities of Europe had experienced centuries earlier. The domestic prosperity worried about was only their own and the constantly expanding trade were unequal trades maintaining the prosperity of the developed world and the impoverishment of the undeveloped world as the imperial-centers-of-capital siphoned the natural wealth of their countryside to themselves.
The managers-of-state had to avert that crisis. While European nations are now more cooperative amongst themselves in comparison to the horrors of World War II and the U. Prosperity for a few has increased, as has poverty for the majority. Structural Adjustment SAP , as described in a previous section on this web site, is an example of that dependency. Neoliberal economic ideology has been almost blindly prescribed to poor countries to open up their economies.
The idea is that opening markets for foreign investment will also help improve exports and contribute to economic growth.
Cutting back on social spending e. But what ends up happening is the poorer nations lose their space to develop their own policies and local businesses end up competing with well-established multinationals, sometimes themselves subsidized hinting a more mercantilist economic policy for the rich, even though free market capitalism is the claim and the prescription for others.
In most countries marasmus, the other severe form of PEM, is now much more prevalent than kwashiorkor. In marasmus the main deficiency is one of food in general, and therefore also of energy. It may occur at any age, most commonly up to about three and a half years, but in contrast to kwashiorkor it is more common during the first year of life. Nutritional marasmus is in fact a form of starvation, and the possible underlying causes are numerous.
For whatever reason, the child does not get adequate supplies of breastmilk or of any alternative food. Perhaps the most important precipitating causes of marasmus are infectious and parasitic diseases of childhood.
These include measles, whooping cough, diarrhoea, malaria and other parasitic diseases. Chronic infections such as tuberculosis may also lead to marasmus. Other common causes of marasmus are premature birth, mental deficiency and digestive upsets such as malabsorption or vomiting. A very common cause is early cessation of breastfeeding. The important features of kwashiorkor and nutritional marasmus are compared in Table The following are the main signs of marasmus.
In all cases the child fails to grow properly. If the age is known, the weight will be found to be extremely low by normal standards below 60 percent or -3 SD of the standard. In severe cases the loss of flesh is obvious: The child appears to be skin and bones. An advanced case of the disease is unmistakable, and once seen is never forgotten.
The muscles are always extremely wasted. There is little if any subcutaneous fat left. The skin hangs in wrinkles, especially around the buttocks and thighs. When the skin is taken between forefinger and thumb, the usual layer of adipose tissue is found to be absent. Children with marasmus are quite often not disinterested like those with kwashiorkor. Instead the deep sunken eyes have a rather wide-awake appearance.
Similarly, the child may be less miserable and less irritable. The child often has a good appetite. In fact, like any starving being, the child may be ravenous. Children with marasmus often violently suck their hands or clothing or anything else available. Sometimes they make sucking noises. Stools may be loose, but this is not a constant feature of the disease. Diarrhoea of an infective nature, as mentioned above, may commonly have been a precipitating factor.
There may be pressure sores, but these are usually over bony prominences, not in areas of friction. In contrast to kwashiorkor, there is no oedema and no flaky-paint dermatosis in marasmus. Changes similar to those in kwashiorkor can occur.
There is more frequently a change of texture than of colour. Although not a feature of the disease itself, dehydration is a frequent accompaniment of the disease; it results from severe diarrhoea and sometimes vomiting. Children with features of both nutritional marasmus and kwashiorkor are diagnosed as having marasmic kwashiorkor. In the Wellcome classification see above this diagnosis is given for a child with severe malnutrition who is found to have both oedema and a weight for age below 60 percent of that expected for his or her age.
Children with marasmic kwashiorkor have all the features of nutritional marasmus including severe wasting, lack of subcutaneous fat and poor growth, and in addition to oedema, which is always present, they may also have any of the features of kwashiorkor described above. There may be skin changes including flaky-paint dermatosis, hair changes, mental changes and hepatomegaly. Many of these children have diarrhoea.
Laboratory tests have a limited usefulness for the diagnosis or evaluation of PEM. Some biochemical estimations are used, and give different results for children with kwashiorkor and nutritional marasmus than for normal children or those with moderate PEM. In kwashiorkor there is a reduction in total serum proteins, and especially in the albumin fraction. In nutritional marasmus the reduction is usually much less marked. Often, because of infections, the globulin fraction in the serum is normal or even raised.
Serum albumin drops to low or very low levels usually only in clinically evident kwashiorkor. Serum albumin levels are not useful in predicting imminent kwashiorkor development in moderate PEM cases. It is often true that the more severe the kwashiorkor, the lower the serum albumin, but serum albumin levels are not useful in evaluating less severe PEM. It has also been suggested that serum albumin levels below 2. Serum albumin determinations are relatively easy and cheap to perform, and unlike the other biochemical tests mentioned below, they can be done in modest laboratories in many developing countries.
Levels of two other serum proteins, pre-albumin and serum transferrin, are also of use and not too difficult to determine. Levels of both are reduced in kwashiorkor and may be useful in judging its severity. However, serum transferrin levels are also influenced by iron status, which reduces their usefulness as an indicator of kwashiorkor. Levels of retinol binding protein RBP , which is the carrier protein for retinol, also tend to be reduced in kwashiorkor and to a lesser degree in nutritional marasmus.
However, other diseases, such as liver disease, vitamin A and zinc deficiencies and hyperthyroidism, may also influence RBP levels. Other biochemical tests that have been used or recommended for diagnosing or evaluating PEM have limited usefulness.
These include tests for: These tests are not specific, and most cannot be performed in ordinary hospital laboratories. All children with severe kwashiorkor, nutritional marasmus or marasmic kwashiorkor should, if possible, be admitted to hospital with the mother. The child should be given a thorough clinical examination, including careful examination for any infection and a special search for respiratory infection such as pneumonia or tuberculosis.
Stool, urine and blood tests for haemoglobin and malaria parasites should be performed. The child should be weighed and measured. Often hospital treatment is not possible. In that case the best possible medical treatment available at a health centre, dispensary or other medical facility is necessary. If the child is still being breastfed, breastfeeding should continue. Treatment is often based on dried skimmed milk DSM powder. The child should receive ml of this mixture per kilogram of body weight per day, given in six feeds at approximately four-hour intervals.
Each feed is made by adding five teaspoonfuls of DSM powder to ml of water. Attention to providing all micronutrients is important. The milk mixture should be fed to the child with a feeding cup or a spoon. If cupor spoon-feeding is difficult - which is possible if the child does not have sufficient appetite and is unable to cooperate or if the child is seriously ill the same mixture is best given through an intragastric tube.
The tube should be made of polyethylene; it should be about 50 cm long and should have an internal diameter of 1 mm. It is passed through one nostril into the stomach. The protruding end should be secured to the cheek either with sticky tape or zinc oxide plaster.
The tube can safely be left in position for five days. The milk mixture is best given as a continuous drip, as for a transfusion. Alternatively, the mixture can be administered intermittently using a large syringe and a needle that fits the tube. The milk mixture is then given in feeds at four-hour intervals. Before and after each feed, 5 ml of warm, previously boiled water should be injected through the lumen of the tube to prevent blockage.
There are better mixtures than plain DSM. They can all be administered in exactly the same way by spoon, feeding cup or intragastric tube. Most of these mixtures contain a vegetable oil e. The vegetable oil increases the energy content and energy density of the mixture and appears to be tolerated better than the fat of full cream milk.
Casein increases the cost of the mixture, but as it often serves to reduce the length of the hospital stay, the money is well spent. A stock of the dry SCOM mixture can be stored for up to one month in a sealed tin.
To make a feeding, the desired quantity of the mixture is placed in a measuring jug, and water is added to the correct level. Stirring or, better still, whisking will ensure an even mixture. As with the plain DSM mixture, ml of liquid SCOM mixture should be given per kilogram of body weight per day; a 5-kg child should receive ml per day in six ml feeds, each made by adding five teaspoonfuls of SCOM mixture to ml of boiled water.
A ml portion of made-up liquid feed provides about 28 kcal, 1 g protein and 12 mg potassium. Children with kwashiorkor or nutritional marasmus who have severe diarrhoea or diarrhoea with vomiting may be dehydrated. Intravenous feeding is not necessary unless the vomiting is severe or the child refuses to take fluids orally. Rehydration should be achieved using standard oral rehydration solution ORS , as is described for the treatment of diarrhoea see Chapter For severely malnourished children, unusually dilute ORS often provides some therapeutic advantage.
Thus if standard ORS packets are used which are normally added to 1 litre of boiled water, in a serious case a packet might be added to 1. Even in tropical areas temperatures at night often drop markedly in hospital wards and elsewhere. The seriously malnourished child has difficulty maintaining his or her temperature and may easily develop a lower than normal body temperature, termed hypothermia.
Untreated hypothermia is a common cause of death in malnourished children. At home the child may have been kept warm sleeping in bed with the mother, or the windows of the house may have been kept closed. In the hospital ward the child may sleep alone, and the staff may keep the windows open.
He or she must be kept in warm clothes and must be kept covered with warm bedding, and there must be an effort to ensure that the room is adequately warm. Sometimes hot-water bottles in the bed are used. The child's temperature should be checked frequently.
Although it is useful to establish standard procedures for treating kwashiorkor and nutritional marasmus in any hospital or other health unit, each case should nevertheless be treated on its own merits. No two children have identical needs.
Infections are so common in severely malnourished children that antibiotics are often routinely recommended. Benzyl-penicillin by intramuscular injection, 1 million units per day in divided doses for five days, is often used.
Ampicillin, mg in tablet form four times a day by mouth, or amoxycillin, mg three times a day by mouth, can also be given. Gentamycin and chloramphenicol are alternative options but are less often used.
In areas where malaria is present an antimalarial is desirable, e. In severe cases and when vomiting is present, chloroquine should be given by injection. If anaemia is very severe it should be treated by blood transfusion, which should be followed by ferrous sulphate mixture or tablets given three times daily. If a stool examination reveals the presence of hookworm, roundworm or other intestinal parasites, then an appropriate anthelmintic drug such as albendazole should be given after the general condition of the child has improved.
Severely malnourished children not infrequently have tuberculosis and should be examined for it. If the disease is found to be present, specific treatment is needed.
On the above regime, a child with serious kwashiorkor would usually begin to lose oedema during the first three to seven days, with consequent loss in weight. During this period, the diarrhoea should ease or cease, the child should become more cheerful and alert, and skin lesions should begin to clear. When the diarrhoea has stopped, the oedema has disappeared and the appetite has returned, it is desirable to stop tube-feeding if this method has been used.
A bottle and teat should not be used. If anaemia is still present, the child should now start a course of iron by mouth, and half a tablet mg of chloroquine should be given weekly. Children with severe nutritional marasmus may consume very high amounts of energy, and weight gain may be quite rapid. However, the length of time needed in hospital or for full recovery may be longer than for children with kwashiorkor.
In both conditions, as recovery continues, usually during the second week in hospital, the patient gains weight. While feeding of milk is continued, a mixed diet should gradually be introduced, aimed at providing the energy, protein, minerals and vitamins needed by the child. If the disease is not to recur, it is important that the mother or guardian participate in the feeding at this stage.
She must be told what the child is being fed and why. Her cooperation with and follow-up of this regime is much more likely if the hospital diet of the child is based mainly on products that are used at home and that are likely to be available to the family. This is not feasible in every case in a large hospital, but the diet should at least be based on locally available foods.
Thus in a maize-eating area, for example, the child would now receive maize gruel with DSM added. For an older child, crushed groundnuts can be added twice a day, or, if preferred by custom, roasted groundnuts can be eaten. A few teaspoonfuls of ripe papaya, mango, orange or other fruit can be given. At one or two meals per day, a small portion of the green vegetable and the beans, fish or meat that the mother eats can be fed to the child, after having been well chopped.
If eggs are available and custom allows their consumption, an egg can be boiled or scrambled for the child; the mother can watch as it is prepared.
Alternatively, a raw egg can be broken into some simmering gruel. Protein-rich foods of animal origin are often relatively expensive. They are not essential; a good mixture of cereals, legumes and vegetables serves just as well. If suitable vitamin-containing foods are not available, then a vitamin mixture should be given, because the DSM and SCOM mixtures are not rich in vitamins.
The above maize-based diet is just an example. If the diet of the area is based on rice or wheat, these can be used instead of maize. If the staple food is plantain or cassava, then protein-rich supplements are important. After discharge, or if a moderate case of kwashiorkor has been treated at home and not in the hospital, the child should be followed if possible in the out-patient department or a clinic.
It is much better if such cases can visit separately from other patients i. A relaxed atmosphere is desirable, and the medical attendant should have time to explain matters to the mother and to see that she understands what is expected of her. It is useless just to hand over a bag of milk powder or other supplement, or simply to weigh the child but not provide simple guidance. Satisfactory weight gain is a good measure of progress.
At each visit the child should be weighed. Weight is plotted on a chart to provide a picture for the health worker and the mother. Out-patient treatment should be based on the provision of a suitable dietary supplement, but in most cases it is best that this supplement be given as part of the diet. The mother should be shown a teaspoon and told how many teaspoonfuls to give per day based on the child's weight.
Many supplements, especially DSM, are best provided by adding them to the child's usual food such as cereal gruel rather than by making a separate preparation. The mother should be asked how many times a day she feeds the child. If he or she is fed only at family mealtimes and the family eats only twice a day, then the mother should be told to feed the child two extra times. If facilities exist and it is feasible, the SCOM mixture can be used for out-patient treatment.
It is best provided ready mixed in sealed polyethylene bags. Most deaths in children hospitalized for kwashiorkor or nutritional marasmus occur in the first three days after admission. Case fatality rates depend on many factors including the seriousness of the child's illness at the time of admission and the adequacy of the treatment given.
In some societies sick children are taken to hospital very late in the disease, when they are almost moribund. In this situation fatality rates are high.
The cause and the severity of the disease determine the prognosis. A child with severe marasmus and lungs grossly damaged by tuberculous infection obviously has poor prospects. The prospects of a child with mild marasmus and no other infection are better.
Response to treatment is likely to be slower with marasmus than with kwashiorkor. It is often difficult to know what to do when the child is cured, especially if the child is under one year of age.
There may be no mother or she may be ill, or she may have insufficient or no breastmilk. Instruction and nutrition education are vital for the person who will be responsible for the child. If the child has been brought by the father, then some female relative should spend a few days in the hospital before the child is discharged. She should be instructed in feeding with a spoon or cup and told not to feed the child from a bottle unless he or she is under three months of age.
The best procedure is usually to provide a thin gruel made from the local staple food plus two teaspoonfuls of DSM or some other protein-rich supplement and two teaspoonfuls of oil per kilogram of body weight per day.
Instruction regarding other items in the diet must be given if the child is over six months old. The mother or guardian should be advised to attend the hospital or clinic at weekly intervals if the family lives near enough within about 10 km or at monthly intervals if the distance is greater. Supplies of a suitable supplement to last for slightly longer than the interval between visits should be given at each visit. The child can be put on other foods, as mentioned in the discussion of infant feeding in Chapter 6.
It is essential that the diet provide adequate energy and protein. Usually kcal and 3 g of protein per kilogram of body weight per day are sufficient for long-term treatment. Thus a kg child should receive about kcal and 30 g of protein daily. It should be noted that a marasmic child during the early part of recovery may be capable of consuming and utilizing to kcal and 4 to 5 g of protein per kilogram of body weight per day. There is little doubt that a disorder due mainly to energy deficiency does occur in adults; it is more common in communities suffering from chronic protein deficiency.
The patient is markedly underweight for his or her height unless grossly oedematous , the muscles are wasted, and subcutaneous fat is reduced. Mental changes are common: It is difficult to attract the patient's attention and equally hard to keep it.
Appetite is reduced, and the patient is very weak. Some degree of oedema is nearly always present, and this may mask the weight loss, wasting and lack of subcutaneous fat. Oedema is most common in the legs, and in male patients also in the scrotum, but any part of the body may be affected. The face is often puffy. This condition has been termed "famine oedema" because it occurs where there is starvation resulting from famine or other causes.
It was commonly reported in famines in Indonesia and Papua New Guinea. Frequent, loose, offensive stools may be passed. The abdomen is often slightly distended, and on palpation the organs can be very easily felt through the thin abdominal wall. During palpation there is nearly always a gurgling noise from the abdomen, and peristaltic movements can often be detected with the fingertips.
It is not uncommon for adult kwashiorkor patients to regard their physical state as a consequence of abdominal upset. For this reason, strong purgatives, either proprietary or herbal, and peppery enemas are sometimes used by these patients before they reach hospital, which may greatly aggravate the condition. The hair frequently shows changes. The skin is often dry and scaly, and may have a crazy-pavement appearance, especially over the tibia.
Swelling of both parotid glands is frequent. On palpation the glands are found to be firm and rubbery. Anaemia is nearly always present and may be severe. The blood pressure is low. There is usually only a trace of albumin in the urine. Oedema may also be caused by severe anaemia. In adult PEM there is less dyspnoea than in anaemia and usually no cardiomegaly. Other features such as hair changes and parotid swelling are common in adult PEM but not in anaemia.
However, the two conditions are closely related. In contrast to adult kwashiorkor or famine oedema, which is not very prevalent, the adult equivalent of nutritional marasmus is very common. There are five major causes. Any older child or adult whose diet is grossly deficient in energy will develop signs almost exactly like those of nutritional marasmus, and if the condition progresses it may often be fatal.
In the case of famines, the condition may be termed starvation see Chapter Famines and severe food shortages resulting from war, civil disturbance or natural disasters such as droughts, floods and earthquakes may result in nutritional marasmus in children and a similar condition in adults, who suffer from weight loss, wasting, diarrhoea, infectious diseases, etc. The second major cause of severe wasting or severe PEM in adults is infections, especially chronic, untreated or untreatable infections.
The most common of these now is acquired immunodeficiency syndrome AIDS resulting from infection with the human immunodeficiency virus HIV. As the disease progresses there is marked weight loss and severe wasting. Advanced tuberculosis and many other long-term chronic infections also lead to wasting and weight loss.
A number of malabsorption conditions cause PEM in adults and children. These diseases, of which some are hereditary, result in the inability of the body to digest or absorb certain foods or nutrients. Examples are cystic fibrosis, coeliac disease and adult sprue.
Another cause of wasting in people of any age is malignancy or cancer of any organ once it progresses to a stage not treatable by surgical excision.
Cachexia is a feature of many advanced cancers. A group of eating disorders cause weight loss leading to the equivalent of PEM. The most widely described is anorexia nervosa, which occurs much more commonly in females than males, in adolescents or younger adults rather than older persons and in affluent rather than poor societies.
Other psychological conditions may also result in poor food intake and lead to PEM. Treatment of adult PEM includes therapy related to the underlying cause of the condition and therapy related to feeding and rehabilitation, when the cause makes that feasible. Thus infections such as tuberculosis or chronic amoebiasis require specific therapy which when effective will eliminate the cause of the weight loss and wasting.
In contrast, curative treatment is not applicable in advanced AIDS or cancer. Dietary treatment for adult PEM should be based on principles similar to those described for the treatment of severe PEM in children, including those recovering from kwashiorkor or marasmus.
Emergency feeding and the rehabilitation of famine victims described in Chapter 24 have relevance to adult PEM. It is much more difficult than controlling, for example, iodine deficiency disorders IDD and vitamin A deficiency, because the underlying and basic causes, as described above, are often numerous and complex, and because there is no single, universal, cheap, sustainable strategy that can be applied everywhere to reduce the prevalence or severity of PEM.
Part V of this book includes various strategies to reduce the prevalence of PEM. Appropriate nutrition policies and programmes are suggested, and separate chapters deal with, for example, improving food security, protection and promotion of good health, and appropriate care practices to ensure good nutrition. These chapters provide guidance on how to deal with the three underlying causes of malnutrition, namely inadequate food, health and care, which in Chapter 1 were included in the conceptual framework for malnutrition.
Other chapters in Part V discuss solutions to particular aspects of the problem, including improving the quality and safety of foods, promoting appropriate diets and healthy lifestyles, procuring food in different ways and incorporating nutrition objectives into development policies and programmes.
Throughout Part V there is an emphasis on improving the quality of life of people, especially by reducing poverty, improving diets and promoting good health. Improving the energy intakes of those at risk of PEM is vital.
In the late s and s it was thought that most PEM was caused mainly by inadequate intake of protein. A great deal of emphasis was placed on protein-rich foods as a major solution to the huge problem of malnutrition in the world.
This inappropriate strategy diverted attention from the first need, which is adequate food intake by children. There is now much less emphasis on high-protein weaning foods and on nutrition education efforts to ensure greater consumption of meat, fish and eggs, which are economically out of the reach of many families who have children with PEM.
Protein is an essential nutrient, but PEM is more often associated with deficient food intake than with deficient protein intake. In general, when commonly consumed cereal-based diets meet energy needs, they usually also meet protein needs, especially if the diet also provides modest amounts of legumes and vegetables.
Primary attention needs to be given to increasing total food intake and reducing infection. Sensible efforts are needed to protect and promote breastfeeding and sound weaning; to increase the consumption by young children of cereals, legumes and other locally produced weaning foods; to prevent and control infection and parasitic disease; to increase meal frequency for children; and, where appropriate, to encourage higher consumption of oil, fat and other items that reduce bulk and increase the energy density of foods fed to children at risk.
These measures are likely to have more impact if accompanied by growth monitoring, immunization, oral rehydration therapy for diarrhoea, early treatment of common diseases, regular deworming and attention to the underlying causes of PEM such as poverty and inequity.
Some of these measures can be implemented as part of primary health care. Nutritional anaemias are extremely prevalent worldwide. Unlike protein-energy malnutrition PEM , vitamin A deficiency and iodine deficiency disorders IDD , these anaemias occur frequently in both developing and industrialized countries. The most common cause of anaemia is a deficiency of iron, although not necessarily a dietary deficiency of total iron intake.
Deficiencies of folates or folic acid , vitamin B 12 and protein may also cause anaemia. Ascorbic acid, vitamin E, copper and pyridoxine are also needed for production of red blood cells erythrocytes.
Vitamin A deficiency is also associated with anaemia. Anaemias can be classified in numerous ways, some based on the cause of the disease and others based on the appearance of the red blood cells. These classifications are fully discussed in medical textbooks. Some anaemias do not have causes related to nutrition but are caused, for example, by congenital abnormalities or inherited characteristics; such anaemias, which include sickle cell disease, aplastic anaemias, thalassaemias and severe haemorrhage, are not covered here.
Based on the characteristics of the blood cells or other features, anaemias may be classified as microcytic having small red blood cells , macrocytic having large red blood cells , haemolytic having many ruptured red blood cells or hypochromic having pale-coloured cells with less haemoglobin.
Macrocytic anaemias are often caused by folate or vitamin B 12 deficiencies. In anaemia the blood has less haemoglobin than normal. Haemoglobin is the pigment in red cells that gives blood its red colour.
It is made of protein with iron linked to it. Haemoglobin carries oxygen in the blood to all parts of the body. In anaemia either the amount of haemoglobin in each red cell is low hypochromic anaemia or there is a reduction in the total number of red cells in the body. The life of each red blood cell is about four months, and the red bone marrow is constantly manufacturing new cells for replacement. This process requires adequate amounts of nutrients, especially iron, other minerals, protein and vitamins, all of which originate in the food consumed.
Iron deficiency is the most prevalent important nutritional problem of humans. It threatens over 60 percent of women and children in most non-industrialized countries, and more than half of these have overt anaemia. In most industrialized countries in North America, Europe and Asia, 12 to 18 percent of women are anaemic.
Although deficiency diseases are usually considered mainly as consequences of a lack of the nutrient in the diet, iron deficiency anaemia occurs frequently in people whose diets contain quantities of iron close to the recommended allowances.
However, some forms of iron are absorbed better than others; certain items in the diet enhance or detract from iron absorption; and iron can be lost because of many conditions, an important one in many tropical countries being hookworm infection, which is very common. Nutritional anaemias have until recently been relatively neglected and not infrequently remain undiagnosed.
There are many reasons for the lack of attention, but the most important are probably that the symptoms and signs are much less obvious than in severe PEM, IDD or xerophthalmia, and that although anaemias do contribute to mortality rates they do not often do so in a dramatic way, and death is usually ascribed to another more conspicuous cause such as childbirth.
However, research now indicates that iron deficiency has very important implications, including poorer learning ability and behavioural abnormalities in children, lower ability to work hard and poor appetite and growth. To maintain good iron nutritional status each individual needs to have an adequate quantity of iron in the diet.
The iron has to be in a form that permits a sufficient amount of it to be absorbed from the intestines. The absorption of iron may be enhanced or inhibited by other dietary substances. Human beings have the ability both to store and to conserve iron, and it must also be transported properly within the body.
The average male adult has 4 to 5 g of iron in his body, most of it in haemoglobin, a little in myoglobin and in enzymes and around 1 g in storage iron, mainly ferritin in the cells, especially in the liver and bone marrow. Losses of iron from the body must not deplete the supply to less than that needed for manufacture of new red blood cells. To produce new cells the body needs adequate quantities and quality of protein, minerals and vitamins in the diet.
Protein is needed both for the framework of the red blood cells and for the manufacture of the haemoglobin to go with it. Iron is essential for the manufacture of haemoglobin, and if a sufficient amount is not available, the cells produced will be smaller and each cell will contain less haemoglobin than normal.
Copper and cobalt are other minerals necessary in small amounts. Folates and vitamin B 12 are also necessary for the normal manufacture of red blood cells. If either is deficient, large abnormal red blood cells without adequate haemoglobin are produced. National implementation of the international code Status Report 9 May Use of multiple micronutrient powders for point-of-use fortification of foods consumed by pregnant women Guideline 21 March Daily iron supplementation in adult women and adolescent girls Guideline 11 March Daily iron supplementation in infants and children Guideline 11 March Archived: Breastfeeding advocacy initiative For the best start in life Birth defects surveillance training: Joint child malnutrition estimates Key findings of the edition Biennium report: A systematic review with meta-analyses Food and nutrition surveillance systems: Anaemia policy brief Global Nutrition Targets Breastfeeding policy brief Global Nutrition Targets Childhood overweight policy brief Global Nutrition Targets Low birth weight policy brief Global Nutrition Targets Policy brief series Global Nutrition Targets Stunting policy brief Global Nutrition Targets