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Malnutrition as a Neglected Dise

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									Infectious Diseases on an Empty
Stomach:
                         Malnutrition as a
                        Neglected Disease



                                  Dr. Frances Davidson
                                               USAID
                                                Burden of disease


                                                    Malnutrition:
 Each year…
                                   2 to 5 million under five deaths
Malaria:1 million deaths
              750,000 children
HIV:          2.9 million deaths
              540,000 children infected
TB:           1.6 million deaths
AI:           200 deaths*
*since 2003
Are these conditions related?
                            Is malnutrition a neglected disease?

WHO definition of Neglected Diseases:
•Afflict the poor and most vulnerable (kids and
women)
•Affect rural areas of low-income countries       Lymphatic Filariasis: 120
                                                  million cases, 5 million DALYs
•Cause suffering, life-long disabilities
•High degree of morbidity                         Onchocerciasis: 18 million
                                                  cases, 1 million blind or
•Associated with social stigmatization            visually-impaired
•Impair childhood growth and development          Trachoma: 84 million cases, 8
•Do not receive attention and funding of high-    million blind or visually-
mortality diseases                                impaired

•No commercial markets for drugs or vaccines      Schistosomiasis and soil-
                                                  transmitted helminths: 300
                                                  million infected, 20,000 annual
                                                  deaths
9.7 million under
  five deaths in
       2006

                    The single largest
                          common
                      denominator in
                    global child deaths
                       is malnutrition
                                                                  Malnutrition…

•Causes lymphoid atrophy,
reducing the size of the
thymus and spleen
•Decreases phagocytic
activity by neutrophils and
macrophages
                               MICRONUTRIENTS
•Decreases number of
circulating T cells            Vitamin A deficiency: reduces leukocyte numbers,
                               lymphoid tissue weights, T cell function, natural killer
•Impairs lymphokine            cell numbers and complement activation
production
                               Vitamin B deficiencies: reduce lymphocyte number,
•Depresses integrity of skin   lymphoid tissue weights, antibody responses, and
and mucosal surfaces of        depress phagocyte functions and T cell proliferation
the lung and GI tract
                               Iron deficiency: reduces cytotoxic activity of
•Impairs complement            phagocytes and proliferation of T helper cells
activation
                               Zinc deficiency: reduces T cell development and
                               function
     Under Five Mortality


20-50% of the 9.7 million
child deaths each year…

60.7% of diarrhea deaths
57.3% of malaria deaths
52.3% of pneumonia deaths
44.8% of measles deaths
…are attributable to
undernutrition


                 Caulfield et al, 2004
                                                                 And Infection…

   •Causes protein catabolism and negative nitrogen balance
   •Increases resting energy metabolism
   •Redistributes trace elements like iron and zinc
   •Increases vitamin utilization and excretion




                                  MICRONUTRIENTS
Reduces serum Vitamin A concentrations, precipitating xerophthalmia
Sequesters serum iron in reticuloendothelial system and phagocytes release
lactoferrin—deprives infectious agent of iron for replication by competing with bacteria
for iron
Decreases plasma zinc concentrations due to redistribution of metal to the liver (acute
infections)
Risk Factors




 Lopez, et al. Lancet 2006
Nutrition in the Life Cycle
Keith West
                                                   Maternal anemia

Iron deficiency anemia is associated with 22% of maternal deaths worldwide,
                        and about 50% of all anemia




The risk of maternal mortality decreases by 20% for each 1 g/dL increase in
                                hemoglobin.
Measles (4% of child deaths): 200,000 IUs vitamin A decreases
    measles-specific mortality by 50%
ARIs (19-25% of child deaths):
Low Birth Weight: Children born below 2,500 g at birth are 2.9 times more
   likely to die of ALRI and pneumonia
Breastfeeding: Children who are not breastfed are two times more likely to
   die of ALRIs
Weight-for-height: Wasted kids are over 4 times as likely to die of ARIs
Diarrhea (17% of child deaths):
Zinc decreases the duration and severity of acute and persistent diarrhea
Vitamin A supplementation decreases the severity of diarrheal episodes
    and diarrhea case-fatality rates (but not incidence)
Wasting and stunting both associated with increased incidence, severity,
    and duration of diarrhea
Consumption of specific lactic acid producing organisms reduces incidence
    of diarrheal infections by as much as 50%
                                                          Malaria (8%)


•Stunted children are over 2 times more likely to die from malaria
•Children 1-7 months who were breastfeeding poorly were 5.5 times
more likely to die than those feeding normally
•Children in the lower quartile of weight-for-age were 2.5 times as
likely to die


                           Undernutrition reduces T lymphocytes,
                           impairs antibody formation, decreases
                           complement formation, and causes atrophy
                           of lymphoid tissues—all necessary in
                           combating the malaria parasite
                                                       Neonatal (37%)

                     The risk of neonatal death for infants weighing
                     2000-2499g at birth is four times higher than
                     those weighing 2500-2999g.

                                      •Infants born LBW are 2-4 times more
                                      likely to develop acute diarrhea or to be
                                      hospitalized for diarrhea
                                      •Infants born LBW are twice as likely
                                      to contract ALRIs



                     Maternal undernutrition is a major causal
                     factor, including low gestational weight gain,
Bryce, et al. 2005   low pre-pregnancy BMI, short maternal
                     stature, micronutrient deficiencies
Newborn VAS
                                           HIV (3%)

   HIV compromises nutritional status and increases
              susceptibility to secondary infections

Malnutrition exacerbates the effects of HIV by further
                     weakening the immune system

  Low serum retinol levels associated with increased
                  risk of vertical transmission of HIV
HIV/AIDS                                 Malnutrition

                        Increases
                      susceptibility
Loss of appetite      to infections            Weight loss

Nausea
                                                    Loss of
                      Medication                livelihoods
Diarrhea
                     malabsorption
                                          Loss of economic
Difficulty                                     productivity
swallowing             Nutrient
                     malabsorption
Depression                               Maternal mortality

Infant feeding     Increases mortality
practices          and morbidity from
                    infectious agents
 Undernutrition isn’t just a risk factor for increased
mortality and morbidity, but also a barrier for effective
           treatment of infectious diseases

“Some poor ART clients have
benefited clinically from ARVs through
improved CD4 counts and reduced
viral load but have continued to lose
weight. These are normally clients
from poor backgrounds and this may
point to the unmet need for food
support. We are now convinced that
food is key to the success of treatment
with ARVs”.
Interaction between food and ARVs




                                FANTA
Is the USG funding the right stuff?
In FY2005, PEPFAR provided $482 million to support
          ART for 401,000 AIDS patients

PEPFAR Guidance on the use of funds to address food
and nutrition needs:
•Food support may be provided only to severely
malnourished patients, defined as BMI<16
•“Emergency Plan funds may pay for the procurement
of food only as a last resort.”
•Supplemental and replacement feeding to children
and pregnant/lactating women
                                                        Ethiopia Case Study

Total Population:       77.4 million
Under Fives:            15.8 million          Causes of death in children under five

HIV Adult Prevalence:   0.9-3.5%            Causes of death in children
Children 0-14 infected: 0.1-0.7%                under five (2005)
                                                        Other
                                                        14%
Stunting:               50.7%                                                 Neonatal
                                             Injuries
                                                2%                              31%
Underweight:            34.6%


FY06 PEPFAR funding:                   Pneumonia
                                          22%
$66,526,307                                                                     HIV/AIDS
                                                                                   4%

FY06 child survival and                            Malaria
                                                    6%                  Diarrheal Diseases

nutrition funding:                                      Measles
                                                          4%
                                                                               17%


$5,427,000
                            US Private Foundation Funding

                     $0   $50   $100   $150   $200   $250

   Infectious Diseases

        Human Rights

            Education

             Conflicts

Sanitation/Clean Water

Economic Development

     Natural Disasters

  Reproductive Health

     The Environment

          Malnutrition
                             The importance of nutrition
                             Cost-effectiveness

                             VCT
Vitamin A Supplements
                             US$249-346 per case of
US$0.50 per child            HIV averted
(US$182-327 per child
death averted)               Obesity in middle school
                             students
Iron Supplements
                             US$4,300 per DALY
US$3.17-5.30 per child (In   averted
Africa, US$30-66 per
DALY averted)                Expanded Program on
                             Immunization
Zinc Supplements with
ORS                          US$14-20 per year of
                             healthy life gained in low-
US$0.47 per child            income countries
(US$2,100 per child death
averted)                     Treatment for
                             hypertension in the US
                             US$4,430-87,940
                     So, is nutrition a neglected disease?

Afflict the poor and most vulnerable
Affect rural areas of low-income countries and urban populations
Cause suffering, life-long disabilities and death
High degree of morbidity and mortality
Associated with social stigmatization
Impair childhood growth and development with life-long consequences
Do not receive attention and funding of high-mortality diseases
No commercial markets for drugs or vaccines

         Nutrition is THE
       neglected disease.
            Everyone is scared of avian influenza

 AI

HIV
Malaria

Nutrition
And we know what to do

								
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