MALNUTRITION IN THEPHILIPPINES

Edgar M. Gerodias, R.N.,ECF,PCM, Hep. B Prec. CAP I, FMD

Joanna Ruth Palermo, R.N., ICF,PBL, AIDS Prec., TB Stage V, FMD

Common Malnutrition Problems

in the Philippines

•Protein -Energy Malnutrition (PEM) - A lack of energy and protein which results in growth redardation.

•Iron Deficiency Anemia (IDA) - A deficiency in iron wherein hemoglobin concentration is below the normal level which results in short attention span, reduced ability to learn and irritability.

Common Malnutrition Problems in the Philippines

Vitamin A Deficiency (VAD) - Lack of vitamin A that may result to xeropthalmia (dryness of the eye), nightblindness (inability to see in dim light) eyes sensitive to bright light, rough dry skin and membranes of nose and throat , low body resistance to disease, poor growth, and blindness in severe cases.

Iodine deficiency Disorders (IDD) - Lack of iodine in the body which results in goiter, mental retardation, deaf-mutism, difficulty in standing or walking normally, and stunting of the limbs.

Common Malnutrition Problems in the Philippines

Vitamin A Deficiency (VAD) - Lack of vitamin A that may result to xeropthalmia (dryness of the eye), nightblindness (inability to see in dim light) eyes sensitive to bright light, rough dry skin and membranes of nose and throat , low body resistance to disease, poor growth, and blindness in severe cases.

Iodine deficiency Disorders (IDD) - Lack of iodine in the body which results in goiter, mental retardation, deaf-mutism, difficulty in standing or walking normally, and stunting of the limbs.

– This condition is characterized by an enlargement of the entire gland, or of one of its two lobes, caused by a deficiency of iodine in the diet.

Simple Goiter

The Food Fortification Program RA 8976

Republic Act 8976 or the Food Fortification Act of 2000 was signed into law on November 7, 2000 for full implementation on November 7, 2004, to address the problem of micronutrient malnutrition

This law is complimentary to RA 8172 or the ASIN Law (An Act Promoting Salt Iodization Nationwide), passed in December 1995, mandating the iodization of all salt sold in the country.

Key Provisions of the Law:

Rule IV: The Philippine Food Fortification Program

Sec. 1 – The Philippine Food Fortification Program shall cover all imported or locally processed foods or food products for sale or distribution, for human consumption in the Philippines.

Key Provisions of the Law:

Sec. 2 – The Philippine Food Fortification Program shall consist of two systems:

•  Voluntary food fortification

•  Mandatory food fortification for specific food products enumerated in Sec. 6 of RA 8976 and those that may be required by the National Nutrition Council.

Key Provisions of the Law:

Sec. 3 – The Implementing Rules and Regulations shall apply to all manufacturers, or producers, importers, traders, tollees, retailers, repackers of food products covered by Sec. 2 of Rule IV of the IRR, as well as restaurants and food service establishments where such food products are encouraged to be served.

Sangkap Pinoy a term used by the DOH for micronutrients added to

food to enhance its nutritional quality These micronutrients are vitamin A, iron and iodine,

which cannot be synthesized by the human body, and therefore must be provided through the diet.

The intake of these micronutrients through the Filipino diet is often inadequate and is responsible for the micronutrient malnutrition afflicting a majority of the population.

SANGKAP PINOY SEAL

Sangkap Pinoy Seal (SPS) is a mark of DOH recognition of a food product that is properly fortified with either vitamin A, iodine or iron or a combination of these micronutrients and that complies with regulations of the Bureau of Food & Drug (BFAD) of the DOH for quality, labeling and addition of fortificants.  

SANGKAP PINOY SEAL Approved Products

NOODLES

No. PRODUCT FORTIFICANT 1 Dolphin Plus Vermicelli Bihon Iron, Iodine 2 Excellent Insant Mami   Chicken, Beef Vitamin A, Iron 3 Goodah Instant Noodles   Beef, Chicken Vitamin A, Iron 4 Lucky Me Instant Mami     Chicken, Beef Vitamin A, Iron

  Pancit Canton, Chicken and egg, Pancit Canton with Kalamansi Vitamin A

5 MAGGI Rich Mami Noodles   Beef, Chicken, Chicken Asado Vitamin A

NOODLES

6 Maggi Noodle Buddies

  Buttered Corn, Cheezy Bacon Vitamin A

7 Saucy-Mi (Original, Toyomansi, Hot & Spicy, Beef & Onion, and Instant Pancit Palabok Vitamin A

8 Ho-Mi Canton (Classic, Toyomansi, Chili Anghang, and Pinoy Beefsteak) Vitamin A

9 Ho-Mi Instant Mami (Chicken & Garlic, Beef Wanton and Beef Brisket) Vitamin A

10 Nooda Crunch Ready to Eat Noodle (Cheese, Barbeque, and Pizza) Vitamin A

11 Payless Instant Mami

  Chicken, Beef, Pancit Canton with Chilimansi, Beef Bulalo Vitamin A

SNACK FOODS

12 Granny Goose Tortillas  

  Barbecue, Cheese, Chili, Cheese Party flavored, Corn Snack

Vitamin A, Iron & Iodine

13 Granny Goose Nibbles  

  Cheese, Ham and Cheese, Sizzling Hot Cheese, Corn Snack

Vitamin A, Iron & Iodine

14 Granny Goose Kornets

  Natural, Barbecue, Cheese Vitamin A, Iron & Iodine

15 Clover Chips   Cheese flavor Vitamin A 16 Oishi Prawn Crackers Vitamin A 17 Oishi Kirei Yummy Flakes Vitamin A

SNACK FOODS

18 Oishi Boogyman Vegetable Crunch Vitamin A 19 Oishi Cheese Barrel Vitamin A 20 Oishi Rinbee Cheese Sticks Vitamin A

21 PeeWee Crunchy BBQ and Pizza flavored snack Vitamin A, Iron

22 Cheez-it Tasty Snack Cracker Vitamin A, Iron 23 Moby Caramel Puff Vitamin A 24 Moby Chocolate flavored Snack Vitamin A, Iron 25 Ri-Chee Crunchy Snacks Milk flavored Vitamin A 26 Kenken Puffcorn Iron

  Honey Caramel, Chocolate

27 Regent Golden Sweet Corn Iron

SNACK FOODS

28 Regent Snack Rice Cracker- Vegetable Flavor Iron

29 Regent Cheese Ball - Cheese flavored snack Iron 30 Regent Cheese Ring - Cheese flavored snack Iron 31 Regent Ebisen Prawn Crackers Iron 32 Tomi Corn Chips

  Chicken, Sweet Corn, Keso Vitamin A, Iron

33 Humpy Dumpy Corn Chips Buttered Corn Vitamin A, Iron

  on a cob, Chili & Garlic   Mexican Barbecue   Royal Cheese  

SNACK FOODS

34 Fastsnax Corn Snacks

  Barbecue Fries Vitamin A   Cheeseburger  

35 Jack 'n Jill Mr. Chips Vitamin A, Iron

  Nacho Cheese, Sweet Corn

36 Jack 'n Jill Chiz Curls Vitamin A, Iron

37 Roller Coaster Potato Rings Cheese flavor Vitamin A, Iron

38 Maggi No Cook Rice Porridge

Guinataang Monggo, Champorado, Goto, Arroz Caldo

Vitamin A

SUPPLEMENTARY FOODS FOR INFANTS

39 Cerelac infant Cereals Vitamin A, Iron & Iodine

  Rice-soya, Wheat, Wheat-Banana, Rice, Squash & Spinach, Choco-Cereal  

40 Gerber Infant Cereals Vitamin A, Iron

 

Brown Rice, Brown Rice with Soya, Mix fruit with soya, Chicken Stew with vegetable and milk, Cream of Chicken with rice & milk, Cream of brown rice with milk, Green mongo

 

41 Nutri-Pak Champorado, Monggo, Beef, Chicken, Raisin-Nuts, Guinataan Vitamin A

BISCUITS

42 Goya Knick Knacks Coated Biscuit

  Chocolate, Milk Vitamin A, Iron

43

Magic Flakes Crackers Sandwich Butter Cream, Chocolate, Orange, Peanut Butter, Artificial Coconut Flavor

Vitamin A

BREADS

44 Arlee's Power Bread Loaf, Bun Vitamin A, Iron

45 Sandwich Bread Egg and

Milk, Wheat, Raisin, Sandwich White

Vitamin A

46

Goldilocks Fresh Bake buns and rolls, pandesal, dinner rolls, buns

Vitamin A

SANDWICH SPREAD

47 Miracle Whip Spread

  Sandwich Spread, Salad & Sandwich Spread, Ham and Bacon Spread Vitamin A

48 Miracle Whip All-Purpose Dressing Vitamin A   Regular all-purpose   Reduced Fat all-purpose dressing   49 Star Margarine

  Classic, Mantekeso, Sweet Blend & Garlic Vitamin A, Iodine

50 Dari Crème Margarine   Classic, Buttermilk Vitamin A 51 Minola Margarine Vitamin A

CHEESE PRODUCTS

52 Eden Pasteurized Filled Cheese Spread

Vitamin A, Iodine

53 Kraft Cheddar-Cheese Spread Vitamin A, Iodine

54 Kraft Chiz Whiz Processed Cheese Spread

Vitamin A, iodine

55 Cheezee Pasteurized Processed

Filled Cheese (in block form and jar)

Vitamin A

MILK

56 Alacta Grow Milk for older kids Vitamin A, Iron

57 Lactum Powder Regular, Chocolate

Vitamin A, Iron & Iodine

CHOCOLATE DRINKS

58 Ovaltine Chocolate Beverage Powder

Vitamin A, Iron, Iodine

FRUIT DRINKS

59 Eight O'Clock Orange Instant Drink Mix Vitamin A

60

Tang Juice Drink Mangga (instant drink mix full sugar & instant drink mix hybrid) Orange, Mandarin-Orange, Pineapple, Grape, Pomelo, Soursop

Vitamin A

61 Magnolia Fruit Drinks Mango, Orange, Pineapple Vitamin A

62 Magnolia Ice Tea Drinks lemon Vitamin A

63 Fruit C Orange Juice Drink Vitamin A

MEAT AND FISH PRODUCTS

64 555 Sardines Regular, Hot Vitamin A

65 Toyo Canned Sardines Vitamin A

66 Señorita Canned Sardines Vitamin A

67 Mekeni Picnic Premium Hotdog Vitamin A

68 Swift Mighty Meaty Hotdog Vitamin A

69 Boomboom Hotdog Regular, Jumbo Vitamin A

70 Purefoods Beefies Hotdog Vitamin A

CONDIMENTS

71 Papa Banana Catsup Vitamin A

DIAMOND SANGKAP PINOY SEAL

In 2004, the Diamond Sangkap Pinoy Seal was introduced to be used solely for staple products mandated for fortification, namely cooking oil, wheat flour, rice, refined sugar and salt.

Currently there are 71 products under the Diamond SPS

RICE

Iron-Fortified Rice Iron

SALTFirst Choice Iodized Salt Iodine Fidel Iodized Salt Iodine

SUGAR

Azukal Pure Cane Sugar Vitamin A

 

DIAMOND SANGKAP PINOY SEAL

a campaign to support various health programs to reduce childhood illnesses and deaths by promoting positive child care behaviors

A program of the Department of Health in partnership with the Local Government Units and other government and non-government organizations

GARANTISADONG PAMBATA

GARANTISADONG PAMBATA

GP is done twice a year one week in April and one week in October.

Second week of October was designated as "Garantisadong Pambata" week.

GARANTISADONG PAMBATA SERVICES

Giving VIT A capsules (VAC) supplement to all 12-59 months old children.

Catch up immmunizations (children who missed the routine immunizations like BCG, OPV, DPT, Measles)

Distribution of iron supplements to infants and pregnant women

GARANTISADONG PAMBATA SERVICES

Promotion of child positive caregiving behaviors like

exclusive breastfeeding of infants from 0-6months old, feeding infant micronutrient rich complementary foods

starting 6 months old, use of iodized salt daily, Buying and eating fortified foods, brushing of teeth properly and regularly, letting children play safe toys no smoking in front of preschooler

Marasmus speaks:

I am derived from a word meaning withering or wasting… Hence, my physical manifestations

are related to my meaning…

Kwashiorkor reacts:

I come from the African language meaning “the sickness of the older child when the next

baby is born. This corresponds to the “weaning time of the older child.” Therefore, I am the result of the misfortune in the family…

Etiology:

Marasmus-due to a diet very low in calories (CHO, fats

and protein)-BALANCED STARVATIONKwashiorkor-a deficiency of PROTEIN with adequate or

even excess of calories.

Age Incidence:

Marasmus-often the result of unsuccessful BF or

insufficient BM supply with little or no other food given.

BF may be given on:a. Scheduledb. Per Demand

Marasmus-failure to gain weight leads to loss of weight

which leads to emaciation-the face becomes shrunken (old man’s face),

muscle wasting best seen and felt at the buttocks, thighs , upper arms and scapular region (winged scapula)

Kwashiorkor-usually occurs in a breastfed child until he is

weaned gradually into starchy diet, without high protein foods

-it is highly probable that deficiencies of other nutrients such as Vit. A, B complex, other minerals and etc. are frequent contributing factors

Clinical Features

1. DiagnosticEdema-is a cardinal sign (meaning syndrome

should not be diagnosed in its absence) -1st detected at the anklegeneralized but more marked on the subcutaneous tissues of the dependent parts such as legs, forearms, penis, scrotum, the lower back, and the lower face (moonface)

-protruding abdomen is due to hypotonia of the abdominal muscles and the intestine and edema of the abdominal wall

-muscle wasting can be demonstrated functionally by testing the infants ability to hold his head when gently pulled from a lying to a sitting position

Psychomotor changes-looks miserable and does not smile-motor development is retarded

Irritability-psychological trauma d/t maternal withdrawal assoc. with weaning from the breast plays an impt. role

Mental changes-1st 3 years of life is very critical in brain

development

2. Common Signs-certain signs though not necessary for

diagnosis are common and are usually present singly or in combination

a. Hair changes-occasionally serve to indicate the duration of the deficiency: long scanty, pale,pluckability records a prolonged period of deprivation

FLAG SIGN-alternate light and dark bands in the hair indicates alternating periods of protein adequacy and deprivation

b. Depigmentation of the skin-there is general lightening of the color of the pigment of the skin due to interference in melanogenesis

c. Anemia-nutritional anemia-the hemoglobin content of the blood is lower than the

prescribed value for a given age group as a result of deficiency of folic acid or B12 like hookworm infestation

3. Occasional Signs of Kwashiorkora. Flaky Paint Rash or Enamel Dermatoses -seen in advanced cases; if present it is

pathognomonic of the disease -these are patches of skin turn reddish, then

purplish with macules and vesicleslater they become dry, peel off, leaving a raw, weeping areas like burns

-seen mostly in the hidden parts of the body like buttocks, groins and trunk.

Grave Prognosis:Hepatomegaly-there is usually enlargement of

the liver which has a smooth surface and edge

Marasmus and Kwashiorkor are assoc. with Vit. A deficiency

Difference Between Marasmus and Kwashiorkor

Marasmus KwashiorkorMuscle Wasting Poor appetiteGrowth Retardation DiarrheaApathetic, Quiet Diffuse depigmentationGood Appetite Flaky-paint/enamel orDiarrhea dermatosis

MoonfaceHepatic Enlargement

Kwashiorkor Ching!

Kwashiorkor Triple Treat!

Mr. Marasmus 2007! Bongga!

Pathophysiology of Diarrhea in Malnutrition

Types of Diarrhea:1. Infectious Diarrhea2. Non- Infectious Diarrhea

Infectious Diarrhea- PCM inflicts profound damage on the GIT particularly the stomach and duodenum.

Infectious Diarrhea-damage further the intestinal pits which has already been weakened by malnutrition

Vicious Cyclemalnutrition

malabsorptiondiarrhea

2. Non-Infectious DiarrheaMalnutritionatrophy of the intestinal villi which

contains the brush borderdissacharide: Lactose) enzyme lactase is secreted in the outermost layer of the brush borderin severe casessucrase and maltase TOTAL DISSACHARIDE INTOLERANCE or malabsorption

Lactose Intolerance-80% of the malnourished child. The intake of

regular milk which contains lactose promote and perpetuate diarrhea

Intake-1 hour after ingestion, vomiting, abdominal cramps.

How to confirm the dx. Of lactose intolerance:Aspirate watery-portion of the feces and test for -ph, reducing substancepH=<6 acidicReducing substance= trace to +1

TREATMENT OF PCM

1. Evaluate the Clinical Condition- determine the presence of any

medical emergency, make a clinical diagnosis and treat accordingly.

Ex. Severe dehydration secondary to Infectious Diarrhea

Dehydration:

REPLACEMENTMild – 5% weight loss 50 ml/kg BWModerate – 10% weight loss 100ml/kg BWSevere – 15% weight loss 150ml/kg BW

Treat with antibiotics

TREATMENT OF PCM

2. Assess the Nutritional Status- make Nutritional diagnosis

3. Rehabilitate the malnourished childa.) refer to malward if warranted

- institute medical and nutritional managementb.) home basis

- enroll in teaching programs if necessary

TREATMENT OF PCM

4. Institute follow-up measures such as:Weighing Medical and nutritional advice Immunization, deworming , sanitation advice,

family planning advice food production information Income- generating activities

HOW TO RE-INTRODUCE MILK FEEDINGS

Since early introduction of full-strength milk which contain lactose will provoke and perpetuate diarrhea, milk feedings should be resumed with extreme caution.

After 2-3 days without milk, a very dilute mixture of milk preparation is given :

S26 or Bona 1:2 dilution

1 part milk : 2 parts water1:7 1:6 1:2 (1 – 2 days)By starting gradually, exacerbation of

diarrhea due to lactose intolerance is AVOIDED

HOW TO RE-INTRODUCE MILK FEEDINGS

HOW TO RE-INTRODUCE MILK FEEDINGS

To increase the caloric content of the dilute milk, one may add sugar (sucrose or pure glucose) provided there is no intolerance to them.

For patients who are not tolerant to milk Re-feeding - Give NON LACTOSE FORMULA:

Al 110 – glucose Isomil and Nutratigen – sucroseSobee - DextrimaltoseNursoy – soya

DIETARY MANAGEMENT OF MALNOURISHED CHILD

- the essence of dietary management is to give the child HIGH CALORIC, HIGH PROTEIN DIET aiming at 100 – 200 cal/kg BW/ day 4-8 gm protein/kg BW/ day mode: feed frequently

DIETARY MANAGEMENT OF MALNOURISHED CHILD

NPO for 24 – 48 hours – IVF

50 – 75 cal/kg/day2 gm/kg/day of protein

No bouts of diarrhea

- Starting them on a full diet will definitely cause a relapse of their diarrhea:

DIETARY MANAGEMENT OF MALNOURISHED CHILD

Increase 200 mg/day of caloriesIncrease protein 8gm/day

Until weight gain is OPTIMAL (2-4 weeks)

Maintain CHO = 110 – 120 cal/kg/dayPROTEIN = 4 – 8 gm/BW/day

DIETARY MANAGEMENT OF MALNOURISHED CHILD

PROGNOSIS: most of the clinical features and pathologic changes are REVERSIBLE but if SEVERE malnutrition occurs early in life, specially before 6 months of age, when psychomotor and brain development is critical the changes noted maybe IRREVERSIBLE.

“A child should never be the result of chance, but should always be the product of a responsible gift of love of its parents to each other

and to the Creator Himself”