“How Little Progress”? A Political Economy of Postcolonial Nutrition

476 5. C hildhood malnutrition encompasses a plethora of nutritional disorders that include stunting, underweight, wasting, severe acute malnutrition (SAM), and micronutrient deficiency disorders. Overweight and obesity, at the other end of the nutritional spectrum, are also manifestations of childhood malnutrition. Nearly 24 million children (younger than 5 years) worldwide experience SAM. The vast majority is located in Africa and Asia (8 million are in India alone). A child with SAM is 10 times more likely to die than a wellnourished child. SAM is one of the top 3 nutrition-related causes of death in children younger than 5 years. Estimates of deaths directly attributable to SAM varied from 0.5 to 2 million annually. Moderate and severe child malnutrition account for 40% to 50% of all deaths in children younger than 5 years. If the United Nations Millennium Development Goals (http://www.un.org/millennium goals) of reducing children malnutrition and mortality by 50% by 2015 are to be met, SAM needs to be prevented and controlled effectively.

Comment on RUTF and correction of anaemia and iron deficiency in severe acute malnutrition.

Risk factors for death in children during inpatient treatment of severe acute malnutrition: a prospective cohort study ,

As Nutrition Activism gains ground the basic political causes of malnutrition are now being given much greater prominence. Nevertheless, activism remains suspect in the scientific and especially in the academic environment. For activism to be successful, reliable nutritional data are required and cooperation between nutrition scientists and activists is essential. Following involvement in four United Nations Food and Nutrition Evaluation Missions to Iraq in 1993, 1995, 1997 and 2000. I became convinced that, despite the oil‐for‐food programme (SCR 986), the economic sanctions themselves were the largest single cause of malnutrition and child mortality in Iraq and therefore should be opposed on humanitarian grounds. The conclusions of these studies, however, generally remained within UN and development circles, with only limited impact on the Security Council's sanctions policy. Nevertheless, all food, nutrition and health surveys since the early days of the embargo have told essentially the same story: severe malnutrition in hospitals, malnourished children and under‐nourished adults in the towns, ever changing food prices, increased mortality and a general breakdown in the whole fabric of society. In this, they have supported those made by independent activist groups whose reports have often been dismissed by Western governments as naive and biased. This important story of death and deprivation, has been significantly under‐reported in Western media. Nutritionists and Activists working in cooperation together, can perhaps help to change misguided United States and United Nations policies.

Background: Inadequate intake of carbohydrates, proteins, vitamins and minerals is one of the causes for malnutrition. It often affects young children and contributes to more than 60% of deaths in children in developing countries. One in four of malnourished children receiving traditional treatment die during or soon after treatment. The study aimed to assess the treatment outcome of children treated in therapeutic feeding centers (TFC) in southern Ethiopia.Methods: A retrospective review of reports submitted by the TFCs was done during 2003-2004. Data was collected from the monthly reports using standardized formats. The variables included age, treatment centers, type of malnutrition and treatment outcome which were analyzed using descriptive statistics.Results: Of 11,335 cases of malnutrition, 47% (5447) had severe wasting and 53% (6103) had edematous malnutrition. Of the total, 87% (11,191) were cured while 3.6% (468) had died. The average length of stay was 25 and 21 days with an average weight gain of 14 and 13.4 g/kg/d for children with severe wasting and edematous malnutrition, respectively. With increasing age, the death rate decrease and cure rate increased (p < 0.05 for both).Discussion: Our results show that the new management approach implemented in the TFC improved the treatment outcome of malnourished children compared to the minimum international standard set for management of severe acute malnutrition which is cure rate of at least 75% and death rate less than 10%, average length of stay of less than30 days and average weight gain of 8g/kg/day.

To determine the predictors of mortality within 30days of hospital admission in a diarrhoeal disease hospital in Bangladesh. Cohort study of hospitalised children aged 0-59months with severe acute malnutrition (SAM) and severe pneumonia in Dhaka Hospital, icddr,b, Bangladesh from April 2015 to March 2017. Those discharged were followed up, and survival status at 30days from admission was determined. Children who died were compared with the survivors in terms of clinical and laboratory biomarkers. Multivariable logistic regression analysis was used for calculating adjusted odds ratio for death within 30days of hospital admission. We enrolled 191 children. Mortality within 30days of admission was 6% (14/191). After adjusting for potential confounders (hypoxia, CRP and haematocrit) in logistic regression analysis, independent factors associated with death were female sex (aOR=5.80, 95% CI: 1.34-25.19), LAZ <-4 (aOR=6.51, 95% CI: 1.49-28.44) and Polymorphonuclear Leucocytes (PMNL) (>6.0×109 /L) (aOR=1.06, 95% CI: 1.01-1.11). Using sex, Z-score for length for age (LAZ), and PMNL percentage, we used random forest and linear regression models to achieve a cross-validated AUC of 0.83 (95% CI: 0.82, 0.84) for prediction of 30-day mortality. The results of our data suggest that female sex, severe malnutrition (<-4 LAZ) and higher PMNL percentage were prone to be associated with 30-day mortality in children with severe pneumonia. Association of these factors may be used in clinical decision support for prompt identification and appropriate management for prevention of mortality in this population.

Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause. At the global level, a science and technology initiative is required to solve the listed problems such as increasing food prices, economic recession, increased competition for natural resources and climate change. Diseases like cancer, HIV/AIDS, oral health and chronic renal failure also breakdown the nutritional status. Bio fortification, probiotic foods and food processing strategies have shown the potential to overcome the malnutrition. A recently developed home based treatment for severe acute malnutrition is recovering the lives of hundreds of thousands of children a year. Ready-to-use Therapeutic Food (RUTF) has changed radically the treatment of severe malnutrition – providing foods that are safe to use at home and ensure quick weight gain in severely malnourished children. This review of the literature throws light on the causes of malnutrition and some important strategies like bio fortification, therapeutic diets, prebiotic foods and food processing to overcome malnutrition.

Identifying Malnutrition in PALTC Communities

BackgroundGlobally, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) affect approximately 52 million children under five. This systematic review evaluates the effectiveness of interventions for SAM including the World Health Organization (WHO) protocol for inpatient management and community-based management with ready-to-use-therapeutic food (RUTF), as well as interventions for MAM in children under five years in low- and middle-income countries.MethodsWe systematically searched the literature and included 14 studies in the meta-analysis. Study quality was assessed using CHERG adaptation of GRADE criteria. A Delphi process was undertaken to complement the systematic review in estimating case fatality and recovery rates that were necessary for modelling in the Lives Saved Tool (LiST).ResultsCase fatality rates for inpatient treatment of SAM using the WHO protocol ranged from 3.4% to 35%. For community-based treatment of SAM, children given RUTF were 51% more likely to achieve nutritional recovery than the standard care group. For the treatment of MAM, children in the RUSF group were significantly more likely to recover and less likely to be non-responders than in the CSB group. In both meta-analyses, weight gain in the intervention group was higher, and although statistically significant, these differences were small. Overall limitations in our analysis include considerable heterogeneity in many outcomes and an inability to evaluate intervention effects separate from commodity effect. The Delphi process indicated that adherence to standardized protocols for the treatment of SAM and MAM should have a marked positive impact on mortality and recovery rates; yet, true consensus was not achieved.ConclusionsGaps in our ability to estimate effectiveness of overall treatment approaches for SAM and MAM persist. In addition to further impact studies conducted in a wider range of settings, more high quality program evaluations need to be conducted and the results disseminated.

Geographical and economic access barriers to health facilities (HF) have been identified as some of the most important causes of the low coverage of severe acute malnutrition (SAM) treatment. The objective of this study is to assess the effectiveness and coverage of SAM treatment delivered by community health workers (CHWs) in the Guidimakha region in Mauritania, compared to the HF based approach. This study was a nonrandomized controlled trial, including two rural areas. The control group received outpatient treatment for uncomplicated SAM from HF, whilst the intervention group received outpatient treatment for uncomplicated SAM from HF or CHWs. A total of 869 children aged 6–59 months with SAM without medical complications were included in the study. The proportion of cured children was 82.3% in the control group, and 76.4% in the intervention group, we found no significant difference between the groups. Coverage in the intervention zone increased from 53.6% to 71.7%. In contrast, coverage remained at approximately 44% in the control zone from baseline to end-line. This study is the first to demonstrate in Mauritania that the decentralization model of CHWs treating SAM improves acute malnutrition treatment coverage and complies with the international quality standards for community treatment of acute malnutrition. The non-randomized study design may limit the quality of the evidence, but these results could be used by political decision-makers as a first step in revising the protocol for acute malnutrition management.

BackgroundCommunity-based treatment of severe acute malnutrition (SAM) has proven to be safe and cost-effective, although identifying additional factors that can increase recovery and decrease treatment failure may improve program effectiveness. We examine the association of dietary diversity and clinical and program treatment outcomes among children treated for uncomplicated SAM in Niger.MethodsTwo thousand four hundred twelve children were enrolled in a randomized trial of routine amoxicillin in the treatment of uncomplicated SAM from 2012 to 2014. All children received ready to use therapeutic food (RUTF) and standard clinical care. Child dietary diversity was assessed using a 7-day food frequency questionnaire and 8-food group diet diversity score. We assessed the association of dietary diversity at admission with nutritional recovery, hospitalization, and death at program discharge and 12 weeks, and weight and height gain.ResultsFood groups most commonly consumed by children in seven days preceding SAM treatment were cereals, roots and tubers (N = 2364, 99.5%) and vitamin A rich fruits and vegetables (N = 2253, 94.8%). Egg (N = 472, 19.9%) and dairy (N = 659, 27.7%) consumption was low. Mean (SD) diet diversity score was significantly lower in the lean vs. non-lean season [2.7 (1.1) vs. 2.9 (1.0)]. There was no evidence that dietary diversity increased nutritional recovery at discharge (RR: 1.02, 95% CI: 1.00, 1.04) or 12 weeks (RR: 0.98, 95%CI: 0.94, 1.02). No significant association was found with risk of hospitalization or death, or weight and height gain. Egg consumption was protective against death at discharge (RR: 0.53, 95% CI: 0.39, 0.70) and 12 weeks (RR: 0.66, 95% CI: 0.45, 0.96). Vitamin A rich fruits and vegetable consumption was associated with greater risk of mortality in children at discharge (RR: 1.30, 95% CI: 1.08, 1.56) and 12 weeks (RR: 1.19, 95% CI: 1.03, 1.36).ConclusionsWe did not find evidence that dietary diversity influenced nutrition recovery or response to treatment for children with uncomplicated SAM in Niger. It is feasible consumption of nutrient-dense foods like eggs may be important for recovery from SAM. There is need for continued research to further elucidate drivers of nutritional recovery from acute malnutrition in different settings.Trial registrationTrial registration number: ClinicalTrials.gov NCT01613547. Registered May 26, 2012.

Aims Effectively tackling severe acute malnutrition (SAM) is a global public health priority. Most treatment programmes report short-term outcomes at discharge. There is limited evidence about subsequent mortality and morbidity. The authors aimed to address this research gap by describing longer-term outcomes following SAM treatment. Methods One year after discharge, the authors attempted to trace all survivors from a large urban, inpatient-based SAM treatment programme. 796/1024 (78%) had been enrolled in a probiotic randomised controlled trial which had no overall effect. Detailed baseline and follow-up data were available. Results From July 2006 to March 2007, 1024 patients contributed to 1187 admission episodes for SAM treatment. 697/1024 (68.1%) had oedematous malnutrition. 459/1024 (45%) were known HIV seronegative, 445/1024 (43%) known seropositive. Long-term outcomes were determined for 899/1024 (88%). Mortality risk was greatest early in the programme: 238/1024 (23%) children died during initial inpatient treatment, 84/1024 (8%) in the subsequent 90 days and a further 105/1024 (10%) over the subsequent year. Preliminary Cox regression showed that HIV was strongly associated with mortality. Of the total 427 deaths, 274/427 (64%) were known seropositive but only 77/427 (18%) were known seronegative. Low admission weight-for-age, low admission weight-for-height were and age Initial treatment cure (reaching weight-for-height >80% of NCHS median) was associated with long-term survival. Of 471 initial cures, 372/471 (79%) were still alive at 1 year. Total known long-term programme survivors were 472/1024 (46%). At 1 year, mean weight-for-height z-score (WHZ) of those measured was −0.03 (SD 1.2, n=396) compared to baseline WHZ of −2.25 (SD1.3, n=976). Height-for-age (HAZ) remained low: HAZ −3.05 (SD 1.4) at 1 year compared to −3.23 (SD 1.4) at baseline. Putting these in context, mean WHZ of the oldest sibling in the family was −0.23 (SD 0.9, n=59) and HAZ −1.75 (SD 1.7, n=59). Conclusions In this study, most children who were successfully cured in a SAM treatment programme remained alive 1 year after discharge. Overall mortality was however high. Community-based strategies could play an important role in earlier identification and treatment of high-risk children as well as longer-term support of children discharged from nutrition programmes.

To investigate the nutritional risk, malnutrition, severe malnutrition, and malnutrition prevalence of different stages in chronic kidney disease (CKD) patients with and without diabetes mellitus using the Global Leadership Initiative on Malnutrition (GLIM), and to analyze the causes of malnutrition and to improve the clinical outcomes of patients for early intervention. A total of 683 patients with CKD who were hospitalized in our hospital from January 2020 to January 2021 were enrolled and divided into subgroups 1 to 5 according to whether they were complicated with diabetes and glomerular filtration rate. Using the second step of the malnutrition (GLIM) diagnostic tool and 2 previously commonly used malnutrition assessment methods (body mass index <18.5 kg/m2 with poor general condition, 3 points for nutritional deficiency in nutritional risk screening), combined with clinical research on the main causes of malnutrition, the intervention measures were discussed. The prevalence of malnutrition was 16.7% (114/683) in the patients included in the survey using the diagnostic criteria of malnutrition (GLIM) (excluding whole body muscle mass index). The prevalence of malnutrition in CKD patients with and without diabetes was 23.7% and 12.6%, respectively. The overall prevalence rate of severe malnutrition was 14.2%, and the prevalence rates of those with and without diabetes were 19.0% and 11.4%, respectively; the results of the two methods of malnutrition assessment showed that the prevalence of malnutrition in CKD patients with diabetes was higher than that in the uncombined group. There was no severe malnutrition in patients with CKD stages 1 and 2. From CKD stage 3 onwards, the severe malnutrition in the diabetic group was significantly higher than that in the uncombined group. With the progression of CKD, the incidence of malnutrition also gradually increased, indicating that malnutrition is related to primary diseases and concomitant diseases. Attention should be paid to the malnutrition of CKD patients with diabetes, and clinical medical staff need to pay early attention to various diseases that lead to the progression of CKD, such as diabetes, primary nephropathy, and other factors, to prevent complications and delay the progression of CKD.

Mild protein-calorie malnutrition is common in Western Samoa. Severe protein-calorie malnutrition is also an important cause of death in infants and toddlers, and anemia is frequently found in small children. This paper investigates child feeding practices because of its possible relationship with the occurrence of severe early malnutrition. Data on infant and toddler feeding practices were collected from 90 mothers from the town of Apia and 38 mothers from the island is Savai'i. Average age of mothers in Apia was 29.0 years and in Savai'i, 30 years. Most belonged to the low income group. Average interval between births in Apia was 22.3 months, in Savai'i, 25.7 months. The proportion of bottlefed children was much lower in Savai'i than in urban Apia, 28.2 vs. 57.9%. 31.3% of Apian mothers weaned their last child abruptly compared with 41.6% of Savai'i mothers. In Apia, weaning foods consisted of milk, meat, and other protein-rich foods; in Savai'i, taro, orange leaf tea, rice, and other were the main weaning foods. Generally, semisolids were not introduced before the child was more than 6 months of age. Some mothers in Savai'i appeared to give their children monotonous diet. A number of cultural taboos appear to affect the children's diet as well as that of pregnant and lactating mothers. Many women believed in them and would not eat or do certain things. Overall, it appears that many of the mothers are ignorant about the nutritional needs of their children. Almost 7% of the 0-5 year old children suffered from borderline malnutrition. 9% of the total number of admissions during the period October 1968 to April 1972 were malnourished children. The increase in borderline malnutrition and severe malnutrition among the children towards the end of the 1st year is attributed mainly to the late introduction of semisolid and solid foods. Other causes of malnutrition include lack of money, especially in urban areas, large families, changes in the diet because of higher consumption of imported foods (soft drinks, refined foods), decline in breastfeeding, and increase in early bottlefeeding.

Severe acute malnutrition affects 20 million children aged under 5 years old worldwide. Medical complications and death are common, but nutritional and medical treatment can result in good outcomes. Randomized trials of treatment after in-patient stabilization have shown community-based treatment to have similar outcomes to hospital-based treatment, at lower cost. Community-based ambulatory treatment, with in-patient care reserved for the most severe cases, is increasingly being implemented in Africa but has not been evaluated in randomized trials. Community-based treatment programs have shown favorable outcomes. Economic evaluations of community-based treatment have included cost analyses, cost and consequence analyses and decision analyses. Treatment costs have been consistently lower than for institution-based treatment. Costs of ambulatory community-based treatment of severe acute malnutrition have ranged between US$46 to $453 per child, depending on the type of care provided and the costing methods used. Recent studies have reported on costs and outcomes of similar large-scale African programs covering geographically defined populations, with ambulatory care for most children, and initial in-patient stabilization for the minority with most severe disease. In these studies the costs ranged from US$129 to $201 per child, and mortality rates ranged from 1.2 to 9.2%, depending on length of follow-up. A decision tree model based on such a program in Zambia estimated that community-based treatment of severe acute malnutrition in primary-care centers, with hospital access, cost US$203 per case treated, US$1760 per life saved, and US$53 per disability-adjusted life year gained, compared with no treatment. This latter cost per disability-adjusted life year gained suggests that community-based treatment of severe acute malnutrition is cost effective compared with other priority health interventions in low-income countries, and compared with such countries’ national incomes.