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This is consistent with major histological changes in muscle tissue observed in malnourished children, with a decreased proportion of myogenic cells compared with vascular, nerve, and interstitial cells [42]. The presence of low muscle mass in wasting and the link between muscle mass and survival in a wide range of clinical conditions suggest that wasting could increase the risk of death through a decreased muscle mass [26] Figure 1.

If malnutrition is sustained and is associated with changes in relative organ weights and reduced function of key organs, such as the heart, kidney and immune system, this can also compound the effect of the lack of fuel resulting from low muscle mass during an acute food shortage. An effect of wasting on mortality through reduced muscle mass suggests that young infants and children are especially vulnerable to malnutrition because they have a low muscle mass in relation to body weight, even in the absence of malnutrition as mentioned above [].

Fat mass in wasting: Effect on mortality. Fat stores are deeply depressed in cases of wasting [60]. As noted above, in the absence of infection, fat is the main fuel for the organism in case of insufficient energy intake and survival can, therefore, be connected to fat mass [20]. Fat and especially central fat, can also play a role in maintaining the immune system, which is energy demanding when stimulated [61]. Leptin, which is produced by adipocytes and reflects body fat stores, may have a stimulating effect on the immune system by increasing cytokine and lymphocyte secretion [62,63].

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Thus, fat can also be linked to survival through an effect on the immune system. In this regard, a recent study has shown that leptin levels are linked to survival in children with SAM treated in the hospital [64]. Thus, fat depletion could also provide an additional common mechanism linking wasting with increased mortality. There are several circumstances that might lead to micronutrient shortages during the lifetime of an individual living in developing countries.

Such circumstances usually affect a range of micronutrients simultaneously, some of them clustering in the foods commonly consumed in those countries, i. Hence, in populations where the major reason for iron deficiency is poor availability of iron from the diet, there is also a risk for marginal zinc status and possibly low calcium intake.

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The micronutrient density of such diets is low, and the high phytate content impairs micronutrient absorption, resulting in a high risk of inadequacy. In periods of increased need, such as pregnancy, such a risk is even higher and frank deficiencies develop. Iron deficiency increases among pregnant women of most world populations.

Zinc deficiency in pregnant women has been reported in Egypt [65], Nigeria [66] and Malawi [67]. Folic acid deficiency have also been described in pregnant women in South Africa [68]. After birth and in the first 6 months of life, exclusive breastfeeding should allow complete coverage of energy and nutrient needs, although maternal deficiency can lead to low levels of water-soluble vitamins and possibly zinc in breast milk [70].

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A comparison of predominantly breastfed babies with children given complementary foods earlier than 6 months indicates that linear growth is better in the former [71]. However, in many world populations, few children are exclusively breastfed, particularly as a result of the early introduction of liquids or other foods. Breast milk is usually replaced with fruit juice or other sweet drinks or cereal-based gruels, all of which are micronutrient-poor items, thus leading to a high risk of inadequacy.

After the age of 6 months, complementary foods should be introduced in addition to breast milk. Nutrient density, the frequency of feeding and factors related to the palatability and ease of consumption of the foods viscosity, flavor, variety are all determinants of child micronutrient intake. A comparison of the diets of Peru and Mexico with the diets of US children indicates that the density of iron, zinc, and calcium in complementary foods is low and inadequate coverage of nutrient requirements is likely [73]. If foods with low iron bioavailability such as beans are used, more than two-thirds of the total dietary energy should be provided by that food, which is totally non-feasible.

Where animal products are not available, the provision of fortified foods or supplements may be necessary. Mineral bioavailability can also be enhanced by reducing the food factors limiting absorption, e. Older children are fed the family diet based on cereals and pulses, in which again animal products are only occasionally present, and hence again, zinc, iron, and calcium intakes are likely to be inadequate. Data from the Nutrition CRSP supports the existence of multiple micronutrient deficiencies in developing countries.

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The Nutrition CRSP was a longitudinal study of the impact of marginal malnutrition on the function of infants, pre-school children, school children and adults in Mexico, Kenya and Egypt []. Multiple food intake measures on these individuals made it possible to explore the relationships between the intake of specific foods, nutrients, and growth. Table 1 presents an elaboration of the data reported in the literature for pre-schoolers, comparing the intake of energy, protein and some key micronutrients with the average intake desired for those micronutrients in that age group.

Since raw data have not been used, a proper calculation of dietary adequacy cannot be done, but an overall understanding can be obtained of the nutritional value of such diets. All micronutrients were below the desired intake in Mexico and Kenya, and they were marginally sufficient for iron and copper in Egypt []. Micronutrients were also obtained largely from cereals, which are sources with low bioavailability. It is therefore easy to see how the lack of sufficient micronutrient intakes fails to sustain increased growth rates for catch-up towards the normal growth curve. This concept of micronutrient clustering in foods is well known to scientists who try to selectively induce deficiencies of individual nutrients, particularly zinc: when trying to induce zinc deficiency, copper deficiency is also induced [].

Wasting is the result of repeated insults to the growth plate, with reduced chondrocyte proliferation and maturation. Wasting is also associated with a developmental delay, with the retarded achievement of the main child development milestones, such as walking. This might create an overall comparative disadvantage in an already difficult environment []. Body fat plays a critical role in regulating bone mass and linear growth [90].

The fact that wasting is a reflection of depletion in fat and muscle masses implies that a child who is wasted may suffer from linear growth. It has been demonstrated that fat tissues produce leptin, which has an influence on bone density and catch-up growth [91,92]. Fat secretes multiple hormones, including leptin, which may have a stimulating effect on the immune system.

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Once leptin has an effect on bone growth, it is presupposed that wasting indirectly affects linear growth. This perhaps explains why wasted children who usually have low-fat stores have reduced linear growth [93]. We do know that high fat concentration is associated with obesity. Obviously, nutrients such as sulphur, phosphorus, calcium, magnesium, vitamins D, K and C, and copper are required for skeletal growth rather than for growth of other lean tissues [94]. As previously stated, a malnourished or lower weighing child is going to be an adult of having lower weight A lower weighing adult has some functional limitations compared to a higher one, such as reduced working capacity.

Wasted individuals often remain in a state of poverty throughout their lives, as they are not able to produce the extra income that might allow them to escape the cycle of mere subsistence. Reproductive performance may also be affected by stature: a lower weighing woman will usually deliver a low birth weight baby. The combined presence of growth retardation, developmental delay, defects in cognitive function, defects in substrate metabolism, increased morbidity and mortality indicates that wasting is by no means a condition affecting just the skeletal system, although the most apparent and easily diagnosable feature is thinness.

Wasting cannot be considered a form of cost-free adaptation or just an indicator of socio-economic status. Are the features of the wasting syndrome just a coincidence or is there a common basis for their origin? We have discussed that wasting might result from past exposure to multiple micronutrient deficiencies that may still be present. In most cases, the micronutrient status of wasted children has not been investigated, both because of the technical difficulties and because of the failure to identify wasting as an active condition of poor health.

Poor zinc status would compromise immunity and neurological function; iron and copper deficiency would produce anemia and affect the development of cognitive function and inadequate vitamin A status would also lead to increased susceptibility to infections.

In other words, the outcome typical of the wasting syndrome, i. Improved methods and linkages for identification and treatment of wasting are needed, both within the health sector and cross-sectorally, in order to reduce and maintain reductions in wasting in the long-term. The global extent and consequences of wasting, particularly in some high-burden countries, has been recognized through joint statements issued by the United Nations UN , in which the UN has endorsed community-based approaches for improving coverage of the treatment of wasting.

This includes the use of MUAC as an alternative to assessing weight-for-height to aid in the timely identification of wasting. Supplementary foods are provided to those who are moderately wasted and who do not have access to diets that cover their nutrient needs while their medical conditions are treated.

The Lancet series on under nutrition recognized treatment of severe acute malnutrition as the most cost-effective of the various direct nutrition interventions [83]. The earlier the child receives treatment, the cheaper it will be, as they are less likely to have developed additional medical complications and recovery times will be shorter. Nutrition offers one of the best returns on investment.

While the treatment of severe wasting is a well-established, evidence-based intervention [84,85] integrating it into essential health packages at national level has proven to be challenging. This is partly due to existing weaknesses in health systems and challenges in securing sufficient long-term funding to adequately scale up the service to the national level, as well as issues related to the supply chain and availability of treatment commodities. Moreover, the challenges in identification and treatment of wasting are also partly due to disagreements over where responsibilities lie.

The international community has often supported the treatment of wasting during emergency situations.

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In many countries where the burden of wasting is high, there are no specific activities for either treatment or prevention of moderate wasting. For older children, the focus should be on improving family foods diversity, quality, and safety. Linear programming e. Optifood is a tool that can be used to assess whether specific available foods: i can meet recommendations for nutrient intake; ii can be afforded by households; and iii are part of the current diet. Moderately wasted children also need to have access to health services and be treated for any medical conditions they might have.

In emergency contexts, including food-insecure settings, treatment of moderate wasting usually consists of provisions of supplementary food.

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However, there is still a limited consensus among the international community about the best approaches for either the treatment or prevention of moderate wasting. The nature of nutrition is that it spans many sectors and relationships are key to reaching multiple global targets. Currently, evidence regarding the best ways to integrate nutrition within other sectors to achieve the desired improvements is limited. The impact of nutrition-sensitive interventions on wasting e.

Improvements in the design of nutrition-sensitive services will increase the ability to:. Progress to achieve this target will depend not only on the scale-up of interventions to treat severe wasting but also on the strength and effectiveness of prevention strategies. While Ethiopia is having impressive success in treating hundreds of thousands of children each year, the large numbers of children becoming wasted are only slowly reducing, and seasonal surges of wasting are still occurring, even in years of good harvest.

Better links with preventive services are urgently required in order to reduce the number of wasted children. Services should be tailored to the context and encompass a range of different services; for example, promotion of improved infant and young child feeding; promotion of good hygiene and sanitation; and better social protection policies and programmes e.

Country-level contextualization is essential since strategies that are successful in Asia might not have the same success in Africa, for example.

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Because India accounts for approximately one half of the global burden of wasting [88], reductions in the overall burden of wasting will be highly dependent on the extent to which India places treatment and prevention of wasting as a national priority. Finally, programmes, policy, research and financing for wasting have been separate. Wasting and micronutrient deficiencies shares causal pathways, which suggest that action on one is very likely to impact the other [89].

For this reason, it is important to include treatment and prevention of wasting in development plans and goals.

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  4. It is vital that policymakers understand the importance of the problem of wasting, not only from the humanitarian perspective but with a wider lens, if the dramatic and consistent reductions in wasting are going to be achieved. Good nutrition and a healthy lifestyle are essential throughout the whole life cycle to ensure optimal health both of the individual and future offspring. When a child misses these and his mother loves attention, he may develop wasting.