Determinants of malnutrition in two states in Sudan

Nearly one in three children in the developing world is malnourished. Poor nutrition contributes to one out of two deaths (53%) associated with infectious diseases among children aged under five in developing countries. Using data from the 2005 World Food Program’s (WFP) Livelihood Vulnerability and Nutritional Assessment of Rural Kassala and Red Sea State this study examines the impact of female headed households and maternal education on malnutrition in children 6-59 months old. The dependent variable investigated in this study is moderate to severe wasting or less than -2 weight for height Z-score, also known as global acute malnutrition (GAM). ^ The study population consisted of 450 households in Kassala State and Red Sea State, Sudan. A total of 900 children 6-59 months of age were part of the households sampled from these states and one child per household (773 children) was randomly chosen for the analysis along with the child’s mother. Results of the study found that 18 percent of children between 6-59 months of age had GAM/wasting. Maternal education, main source of water, and income were strongly related to wasting. Gender of head of household was not found to have a significant relationship with GAM/wasting. Mothers with at least primary education were much less likely to have malnourished children, even after controlling for income and environmental conditions. Children in households with unsafe sources of water were 2.6 more likely to have wasting than those with piped in/tube wells as their main source of water. For every increase of 100 dinar in a household, the children in the household are approximately two-thirds times (.662) less likely to be wasted. ^ The results of this study support the alternate hypothesis that there is an association between maternal education on wasting of children 6-59 months old. The results do not, however, support the alternate hypothesis that there is an association between gender of head of household on wasting of children 6-59 months old. Better understanding of the association of wasting and other measures of malnutrition with maternal education levels can program managers and other health officials to target important nutritional and non-nutritional interventions. ^

THE USE OF ARM CIRCUMFERENCE FOR SIMPLIFIED SCREENING FOR MALNUTRITION BY MINIMALLY TRAINED HEALTH WORKERS

Because of its simplicity and low cost, arm circumference (AC) is being used increasingly in screening for protein energy malnutrition among pre-school children in many parts of the developing world, especially where minimally trained health workers are employed. The objectives of this study were as follows: (1) To determine the relationship of the AC measure with weight for age and weight for height in the detection of malnutrition among pre-school children in a Guatemalan Indian village. (2) To determine the performance of minimally trained promoters under field conditions in measuring AC, weight and height. (3) To describe the practical aspects of taking AC measures versus weight, age and height.^ The study was conducted in San Pablo La Laguna, one of four villages situated on the shores of Lake Atitlan, Guatemala, in which a program of simplified medical care was implemented by the Institute for Nutrition for Central America and Panama (INCAP). Weight, height, AC and age data were collected for 144 chronically malnourished children. The measurements obtained by the trained investigator under the controlled conditions of the health post were correlated against one another and AC was found to have a correlation with weight for age of 0.7127 and with weight for height of 0.7911, both well within the 0.65 to 0.80 range reported in the literature. False positive and false negative analysis showed that AC was more sensitive when compared with weight for height than with weight for age. This was fortunate since, especially in areas with widespread chronic malnutrition, weight for height detects those acute cases in immediate danger of complicating illness or death. Moreover, most of the cases identified as malnourished by AC, but not by weight for height (false positives), were either young or very stunted which made their selection by AC better than weight for height. The large number of cases detected by weight for age, but not by AC (false negative rate--40%) were, however, mostly beyond the critical age period and had normal weight for heights.^ The performance of AC, weight for height and weight for age under field conditions in the hands of minimally trained health workers was also analyzed by correlating these measurements against the same criterion measurements taken under ideally controlled conditions of the health post. AC had the highest correlation with itself indicating that it deteriorated the least in the move to the field. Moreover, there was a high correlation between AC in the field and criterion weight for height (0.7509); this correlation was almost as high as that for field weight for height versus the same measure in the health post (0.7588). The implication is that field errors are so great for the compounded weight for height variable that, in the field, AC is about as good a predictor of the ideal weight for height measure.^ Minimally trained health workers made more errors than the investigator as exemplified by their lower intra-observer correlation coefficients. They consistently measured larger than the investigator for all measures. Also there was a great deal of variability between these minimally trained workers indicating that careful training and followup is necessary for the success of the AC measure.^ AC has many practical advantages compared to the other anthropometric tools. It does not require age data, which are often unreliable in these settings, and does not require sophisticated subtraction and two dimensional table-handling skills that weight for age and weight for height require. The measure is also more easily applied with less disturbance to the child and the community. The AC tape is cheap and not easily damaged or jarred out of calibration while being transported in rugged settings, as is often the case with weight scales. Moreover, it can be kept in a health worker's pocket at all times for continual use in a widespread range of settings. ^

MYELINATION IN UNDERNOURISHED RAT BRAIN

Several interactive parameters of protein-calorie malnutrition imposed during postnatal ontogeny on the myelination of rat brain wre investigated. Postnatal starvation depresses the rate of myelin protein synthesis to approximately the same extent in all major brain regions examined (cerebral cortex, cerebellum, striatum, hippocampus, hypothalamus, midbrain and medulla), indicating a relatively uniform reduction in myelination throughout the brain. Early starvation from birth through 8 days, as well as starvation occurring late, from 14 to 30 days, produced no lasting deficit in myelin accumulation. Starvation from birth through 14 days or from birth through 20 days produces lasting, significant myelin deficits in all brain regions when examined following ad libitum feeding to 60 days of age. These data, in combination with the metabolic studies of myelin synthesis, show that severe starvation occurring during the 2nd and 3rd weeks of postnatal life produces an immediate reduction in myelin synthesis, and that the subsequent deficit in myelin accumulation is irreversible by nutritional rehabilitation. With respect to the relative severity of nutritional restriction occurring during this "critical" interval of brain ontogeny, additional studies showed that mild undernourishment (producing less than 20 percent growth lag) produces no myelin deficit. There appears to be a threshold effect such that undernutrition producing a growth lag of between 20 to 30 percent first produces a measurable deficit. Increasingly severe regimens of nutritional restriction which produce approximately 30, 40 and 50 percent body weight lags result in initial myelin deficits of 25, 55 and 60 percent, respectively. Initial myelin deficits do not recover following nutritional rehabilitation, although myelin continues to increase in both normal and all undernourished populations. At the cellular level, severe postnatal nutritional restriction appears to depress both the initial synthesis of myelin precursor proteins (as demonstrated for proteolipid protein) as well as their subsequent assembly into myelin membrane. All of the findings of the present studies are consistent with a hypothetical model of undernutrition-induced brain hypomyelination in which the primary defect consists of a failure of oligodendroglia to myelinate a substantial percentage of axons, resulting in a greatly decreased ratio of myelinated to unmyelinated axons. ^

An assessment of the nutritional status of orphaned adolescents living in Nyanza Province, Kenya

Increasing numbers of children and adolescents are becoming vulnerable or orphaned due to the HIV/AIDS epidemic in Nyanza Province, Kenya. Research indicates food security remains a top concern for those caring for these children or adolescents. This study was a examined thinness, stunting, and perceptions about food availability in adolescents ages 10-17 years in Nyanza Province. No evidence was found suggesting orphaned adolescents experience greater amounts of stunting or thinness over non-orphaned adolescents in the province. Orphans did not perceive less available food in their households. Instead, predictors of thinness, stunting, or low perceptions of food availability included age, household facilities, perceptions of equal or unequal treatment in the household, and perceptions about the household's ability to provide them with basic needs. Findings suggest interventions aimed at decreasing malnutrition focus less on orphaned versus non-orphaned adolescents, but they should focus on adolescents made vulnerable due to lower socioeconomic status. ^

Helicobacter pylori infection and the effect on growth in a cohort of children in the US/Mexico border

Helicobacter pylori (H. pylori) is an S-shaped or curved gram-negative bacterium that is mostly found in the human stomach. H. pylori causes gastritis in adults and children, which can lead to gastric ulcers or risk of cancer. Transmission of this bacterial infection remains to be unknown but is mostly acquired during childhood. Little is known about the effect H. pylori has on growth in children. Although some studies have reported that H. pylori is associated with subnormal growth, the association of H. pylori with growth retardation and malnutrition is poorly described. Data from this study comes from The Pasitos Cohort Study which draws its population from three border communities which include Socorro and San Elizario in Texas, as well as Ciudad Juarez, Chihuahua, Mexico. Birth documentation was obtained for 803 infants and 472 entered follow-up. This cohort study allowed us to assess the growth of children from 6 months to the seventh anniversary, and describe the prevalence of underweight, short stature and overweight in the study population. We also tested the hypothesis that children in the Pasitos Cohort Study who were ever infected with H. pylori show an increased risk of growth retardation or malnutrition at 66 months of age. Using the 2000 CDC Growth Reference, we found that the mean BMI of the study population increased as children grew older, while the mean of their height for age decreased slightly. The proportion of children who were classified as of short stature was under 5%, while those considered underweight were less than 10% at selected six-months of age intervals. Using the subset of children who were 66 months of age we found that the risk of underweight was higher among those who ever tested positive for H. pylori infection using the urea breath test; however, due to small numbers of children with 'wasting' this difference was not statistically significant. Moreover, since the six cases of under weight occurred among children of low socio-economic status we could not rule out potential confounding. The risk of developing short stature was not different among those ever infected and those who never tested positive for H. pylori infection. ^

Household health assessment and associated water sample analysis in the Miches watershed of the Dominican Republic

Background. Diarrhea and malnutrition are the leading causes of mortality for children age one to four in the Dominican Republic. Communities within the Miches watershed lack sanitation infrastructure and water purification systems, which increases the risk of exposure to water-borne pathogens. The purpose of this cross-sectional study was to analyze health information gathered through household interviews and to test water samples for the presence of diarrheagenic pathogens and antibiotic-resistant bacteria within the Miches watershed. Methods. Frequency counts and thematic analysis were used to investigate Human Health Survey responses and Fisher's exact test was used to determine correlation between water source and reported illness. Bacteria cultured from water samples were analyzed by Gram stain, real-time PCR, API® 20E biochemical identification, and for antibiotic resistance. Results. Community members reported concerns about water sources with respect to water quality, availability, and environmental contamination. Pathogenic strains of E. coli were present in the water samples. Drinking aquifer water was positively-correlated with reported stomach aches (p=0.04) while drinking from rivers or creeks was associated with the reported absence of “gripe” (cold or flu) (p=0.01). The lack of association between reported illnesses and water source for the majority of variables suggested that there were multiple vehicles of disease transmission. Antibiotic resistant bacteria were isolated from the water samples tested. Conclusions. The presence of pathogenic E. coli in water samples suggested that water is at least one route of transmission for diarrheagenic pathogens in the Miches watershed. The presence of antibiotic-resistant bacteria in the water samples may indicate the proliferation of resistance plasmids in the environment as a result of antibiotic overuse in human and animal populations and a lack of sanitation infrastructure. An intervention that targets areas of hygiene, sanitation, and water purification is recommended to limit human exposure to diarrheagenic pathogens and antibiotic-resistant organisms. ^

Defining barriers in caring for seriously-ill children in a resource-limited setting: An observational study of 2 children's hospitals in Haiti

Background. According to the WHO 2007 country report, Haiti lags behind the Millennium Development Goal of reducing child mortality and maintains the highest under-5 mortality rate in the Western hemisphere. 3 Overall, few studies exist that seek to better grasp barriers in caring for a seriously ill child in a resource-limited setting and only a handful propose sustainable, effective interventions. ^ Objectives. The objectives of this study are to describe the prevalence of serious illnesses among children hospitalized at 2 children's hospitals in Port au Prince, to determine the barriers faced when caring for seriously ill children, and to report hospital outcomes of children admitted with serious illnesses. ^ Methods. Data were gathered from 2 major children's hospitals in Port au Prince, Haiti (Grace Children's Hospital [GCH] and Hopital d l'Universite d'Etat d'Haiti [HUEH]) using a triangulated approach of focus group discussions, physician questionnaires, and retrospective chart review. 23 pediatric physicians participated in focus group discussions and completed a self-administered questionnaire evaluating healthcare provider knowledge, self-efficacy, and perceived barriers relating to the care of seriously ill children in a resource-limited setting. A sample of 240 patient charts meeting eligibility criteria was abstracted for pertinent elements including sociodemographics, documentation, treatment strategies, and outcomes. Factors associated with mortality were analyzed using χ2 test and Fisher exact test [Minitab v.15]. ^ Results. The most common primary diagnoses at admission were gastroenteritis with moderate dehydration (35.5%), severe malnutrition (25.8%), and pneumonia (19.3%) for GCH, and severe malnutrition (32.6%), sepsis (24.7%), and severe respiratory distress (18%) for HUEH. Overall, 12.9% and 27% of seriously ill patients presented with shock to GCH and HUEH, respectively. ^ Shortage of necessary materials and equipment represented the most commonly reported limitation (18/23 respondents). According to chart data, 9.4% of children presenting with shock did not receive a fluid bolus, and only 8% of patients presenting with altered mental status or seizures received a glucose check. 65% of patients with meningitis did not receive a lumbar puncture due to lack of materials. ^ Hospital mortality rates did not differ by gender or by institution. Children who died were more likely to have a history of prematurity (OR 4.97 [95% CI 1.32-18.80]), an incomplete vaccination record (OR 4.05 [95% CI 1.68-9.74]), or a weight for age ≤3rd percentile (OR 6.1 [95% CI 2.49-14.93]. Case-fatality rates were significantly higher among those who presented with signs of shock compared with those who did not (23.1% vs. 10.7%, RR=2.16, p=0.03). Caregivers did not achieve shock reversal in 21% of patients and did not document shock reversal in 50% of patients. ^ Conclusions. Many challenges face those who seek to optimize care for seriously ill children in resource-limited settings. Specifically, in Haiti, qualitative and quantitative data suggest major issues with lack of supplies, pre-hospital factors, including malnutrition as a comorbidity, and early recognition and management of shock. A tailored intervention designed to address these issues is needed in order to prospectively evaluate improvements in child mortality in a high-risk population.^

Examination of the influence of behavioral, normative and control beliefs on the adherence to a prescribed renal diet among elderly populations with chronic to end-stage renal disease

The 1999-2004 prevalence of chronic kidney disease in adults 20 year or older (15.5 million) is an estimated 7.69%. The risk of developing CKD is exacerbated by diabetes, hypertension and/or a family history of kidney disease. African Americans, Hispanics, Pacific Islanders, Native Americans, and the elderly are more susceptible to higher incidence of CKD. The challenges of aging coupled with co-morbidities such as kidney disease raises the potential for malnutrition among elderly (for the purpose of this study 55 years or older) populations. Lack of adherence to prescribed nutrition guidelines specific to renal failure jeopardizes body homeostasis and increases the likelihood of future morbidity and resultant mortality. The relationship and synergy that exists between diet and disease is evident. Clinical experience with renal patients has indicated the importance of adherence to diet therapy specific to kidney disease. Extension investigation of diet adherence among endstage renal disease patients revealed a sizeable dearth in the current literature. This thesis study was undertaken to help reduce that void. The study design is qualitative and descriptive. Support, cooperation, and collaboration were provided by the University of Texas Nephrology Department, University of Texas Physicians, and DaVita Dialysis Centers. Approximately 105 male and female chronic to end-stage kidney disease patients were approached to participate in elicitation interviews in dialysis treatment facilities regarding their present diet beliefs and practices. Eighty-five were recruited and agreed to participate. Inclusion criteria required individuals to be between 35-90 years of age; capable of completing a 5-10 minute interview; and English speaking. Each kidney patient was asked seven (7) non-leading questions developed from the constructs of the Theory of Planned Behavior. The study presents a descriptive comparison of behavioral, normative, and control beliefs that influence adherence to renal diets by age, race, and gender. The study successfully concluded that behavioral, normative, and control beliefs of chronic to end-stage renal patients promoted execution and adherence to prescribed nutrition. This study provides valuable information for dietitians, technicians, nurses, and physicians to assess patient compliance toward prescribed nutrition and the means to support or improve that performance. ^

THE BACON CHOW STUDY: THE RELATIONSHIP BETWEEN INFECTIOUS ILLNESS AND GROWTH OF INFANTS

Multiple dietary deficiencies and high rates of infectious illness are major health problems leading to malnutrition and limitation of growth of children in developing countries. Longitudinal studies which provide information on illness incidence and growth velocity are needed in order to untangle the complex interrelationship between nutrition, illness and growth. From 1967 to 1973, researchers led by Dr. Bacon Chow of the Johns Hopkins University School of Hygiene undertook a quasi-experimental prospective study in Suilin Township, Taiwan to determine the effects of a nutritional supplement to the diets of pregnant and lactating women on the growth, development and resistance to disease of their offspring. This dissertation presents results from the analysis of infant morbidity and postnatal growth.^ Maternal nutritional supplementation has no apparent effect on the postnatal growth or morbidity of infants. Significant sex differences exist in growth response to illness and in illness susceptibility. Male infants have more diarrhea and upper respiratory illness. Respiratory illness is positively associated with growth rate in weight in the first semester of life. Diarrhea is significantly negatively associated with growth in length in the second semester. Small-for-date infants are more susceptible to illness in general and have a different pattern of growth response than large-for-date infants.^ Principal components analysis of illness data is shown to be an effective technique for making more precise use of ambiguous morbidity data. Multiple regression with component scores is an accurate method for estimating variance in growth rate predicted by indepenent illness variables. A model is advanced in which initial postnatal growth rate determines subsequent susceptibility to nutritional stress and infection. Initial growth rate is a function of prenatal nutrition, but is not significantly affected by maternal supplementation during gestation or lactation. Critical evaluation is made of nutritional supplementation programs which do not afford disease control.^

INFECTION: ITS ECOLOGICAL DETERMINANTS AMONG CHILDREN IN NORTHERN CHILE

In developing countries, infection and malnutrition, and their interaction effects, account for the majority of childhood deaths and chronic deficits in growth and development. To promote child health, the causal determinants of infection and malnutrition and cost-effective interventions must be identified. To this end, medical examinations of 988 children (age two weeks to 14 years) living at three altitudes (coastal < 300m; sierra (TURN) 3,000m; and altiplano > 4,000m) in Chile's northermost Department of Arica revealed that 393 (40%) of the youngsters harbored one or more infections. When sorted by region and ethnicity, indigenous children of the highlands had infection rates 50% higher than children of Spanish descent living near the coast.^ An ecological model was developed and used to examine the causal path of infection and measure the effect of single and combined environmental variables. Family variables significantly linked to child health included maternal health, age and education. Significant child determinants of infection included the child's nutrient intake and medical history. When compared to children well and free of disease, infected youngsters reported a higher incidence of recent illness and a lower intake of basic foodstuffs. Traditional measures of child health, e.g. birth condition, weaning history, maternal fertility, and family wealth, did not differentiate between well and infected children.^ When height, weight, arm circumference, and subcapular skinfold measurements were compared, infected children, regardless of age, had smaller arm circumferences, the statistical difference being the greatest for males, age nine to eleven. Height and weight, the traditional growth indices, did not differentiate between well and infected groups.^ Infection is not determined by a single environmental factor or even a series of variables. Child health is ecological in nature and cannot be improved independent of changes in the environment that surrounds the child. To focus on selected child health needs, such as feeding programs or immunization campaigns, without simultaneously attending to the environment from which the needs arose is an inappropriate use of time, personnel, and money. ^

Study of rural leadership and implications for community participation and development in the health and family planning programs in Bangladesh

The vast majority of Bangladesh are poor and are unable even to provide for the most basic human needs. These are the landless and marginal farmers of Bangladesh. They constitute 70% of the rural population, which in turn constitute about 90% of the country's population.^ Effective development of Bangladesh would largely mean the development of the landless and marginal farmers. Past efforts of development in this section of the population, including that of the government, have not succeeded. One of the development goals of the government of Bangladesh is to improve the quality of life of the rural population through health and population control measures. Overpopulation, malnutrition and diarrhea are the major impediments to socioeconomic development in Bangladesh.^ The current study was designed to identify whether there is effective opinion leadership among the marginal and landless peasants affecting decisions on acceptance or nonacceptance of family planning methods and oral rehydration therapy (ORT) in the selected rural areas of Bangladesh. The study was conducted in eight randomly selected villages with funding from the Ministry of Health and Family Planning, government of Bangladesh. One hundred twenty-five opinion leaders were interviewed after they were identified by 408 rural couples owning land less than 2 acres and wives' age below 50. The study was conducted in two phases; couples' interview preceded that of the leaders.^ Findings of the study reveal that the opinion leaders influencing adoption of health and family planning among the landless and marginal farmers belong to the same class. Theses opinion leaders own land much less than the rich farmers and the formal leaders in the rural areas. Majority of these of opinion leaders are friends, neighbors and relatives, some are other persons who are businessmen and professionals like doctors, while the rest few are the field workers of health and family planning. Source of influence as a factor contribute most in differentiating use and non-use of family planning and ORT among both couples and leaders. The most frequent sources of influence referred by the couples and the leaders are the field workers of health and family planning, followed by the peer opinion leaders (friends, neighbors, relatives) and spouse.^ The opinion leaders do not differ much from the poor couples on land holding, a strong indicator of economic status, they however differ considerably on social factors such as family planning practice, education, and exposure to mass media.^ The study suggests that future development efforts in Bangladesh have to ensure community participation by the landless and marginal farmers and opinion leaders belonging to their class. ^

Literature review of estimation of prevalence rate of HIV/AIDS in India using population survey and sentinel surveillance based data

HIV/AIDS is a treatable although incurable disease that presents immense challenges to those infected including physical, social and psychological effects. As of 2009, an estimated 2.4 million people were living with HIV or AIDS in India, 0.3% of the country's population. In India, it is difficult to not only treat but also to track because it is associated with socio-economic factors such as illiteracy, social biases, poor sanitation, malnutrition and social class. Nevertheless, it is important to know the prevalence of HIV/AIDS for several reasons. At the individual level, the quality of life of people living with HIV/AIDS is markedly lower than their counterparts without the disease and is associated with challenges. At the community level, it is important to identify high risk groups, monitor prevention efforts, and allocate appropriate resources to target programs for the reduction of transmission of HIV. ^

Supplemental Nutrition Assistance Program: A policy analysis of restricting foods with minimal nutritional value

In 2011, expenditures for the Supplemental Nutrition Assistance Program (SNAP) reached an all-time high of $72 billion. The goal of SNAP is " to alleviate hunger and malnutrition…by increasing food purchasing power for all eligible households who apply for participation." It has been well established that proper nutrition is essential to good health, making SNAP an important program to public health consumers. Thus, this analysis examined whether SNAP is meeting its stated goal and whether the goal would be reduced if the purchase of foods of minimal nutritional value (FMNV) were restricted. ^ A review of existing literature found that SNAP has been shown to alleviate hunger, but the studies on the nutritional impact of the program were not sufficient to assert whether change is needed. When considering whether limiting FMNV would reduce or improve the effectiveness of SNAP at alleviating hunger and malnutrition, there is very little information on which to base a policy change, particular one that singles out a low income group to restrict purchases. ^ Several states have attempted to restrict the purchase of FMNV but, to date, no such change has been implemented or tested. Conducting pilot studies on the restriction of FMNV, along with better data collection on SNAP purchases, would guide policy changes to the program. Although there are many potential public health benefits to restricting FMNV purchase using SNAP dollars, research is needed to quantify the cost impact of these benefits.^

Addressing the Challenges of Child and Family Homelessness

Homeless children in families comprise the fastest-growing group of homeless persons in the United States. Indeed, the American Academy of Pediatrics considers homelessness to be an issue with which pediatricians should be concerned. In this article, we review existing literature to provide a background for researchers, policymakers, and social service providers hoping to understand the phenomenon of child and family homelessness and various strategies used to address it. We begin with a definition and description of the population of homeless families with children. We then offer a broad consideration of the effects of child and family homelessness, from physical health problems like malnutrition and increased incidence of infection to emotional and academic impacts. We end with a platform of policies and other action steps for addressing the problems of homelessness for children and their families.