Transcript MALNUTRITION INFECTION AND DISEASE

MALNUTRITION INFECTION AND DISEASE
YOU ARE WHAT YOU EAT!!!!
Genesis 1 verse 29
“Then God said ,I have given you every herb & seed bearing plant in the face of
the whole earth and
every tree that has fruit with seed in it. They will be yours for food.”
presented by
Dr E.G.C. Muchaneta-Kubara (Senior Lecturer)
(HND Applied Biology UK, MSc Applied Immunology UK, PhD Nephrology UK)
Dr P. Nziramasanga (Senior Lecturer) and Ms C. Berejena (Chief Tech)
Department of Medical Microbiology
UZ- College of Health Sciences
UNIVERSITY of ZIMBABWE
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ABSTRACT
• Malnutrition is the condition that results from taking an unbalanced
diet in which certain nutrients are lacking , in excess (too high
intake), or in the wrong proportions. A number of different
nutritional disorders may arise depending on which nutrients are
over or under abundant in the diet. In most of the world,
malnutrition is present in the form of under nutrition, which is
caused by a diet lacking adequate calories and protein.
• The World Health Organization cites malnutrition as the greatest
single threat to the world’s public health. Improving nutrition is
widely regarded as the most effective form of aid. Nutrition-specific
interventions, which address the immediate cause of under
nutrition , have proven to deliver among the best value for money
of all development interventions.
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ABSTRACT (contd)
• Malnutrition is responsible, directly or indirectly
for 54% of the 10.8million deaths per year in
children under five years and contributes to every
second death(53%) associated with infectious
diseases among children under five years of age
in developing countries. Infection causes energy
loss on the part of the individual , which reduces
productivity on the community level and
perpetuates the alarming spiral of malnutrition,
infection, disease and poverty.
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BARRIER DEFENSES
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Background:
THE IMMUNE SYSTEM
• Immune system protects body against infection and disease
• It is a complex network of cells and organs defending the body against
pathogenic organisms and the development of cancer. It is divided into
two parts – Innate and Adaptive System.
• Innate is an immediate nonspecific response to harmful substances (first
line defense against invading pathogens)
• Composed of physical barriers such as skin and chemical and
microbiological barriers including mucuos secretions in respiratory/genital
tract and normal microflora of the gut
• Primary components include monocytes, macrophages, and neutrophilis
involved in phagocytosis
• Complement directly kills bacteria (composed of 20 serum proteins)
found in the blood
• Any breach of the barrier defense will ultimately result in disease
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INNATE IMMUNE SYSTEM
• When innate system fails to eliminate invading microorganism
and resulting infection then adaptive immune response is
summoned via messenger proteins called cytokines
• Key component is the complement classical and alternative
pathway which is a biochemical cascade of at least 20 serum
proteins
• Complement kills invading pathogens by direct lysis (cell
rupture) or promotion of phagocytosis
• Complement proteins float freely in blood, and help to
destroy pathogens (change the surface of bacteria)
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Adaptive(acquired) immune system
• Develops over a long period several days or weeks
• More complex involving antigen- specific responses and
immunologic “memory” (vaccination, immunization)
• Subsequent responses to same antigen are stronger and
more efficient
• Major mediators are specialized white cells (T and B
lymphocytes)
• T-cell responsible for cell –mediated immunity
• B-cell responsible for humoral immunity (antibody)
• Innate and adaptive immune responses interact to protect
the body from infection and disease
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Immune system and Nutritional Status
• Ability of the immune system to prevent infection and
disease depends on nutritional status of host
• Poor overall nutrition can lead to inadequate intake of
energy and macronutrients as well as selected
micronutrients
• Deficiencies can cause immuno-suppression and
dysregulation of immune responses
• Can impair phagocyte function (innate) cytokine
production (acquired) as well as adversely affecting aspects
of humoral and cell-mediated immunity
• Can compromise the integrity of immune system thus
increasing susceptibility to infection
• Nutritional status can modulate actions of immune system
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Nutrition and Immunology
• Protein-energy malnutrition (PEM) is the most common
nutritional problem
• Causes are insufficient intake of protein or energy (developing
world)
• Industrialized nations PEM is due to chronic disease in certain
subgroups, elderly and those hospitalized interferes with
nutrient metabolism in diseases such as inflammatory bowel,
chronic renal failure and cancer
• PEM affects cell-mediated immunity (thymus atrophy) )
• Affects the number of circulating T cells and decreases
responsiveness of the memory cells to antigen (opportunistic
infections)
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YOU ARE WHAT YOU EAT !!!
FOOD SECURITY
• Ability to have food all year round
Support a healthy life style- accessibility of
food supply
•Availability –purchase adequate amounts
Knowledge of how to utilize the food
effectively (disease absorption)
•Policy– conducive polices, environmental
conditions.
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Malnutrition
• Lack of nutritional elements necessary for
human health
• Nutrient deficient foods
• Poor dietary practices
• Diseases that prevent body from absorption
of nutrients
• Education and capacity building are key
components
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Nutrition and Immunology
• Humoral antibody affinity and response is decreased also
reduction of cytokines ,several complement proteins and
phagocyte dysfunction
• Secondary PEM is common in developed countries
• PEM compromises the integrity of mucosal barriers
increasing susceptibility to respiratory , gastrointestinal and
urinary tract infections
• PEM occurs in combination with deficiencies in essential
micronutrients Vitamin A, zinc, copper, selenium and
magnesium
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MALNUTRITION
Moderate, severe (Marasmus-Kwashiorkor
Micronutrients deficiencies
Insufficient supply of protein,
energy or micronutrient
Insufficient
household food
security
Severe or frequent infections:
Diarrhoea, Pneumonia
Insufficient child
maternal care
Poverty
Little education of
women
Unhealthy
environment
Malfunctioning of society Injustices
War, Natural disaster
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The Malnutrition-Infection Complex
• Can be viewed under two aspects;
• Malnutrition compromises host defense, infection can
aggravate a previous existing deficient malnutrition state
triggering malnutrition through disease pathogenesis
• Malnutrition facilitates pathogen invasion and propagation
• A consequence of health issues such as gastroenteritis,
chronic illness especially HIV/AIDS pandemic, and/
diabetes
• Diarrhea and other infections can cause decreased nutrient
absorption and intake of food, increased metabolic
requirements and direct nutrient loss
• Parasite infection also causes malnutrition such as in
giardiasis (Giardia lamblia) and helminthic infections
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Water
• Link between water , sanitation an health are well
understood in Zimbabwe following 2008 cholera
outbreak and recurrent episodes of
typhoid/cholera to quality of life both urban and
rural.
• It is a nutrient food and non food resource
essential for daily living
• Access to water may affect nutrition
• African women walk long distances to fetch water
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Sanitation
• Over 48% of population defeacate in the open
• Microorganisms in faeces can contaminate
into food or water
• Construction of latrines can hide faeces from
flies
• Improved hygiene will cut off faecal
contamination- reducing transmission routes
• Promoting a culture of healthy communities
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The Malnutrition-infection Complex
• Haemophilus influenza type b – mostly an opportunistic infection
pathogen causing invasive infections e.g. pneumonia in children
under 5 years.
• Can increase probability of a secondary infection
• Can modify disease pathogenesis and prognosis
• There is a relationship between malnutrition immune suppression
and infection complex
• Infection can contribute to malnutrition; in gastrointestinal infection
leading to diarrhea, or chronic infections that cause cachexia and
anaemia, intestinal parasites (hookworms, malaria) can cause
anaemia and nutrient deprivation (protozoa and helminth)
• Despite availability of antibiotics mortality and morbidity rates
remain high especially in malnourished children below 24 months.
• Pneumonia and malnutrition are two of the biggest killers in
childhood disease
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The Malnutrition-Infection Complex
Contd
• Acute diarrhea and pneumonia occur frequently in first 2-3 years of
life
• In these immuno-competence is impaired when first exposed to
pathogens
• Infection can suppress appetite and this directly affects nutrient
metabolism
• These events lead to poor nutrient utilization
• Streptococcus pneumonia leading cause of bacterial pneumonia,
meningitis and sepsis in children worldwide.
• Pneumococcal disease precede by asymptomatic nasopharyngeal
colonization especially high in children
• This is natural route of infection of S.pneumoniae - may progress to
invasive diseases if immunological barriers are crossed.
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Infection
• Metabolic effects of infectious process are accompanied by
a significant reduction in food intake
• Due to anorexia and most cultures restrict food intake to
the sick ( children)
• Nutrient loss due to diarrhea and ↑ energy loss due to fear
will aggravate the already unfavourable condition
• Malnutrition makes the infection worse due to unhealthy
micosal surfaces – which allow early introduction of
microorganisms
• Also poor immune system permits rapid multiplication of
invading microoganisms
• Recovery is slow and less available to repair damaged tissue
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Diarrhoea
• Affects nutritional status in child by losing
appetite
• Associated vomiting
• Severe dietary restriction and mal-absorption
• result in weight loss and malnutrition
• Diarrhea is both cause and an effect of
malnutrition
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Relationship Between Malnutrition
and Infection
• Field studies have shown that relationship is bidirectional
• Site of interaction and type of pathogen determines the type
of immune response
• Initiation of both innate and adaptive responses involve
activation and proliferation of immune cells
• There is synthesis of an array of cells, associated DNA
replication, RNA expression and protein synthesis which all
consume anabolic energy
• Nutritional status of host determines the outcome of resulting
infection
• Poor overall nutrition can lead to nutritional deficiencies
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Relationship between Malnutrition & Infection
Infection
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Measurement of Growth/Repair
(Serum levels (ng/ml) of Insulin-like
growth factor-1 (IGF-1))
• IGF-1 increases protein synthesis and suppresses protein degradation
• It is a mediator of growth hormone effects and circulates in blood bound
to binding protein 3
• Important effects on muscle metabolism through stimulation of amino
acid and glucose transport
• Fasting causes a decline in serum IGF-1 and hepatic mRNA, re-feeding
reverses this
• Routine assessment of nutritional status employ anthropometric
measurements
• Cannot be done retrospectively
• The simple IGF-1 Elisa assay can be used to assess accurately large sample
numbers
• IGF-1 is a nutritional status marker that can be used in monitoring and
measuring the impact of a particular dietary manipulation
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Malnutrition and Infection
• In malnourished children a greater proportion suffer from
bacterial GI and respiratory infections
• In these types of infection the first line defense is innate
epithelial barriers and the mucosal immune response
• PEM greatly compromises these responses vitamin A
deficiencies induces loss of mucus producing cells which
increases susceptibility to infection by pathogens ordinarily
trapped
• The barrier defects are critical in the pathogenesis of
respiratory and GI infections
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Malnutrition and Infection Contd
• Upper respiratory infection most prevalent in children
with acute malnutrition. Lower respiratory infection
most prevalent in acute/chronic malnutrition. (Cherish
et al).
• The group studied moderate – severe degrees of
malnutrition and found out that these increases
mortality risk. Pneumonia is more common among
children with Marasmic Kwashiokor than other types of
malnourishment.
• Klebsiella species and Staphylococcus aureus were
most common causative aspects in severely
malnourished children.
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Malnutrition and Infection Contd
• Also pathogenic viruses isolated from malnourished children with
pneumonia. Mycobacterium tuberculosis also detected in
malnourished children with pneumonia.
• Role unclear – present in acute lower respiratory infection in
severely malnourished children.
• In absence of organized effective immune response antibiotic alone
incapable of eliminating bacterial pathogens innate response
provides 1st line of defense against infection estimates that 98%
protection.
• Effective respiratory host defense depends on specific Abs,
complement, neutrophils and other phagocytic cells.
• If pathogens overcome these – and given entrance into blood
stream, systemic protection mediated by anti capsular antibodies –
reduced mucosal immune response might lead to persistent and
reccurrent colonization and subsequence infection.
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“YOU ARE WHAT YOU EAT”
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WHAT IS A BALANCED DIET?
ESSENTIAL MINERALS and VITAMINS
• Best place to find vitamins and minerals (anti-oxidant role) is
food and together contribute to many body functions
• Needed by the body as trace small amounts (micro nutrients)
or macro (large amounts)
• Prevent damage to tissues and cells by electrons (free
radicals) generated as by-product of inflammation and other
body functions
• Supplements should be taken with food for absorption
• Temporal fluctuations as a result of viral infection
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ESSENTIAL MINERALS
• Calcium most abundant in the body needed for
developing and maintaining healthy bones and teeth
• Requires the presence of phosphorous, magnesium,
vitamin D and K for adequate absorption
• Deficit contributes to osteoporosis, hypertension,
elevated cholesterol and rickets
• Dietary source: cheese, milk, yogurt, almonds, dark
leafy green vegetables, broccoli, oysters and sardines
• Many foods are fortified with calcium such soy milk,
juices and cereals
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Essential Minerals
• Chloride electrolyte works together sodium, potassium and
carbon dioxide to maintain acid balance of body fluids
• Increased levels may suggest dehydration or alkalosis
• Low levels : may be a result of Addison disease, congestive
heart failure or vomiting
• Dietary sources: salt, sea salt, tomatoes, celery, olives and
seaweed
• Dietary requirement according to age, sex and health status
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Essential Minerals
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Magnesium necessary for bone and teeth formation
Normal function of nerves and muscles
Enzyme to work properly
Deficiency may cause sleepiness, muscle spasms, nausea and
seizures
• Too much : low blood pressure, difficult breathing and cardiac
arrest
• Dietary source halibut, white beans, oat bran, spinach ,
cashew and brazil nuts
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Essential Minerals
• Potassium active in muscle and nerve communication
• Moving nutrients into cells and waste out of cells
• Deficiencies may arise from Addison’s disease kidney failure
and blood transfusion where the levels are high
• Low levels include Cushing syndrome, chronic diarrhea,
vomiting and diuretics
• Dietary sources: bananas, pears, peaches, grapes, kiwi,
watermelon, tomatoes, pumpkin, sweet potato(skin) green
beans and carrots
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Essential Minerals
• Phosphorous second most abundant mineral in
the body
• Helps build strong teeth and bones
• Filters waste in kidneys
• Helps body to store and use energy
• Active role in tissue ands cell growth and milk and
• repair
• Dietary source: milk and meats
• Adequate calcium and protein will provide
enough phosphorus (zviyo)
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Essential Vitamins- Organic food
substances in plants/animals
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Vitamin A (beta-carotene)converted in the body when needed
Maintains the integrity of barrier defenses and is increased vulnerability to respiratory
and diarrheal diseases
Protects against flu and infections of the kidneys , bladder, mucous membranes,
counteracts night blindness and builds resistance to infection
Derivative retinoic acid functions as hormone to 500 genes several of which are
involved in controlling, production, proliferation and differentiation of immune cells
Stabilizes CD4 counts in HIV positive individuals
Deficiency affects cell-mediated immunity and antibody response to antigen
A common deficiency worldwide especially developing countries
Has detrimental effects on maternal and child health
Severe deficiency in children increases morbidity and mortality related to measles,
malaria and diarrheal infections
Loss of appetite, frequent fatigue, retarded growth and defective teeth and gums
Dietary source: coloured yellow, red orange vegetables and fruits including carrots,
tomatoes, apricots and sweet potato
Papaya rich in carotene (good for eye sight)
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Essential Vitamins
• Vitamin B1(thiamin) is essential in the formation and maintanance
of muscle
• Protects the body from
• Efficient use of carbohydrates as energy
• Required during feverish conditions
• Dietary source ; whole grain, whole-meal bread, brown rice and
pulses
• Vitamin B2(riboflavin) is the building block for glutathione a key
cancer fighting anti-oxidant
• Deficiency symptoms include cracking at the corner of lips/mouth
• Dietary sources : dairy products, leafy vegetables, fruits watermelon, meat and cereals
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Essential Vitamins
• Vitamin B6 (pyridoxine) is involved in the
formation of new cells and maintaining
immunity
• Can reduce the toxicity of TB drugs
• Reduce the risk of heart attack
• It is suggested that the use of ARV increases
the need for this vitamin
• Dietary source; wheat germ and walnuts good
source of B vitamins, bananas, avocado pears
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Essential Vitamins
• Vitamin B12 protects against nerve damage and neutropenia
disorders
• If injected in (toe) HIV patients improves mental functioning
• Supplementation (months) improves mental function
• Reduce risk of neutropenia and anaemia following ARN
treatment
• Deficiency of B12 before treatment prone to neutropenia/anaemia
• Absorption of this vitamin is poor if gastro intestinal problems
present
• All vitamin B operate in combination and in conjunction with each
other and minerals
• Dietary source fish ,eggs dairy products if supplementing take as
vitamin B complex
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Essential Vitamins
• Vitamin C : can prevent HIV from infecting new cells,
activation or replication of HIV in dormant infected
cells
• Potent anti-viral – required by immune cells which fight
bacteria and fungal infections
• High levels assist phagocytes in identifying and
destroying candida species
• Dietary source: kiwi fruit ,orange, apple, guava, papaya
• High doses cause diarrhea, kidney stones due to excess
acidity (use oxalic excretion testing urine)
• More serious effect intravenous in people with
glucose-6-phosphate dehydrogenase deficiency
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“YOU ARE WHAT YOU EAT”
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LET US CHOOSE WHAT WE EAT AND
LIVE LONG
• Hosea 4 verse 6
My people perish because of lack of knowledge because
you have rejected knowledge I ALSO REJECT YOU AS MY
PRIEST because you have ignored the law of your God I
WILL ALSO IGNORE YOUR CHILDREN
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EAT FRUIT ON AN EMPTY STOMACH
• DRINKING COLD WATER AFTER A FATTY MEAL CAUSES
CANCER
• REDUCE SALT INTAKE- Replace with herbs rosemary, thyme,
marjoram, sage
• DRINK NATURAL fruits and vegetables use blender or
pestle/mortar
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Nutrition and Immunology
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MALNUTRITION – INFECTION COMPLEX
Increases probability of a secondary infection
Compromises host defense
Facilitates pathogen invasion and propagation in chronic
illness such as HIV and AIDS
Diarrhoea decreases nutrient intake
Infection can suppress appetite
Nutrient loss related to poor nutritional utilization
Barrier defense critical in the defense of respiratory and GI
infections
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Adaptive(acquired) immune system
• NUTRITION AND IMMUNITY
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PEM – most severe?? Insufficient intake of protein
Chronic disease
Elderly hospitalized
Interferes with nutrition metabolism (chronic renal failure and
cancer)
• Affects cell mediated immunity (circulating Tcells decrease
responsiveness of memory to antigen)
• Increases susceptibility to respiratory, gastro and urinary tract
infection
• Occurs in combination with deficiencies in Vitamin A, Zinc, Copper,
Selenium and Magnesium
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CONCLUSION
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Malnutrition major intervention is at risk in community based/health care
Nutritional supplements are concentrated sources of nutrients with expected
nutritional/physiological benefits
May be used to correct nutritional deficiencies and maintains an adequate intake
of given nutrients
Atnut – Catholic Relief Services also in Zimbabwe – lack of evidence on impact
Corn Soya Blends – protein source for targeted groups. Fortified with vitamins and
minerals
Plumpy nut – peanut based paste – administered at home enriched with vitamins
and minerals
Advocating natural traditional foods – 9 nutripack as a supplement – available
locally and sustainable
Zimbabwe experiencing major burden of malnutrition and working with several
NGOs
Need to evaluate a Nutripack – name given and accessible for sustainable
assistance.
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REFERENCES
• Bonn 2011: No food and Nutrition Security without
Water , sanitation and Hygiene, Nexus Conference, Hot
Topic Session 7, Issue Paper, Convener German WASH
Network.
• Briend A, et al (22 May 1999). The Lancet Volume 253,
Issue 9166. Ready to use therapeutic food for
treatment of marasmus, pages 1767 -1768
• Biesel, W.R. (1996). Nutrition and immune function:
an overview. Journal of Nutrition, 126 (suppl); 2611S2615S
• Chandra, R.K. and Kumari, S. (1994). Effects of
nutrition on the immune system. Nutrition, 207-210
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YOU ARE WHAT
YOU EAT!!!!!
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THANK YOU
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