Deficiency Related Conditions
Conditions related to undernutrition can be categorized as macronutritent deficiencies (related to deficient levels of protein, carbohydrates, and/or fat), or micronutrients deficiencies (related to deficient levels of one or more vitamins and/or minerals). Without essential nutrients physiological pathways can be disrupted leading to various diseases and even death.
Protein Energy Malnutrition (PEM) – Lack of adequate protein leads to insufficient amino acids to build necessary proteins, which can disrupt multiple physiological pathways. Minor PEM can lead to short stature, failure to thrive, and developmental delays (Kuklina et. al, 2006). PEM is related to cognitive delays that can affect earning potential. Extreme PEM leads to more serious conditions or death.
Kwashiorkoris PEM while the diet includes sufficient calories. Because adequate carbohydrates are present and insulin is secreted normally the body is prevented from wasting muscle to fulfill amino acid needs. As a result the body is not able to synthesize various proteins, including albumin, and edema occurs due to the reduction in osmotic pressure in the blood vessels
Marasmus is PEM in conjunction with insufficient calories. Due to a lack of sufficient calories and carbohydrates the body adapts to the starvation condition. The body begins to break down skeletal muscle to fulfill the amino acid needs for other functions. Muscle wasting and diminished mental development follow (Wardlaw, 2009).
Common Micronutrient Deficiencies
|Vitamin A||Xeropthalmia||Eye infections that eventually lead to blindness|
|Vitamin D||Rickets||Soft bones due to improper calcification|
|Riboflavin||Ariboflavinosis||Inflammation of the face, mouth, and tongue as well as nerve disorder|
|Niacin||Pellagra||(4 D’s) Diarrhea, Dermatitis, Dementia, Death|
|Folate||Neural Tube Disorders, Megaloblastic Anemia||Periconceptional folate disorder can cause spina bifida in the child. Megaloblastic anemia is a form of anemia marked by large, immarture red blood cells.|
|Vitamin C||Scurvy||Improperly formed collagen, which weakens bones and connective tissue.|
|Iron||Iron Deficiency Anemia||Diminished oxygen transportation due to lack of hemoglobin|
|Iodine||Goiter||Enlarged thyroid, diminished metabolism|
Undernutrition in Guatemala
According to the World Food Programme (WFP) almost 50% of Guatemalan children under 5 years of age are undernourished (WFP, n.d.). The WFP also reports that Guatemala has the highest rates of undernutrition in all of Latin America and the fourth highest rates worldwide (WFP, n.d.). Undernutrition leads to more deaths amongst children under 5 than any other cause in that country (Kriel, 2011). Despite the work of many organizations undernutrition has not significantly improved in the last decade (Kriel, 2011). In general, the people of Guatemala have enough food, but the foods available are lacking in protein and micronutrients (Loewenberg, 2009). The cost of eggs and beans, the most widely available protein sources, is prohibitive leading to insufficient intake of protein. Sanitation and availability of water presents a problem as well, leading to nutrient losses due to diarrhea (Loewenberg, 2009).
The most serious cases of undernutrition in Guatemala result in kwashiorkor and related complications (Loewenberg, 2009). Some children present with pitting edema that is indicative of kwashiorkor. Others lose pigmentation in their hair or lose their hair altogether. Hypertrophy of the liver is another common side effect (Loewenberg, 2009). It appears, however, that the epidemic of that condition present in Guatemala in the 1950’s and 60’s has largely been eliminated; I found no reports of widespread kwashiorkor in Guatemala and the WHO reports only 1.1% of children under 5 are affected by wasting (WHO, 2009).
Stunting appears to be the most significant complication of undernutrition in Guatemala. A World Health Organization (WHO) graph indicates that while underweight in children under 5 has decreased from 19.6% in 2000 to 13% in 2009, stunting affects 48% of children under 5 as of 2009 (WHO, 2009). In the mountainous regions of the west of the country up to 70% of children have short stature (Kriel). Guatemala has one of the highest rates of stunting amongst women of reproductive age; 29.4% of women ages 15-45 are under 145 cm, a significant risk for the viability of pregnancy and the long-term health of the child (Dewey & Begum, 2011). While most Guatemalans consider their height to be genetic, studies have shown that Guatemalans who grew up in developed nations are significantly taller than their relatives living in Guatemala (Kriel, 2011). Additionally, a clinical trial revealed average height increases of 2.3 cm in those who consumed a high-protein, high-energy supplement during the first 3 years of life than those who consumed a control supplement (Dewey & Begum, 2011).
In children, stunting is associated with decreased education in women and decreased comprehension and intelligence scores for both men and women (Dewey & Begum, 2011). In a clinical trial, women who received high protein supplementation in early childhood (and consequently were protected against stunting) completed 1.2 more grade levels than those who did not receive supplementation and were stunted. In that same trial, adolescents who did not receive high protein supplementation (and subsequently presented with stunting) early in life scored lower on tests of “knowledge, numeracy, reading and vocabulary” than those who had received a high protein supplement and were not stunted (Dewey & Begum, 2011, pg. 14). It is these cognitive delays that are thought to be the cause of decreased earning potential later in life.
|World Health Organization (WHO) (2009)|
Women of short stature have higher rates of complications during pregnancy and their children have worse health outcomes than those of mothers without stunting. Maternal stunting increases incidence of intrauterine growth restriction (IUGR), which can lead to cognitive delay, chronic fetal distress, and even fetal death (Dewey & Begum, 2011). Birth asphyxiation is also more common amongst mothers of short stature due to a smaller pelvic opening. Of the infants who survive birth asphyxiation, many have serious complications, including: “cerebral palsy, mental retardation, and learning disabilities” (Dewey & Begum, 2011, pg. 9). Victora et. al. (2008), reported that a mother’s length at birth is related to the birth length of her children. For every 1 cm variance in a mother’s birth length a corresponding 0.2 cm difference was observed in the birth length of her children. After adjusting for multiple variables, the risk of infant death is 40% higher in those children born to mothers under 145 cm (Dewey & Begum, 2011).
Stunting has been related to diminished cognitive function and decreased earning capacity in adults. Men who received high protein supplementation in the first 3 years of life (and were subsequently not stunted) earned on average $0.62 – $0.67 per hour more than those who did not receive the supplement (Dewey & Begum, 2011). In Guatemala, where 80% of the population lives on less than $2 per day, that increase is quite significant (Loewenberg, 2009). The increased earning potential is related to increased cognitive function for all males, and increased lean muscle mass amongst those with physical occupations (Dewey & Begum, 2011)
Shortened stature in infancy is related to decreased muscle mass in adults (Victora et. al., 2008). Stunting is also associated with central adiposity in adulthood. Additionally, there is limited evidence that childhood stunting may lead to a slight increase in fasting blood glucose in adults (Victora et. al. 2008).
Low birth length and childhood stunting are related to numerous adverse outcomes, including: diminished cognitive ability, decreased educational achievement, reduced muscle mass, diminished earning potential, and adverse outcomes for pregnancy and childbirth. The effects are generational, as mothers of short stature have children of low birth length.
The stunting itself is not the cause of the many associated outcomes. It is the process of stunting and the underlying protein deficiency that lead to the adverse outcomes related to stunting. Short stature is merely the most visible symptom of the deficiency and an indicator of a need for nutritional intervention.
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World Food Programme. (n.d.). Guatemala: Overview. Retrieved from http://www.wfp.org/countries/guatemala/overview.
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