Agriculture Reference
In-Depth Information
1999a), mortality has fallen dramatically. The logistics of the original protocol have
been adapted to meet different circumstances, but the principles have not changed.
edemAtous mAlnutRItIon
Edematous malnutrition tends to arise over a few days in children or adults who are
already malnourished. It often presents during or just after an infection when signs
of vitamin A deficiency also tend to present. It also occurs in particular regions and
seasons, usually damp regions and damp seasons, just as infections do. The fea-
tures are variable apart from the edema. They include misery, apathy or irritability,
anorexia, skin and hair lesions, and fatty hepatomegaly. Edematous malnutrition is
a form of severe malnutrition, and mortality in hospital tends to be higher than that
from severe wasting.
The cause remains unknown. Research was devoted to the “protein deficiency
theory” over several decades (Waterlow 1984). Plasma albumin tends to be very low,
and this was thought to reduce plasma oncotic pressure sufficiently to induce edema.
However, there is no evidence that children who develop edematous malnutrition
have been consuming less protein than those who develop nonedematous malnu-
trition (Gopalan 1968). Also, plasma albumin does not change significantly with
loss of edema (Golden et al. 1980). Finally, giving protein to children or adults with
edematous malnutrition does not help. In a study in young children, increased energy
intake was associated with loss of edema but not increased protein intake (Golden
1982). In a study in adults, increased protein intake was associated with increased
anorexia and death (Collins et al. 1998).
There are several other hypotheses to explain edematous malnutrition; some
encompass others. The most likely is the oxidative stress theory: Antioxidant status
is insufficient to counteract the damaging effects of free radicals on cell structures,
particularly membranes, and hence cell functions. This can explain several features,
in particular the association with infections and numerous indices of poor antioxidant
status and increased oxidative stress (Golden and Ramdath 1987). However, as yet,
there is no good evidence of improvement with antioxidant supplements or evidence
that individuals with particularly low antioxidant status are at high risk of developing
edematous malnutrition.
The management of edematous malnutrition differs little from that for severe
wasting. To the best of our knowledge, both are managed with most success by
adhering to the principles outlined in the WHO manual (WHO 1999a).
globAl buRden of dIseAse
WHO, in its 2002 World Health Report, concluded that micronutrient deficiencies
were of the utmost importance. Compared with all others, iron deficiency was esti-
mated to be 9th, zinc deficiency 11th, and vitamin A deficiency 13th from the top of
the list of risk factors for the world's disease burden (DALYs, disability-adjusted life
years) in 2000. Together, these three deficiencies were estimated to be responsible
for over 2 million (19%) of the total 10.8 million deaths per year in young children;
in contrast, malaria accounted for less than a million deaths. Iodine deficiency is
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