What do you understand by undernutrition and overnutrition? Explain.

Undernutrition denotes insufficient intake of energy and nutrients to meet an individual's needs to maintain good health. In most literature, undernutrition is used synonymously with malnutrition. In the strictest sense, malnutrition denotes both undernutrition and overnutrition. To overcome this, terms such as protein energy malnutrition, specific micronutrient deficiencies as well as other descriptive names such as kwashiorkor and marasmus have been used. However, since protein energy malnutrition does not exist in isolation of specific micronutrient deficiencies, neutral terms such as undernutrition are encouraged because they encompass both protein energy undernutrition as well as micronutrient deficiencies. Similarly overnutrition is used when there is excess intake of macronutrients and micronutrients. In the following pages undernutrition and malnutrition will be used interchangeably. Undernutrition will be discussed in terms of protein-energy undernutrition and those specific micronutrient deficiencies which are considered of public health significance in Malawi i.e. vitamin A, iron and iodine deficiency. Overnutrition which is not as prevalent as undernutrition in Malawi will not be addressed.

Distribution of Undernutrition

Measures of undernutrition

There are several indicators used to measure nutritional status. These include body composition, clinical signs of deficiency, physical function, biochemical compounds, metabolic processes or dietary intake. The choice of which of these indicators is used is dependent on the question being asked. In clinical settings, it is common to use a combination of qualitative and quantitative descriptions of undernutrition e.g. marasmus and kwashiorkor while in community studies of protein-energy undernutrition, body size is widely used because it is readily measurable and is a sensitive indicator of nutritional status and health. However, for specific nutrient deficiencies other indicators are used. For example serum retinol level, a biochemical measure, can be used to measure vitamin A deficiency and a clinical feature e.g. xerophthalmia can also be used as a measure of vitamin A deficiency.

The commonly used anthropometric measures are weight and length (height)^* in combination with age and sex. These measurements are used to construct indices and indicators^** that are used to describe nutritional status of individuals or populations. Other measures of body composition that are used include various body circumferences (mid upper arm, head, chest, abdomen etc) and skin folds (biceps, triceps, sub-scapular etc).

Three basic indices are used in childhood: weight for age Z score (WAZ), length / height for age Z score (LAZ / HAZ) and weight for length / height Z score (WLZ / WHZ).

• Weight for age: defined as weight of a child relative to the weight of a child of the same age in a reference population, expressed either as a Z score or a percentage relative to the median of the reference population. Qualitatively children who have low weight for age are described as being ‘underweight’.

• Height for age (/ length for age): defined as height or length of a child relative to the length or height of a child of the same age in a reference population, expressed either as a Z score or a percentage relative to the median of the reference population. Qualitatively children who have low height for age are described as being ‘stunted’.

Weight for height (/ weight for length): defined as weight of a child relative to the weight of a child of the same height or length in a reference population, expressed either as a Z score^*** or a percentage relative to the median of the reference population. Qualitatively children who have low weight for height are described as being ‘wasted’. Wasting is also sometimes called global undernutrition or global acute malnutrition (GAM). Table 1 shows how the indices are used to define undernutrition.

Table 1

Waterlow classification of undernutrition

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• Without oedema. Presence of oedema denotes severe malnutrition (kwashiorkor) even without severe wasting (Marasmus).

• + Percentage of the median World Health Organization (WHO) / United States National Centre for Health Statistics (NCHS) reference.

In adulthood, since they have stopped attaining height, indices of thinness are more appropriate. The indices used include Body Mass Index which is the weight (in kilograms) divided by the square of height (in meters). Additionally mid upper arm circumference is also used to measure wasting in both children and adults.

Incidence of undernutrition

Primary malnutrition is usually a disease of the dependent and the vulnerable that rely on others for their nutriture while secondary undernutrition accompanies any disease which disturbs appetite, digestion, absorption or utilization of nutrients ². The vulnerable groups include children in utero and within the first 5 years of life, adolescents, pregnant/lactating women and the elderly. Because children are completely dependent on others for their nutriture they are especially vulnerable.

Within the first 5 years of life there are critical periods during which undernutrition occurs, and evidence suggest that this is different for the various forms of undernutrition. In most developing countries underweight and wasting ________ ______ _______ _____ ____ _________ _________.
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