NUTRITIONAL HEALTH PROBLEMSMalnutrition

Presented By: Dr. Kailash Nagar Department of Community health

Discussion Overview

Define and classify malnutrition• Types of malnutrition.• Enumerate causes and effects of malnutrition• Physiologic effects of malnutrition• Diagnosis and management of PEM• Identify strategies for prevention of

malnutrition.• National nutritional health programmes

 INTRODUCTION

• Food is the prime necessity of life. • The food we eat is digested and assimilated in the body and used for its maintenance and growth. 

• Food also provide energy for doing work. 

NUTRITION

The process of providing or obtaining  the food  necessary for health and growth.

BALANCE DIET

A diet that  contain adequate amounts of all the necessary nutrients require for the health growth and activity such as  Carbohydrate, proteins, fats, vitamins and minerals.

                    NUTRIENTS 

 Macronutrients  Micronutrients

MALNUTRITION

PROTEIN ENERGY MALNUTRITION (PEM)

• INTRODUCTION:- PEM major health and nutrition problem

in India as well as developing countries . Occurs particularly in weaklings and children in the first years of life.

Not only an important cause of childhood morbidity and mortality , but leads to permanent impairment of physical and mental growth.

Conti….• Nearly one in five children's under age five

in the developing countries are underweight (WHO)

• One in every three malnourished children of the world lives in India.

• In India, around 43% of under five children were underweight (NFHS).

• Pre-school children are most vulnerable to the effect of protein energy malnutrition (PEM).

BURDEN OF MALNUTRITION

There are 170 million underweight children globally, 3 million of whom will die each year as a result of being underweight.

Let this not come to you

as a surprise….

IT’S REAL

India at the Alarming stage…

The world bank Estimates that India is ranked….

2nd in the world of the Number of children suffering from malnutrition

Prevalence of underweight Children in India Is highest In the world

WHO Estimates that 3 million Indian children die Before reaching age of 5 Every year.

Every 5 second a child Dies.

Because he or she was hungry…..

Over 900 million people go to bed Hungry every day (FAO).

World health report

MALNUTRITION• (Bad Nourishment)

• A pathological state OR resulting from

    Relative    OR Absolute

                 Deficiency

              Excess   of

           One   OR  More      Essential Nutrients

The World Health Organization (WHO) defines malnutrition as

the cellular imbalance between

To ensure growth, maintenance, and specific functions

supply of nutrients & energy

and the body's demand for them

TYPES OF MALNUTRITION

• Marasmus• kwashiorkor • OBESITY

UNDERNUTRITION   OVERNUTRITION 

UNDERNUTRITION

ACUTE UNDERNUTRITION 

CHRONIC UNDERNUTRITION

• Marasmus• kwashiorkor• Marasmic- kwashiorkor• Wasting

• Stunting• Underweight

UNDERNUTRITION 

Is the result of food intake that is continuously insufficient to meet dietary energy requirements, poor absorption and/or poor biological use of nutrients consumed. This usually results in loss of body weight.

WHY MORE COMMON IN CHILDREN…?

• High nutrient requirement/unit weight.• Dependence on adults for food • Immunity power

Water - Higher body water > older children Fat - Rapid increase in the 1st 6 months Growth - Rapid from birth till six months - Growth rate increase at puberty.

Factors related to Malnutrition

Social & EconomicBiological factors

 Poverty Ignorance Female genderRural areaLow birth weightIlliterate mother Scheduled caste/        scheduled  tribe 

Cultural  & social practices

Maternal malnutrition, prematurityBirth spacing < 47 monthsAge of mother: 18 – 23 yrsBirth order > 3Underweight status of mothers

           Infectious diseaseDiarrhea,  TB,  measles,  Malaria, AIDS

Environmental Unsanitary living, Droughts, floods, wars, forced migrations

Nutritional  intakes

Nutrition needs

Nutritionalintakes

 

Nutritional status

     The result is Under- Nutrition

Web of causation in this case

CONCEPTS OF DISEASE CAUSATION

1. Traditional Bio-medical concept Disease caused due to the presence of causative agents Basis in Germ theory of disease.

2. Socio- Epidemiological Concept Causative  agents  alone  may/may  not  be sufficient  for  disease  occurrence  Social  factors important  in  the  disease  causation  & progression.

3. Politico- Developmental Concept  Comprehensive  approach,  puts  health  in  the context  of  politico-developmental  situations Effects  of  government  policies  &  outfalls  of development    on  disease  occurrence,  Stems from the multi-factorial causation of disease.

DISEASEMULTIFACTORS

ntake Malnutrition in

children

Traditional Bio-Medical Concept

Decrease immunity

Recurrent ARI/GI tract 

infections

Low birth weigh

Inadequate energy intake

Age group affected

Usually b/w 6 months to 3 years

• PEM (45%)    =  1 to 2 years• PEM (69%)   =   1 to 3 years

Marasmus  = 6 months  to 15 months

Kwashiorkor  =  1 to 3 years

           Etiology of PEM

                                     PRIMARY PEMProtein + energy intakes below requirement for normal growth.

Linear growth ceases 

                                           SECONDARY PEM-the need for growth is greater than can be supplied.- decreased nutrient absorption-  increase nutrient losses

Linear growth ceases

Static weight  

                       Malnutrition and its signs 

Weight loss  

 Wasting   

KWASHIOKOR

• It is the body’s response to insufficient protein intake but usually sufficient calories for energy.

•  The term kwashiorkor is taken from the Ga language of Ghana and means "the sickness of the weaning”.

• Williams first used the term in 1933, and it refers to an inadequate protein intake with reasonable caloric (energy) intake.

•KWASHIOKOR :-

• Kwashiorkor, also called protein-energy malnutrition, is a form of PEM characterized primarily by protein deficiency.

• This condition usually appears at the age of about 12 months when breastfeeding is discontinued, but it can develop at any time during a child's formative years.

Signs and symptoms of kwashiorkor

kwashiorkor

• Weight loss: -arms and legs -decrease of muscle mass

• Swollen abdomen -ascites: increase of capillary permeability -enlarged liver: fatty liver

• Peripheral oedema• Anaemia: lethargy• Changes in skin pigment. • Diarrhea

• Failure to gain weight and grow• Fatigue• Hair changes (change in color or texture)• Increased and more severe infections due

to damaged immune system• Irritability• Large belly that sticks out• Loss of muscle mass• Rash (dermatitis)

MARASMUS• The term marasmus is derived from the

Greek word marasmos, which means ‘ wasting’.

• Marasmus is a form of severe protein-energy malnutrition characterized by energy deficiency.

• Primarily caused by energy deficiency, marasmus is characterized by stunted growth and wasting of muscle and tissue.

• Marasmus usually develops between the ages of six months and one year in children who have been weaned from breast milk or who suffer from weakening conditions like chronic diarrhea

SIGNS & SYMPTOMS MARASMUS

• Severe growth retardation• Loss of subcutaneous fat• Severe muscle wasting• The child looks appallingly thin and limbs appear as skin and bone

• Wrinkled skin• Bony prominence• Associated vitamin deficiencies

• Failure to thrive• Irritability, fretfulness and apathy• Frequent watery diarrhea and acid stools• Mostly hungry but some are anoretic.• Dehydration• Temperature is subnormal• Muscles are weak• Edema and fatty infiltration are absent.

DIAGNOSIS OF PEM

DIAGNOSIS OF PEM:-

Physical examination• History- including detailed dietary history.

-Anthropometric measurements.» Weight »Length/height »Mid upper arm circumference MUAC)»Chest circumference»Head circumference»Anthropometric Measurements of

Nutritional Status

WEIGHTAt 5-6 month double of birth weight

At 3 years weight 5 time double of birth weight

At 6 years weight 6 times double of birth weight.

HEIGHT

• 1 yr 72-75 cm• 2 yrs 88-90 cm • 4 yrs 100 cm.

Mid-upper arm circumference

MEASUREMET COLOR INDICATION

MUAC less than (11.0cm)

Red color Severe malnutrition

Between(11.0- 12.5cm)

Orange Moderate

Between(12.5- 13.5cm)

Yellow At risk or mild

Over (13.5cm) Green Well nourished

CHECKING FOR BILATERAL OEDEMA

Gomez classification

Parameter: weight for ageReference standard (50th percentile) WHO chart 

• If the wt is > 90 % of the expected weight –no malnutrition

• 1st degree- wt is 75-90% of the expected weight• 2nd degree- wt is 60-75% of the expected weight

• 3rd degree- wt is < 60 % of the expected weight

PHYSICAL EXAM

Muscular Tone. ,muscle wasting ,delayed walking.

• Abdomen- Hepatomegally. spleenomegally,

• CVS -Cardiomegally ,oedema • CAN- Apathy, confusion, psychosis, depression….

Developmental Milestones: 

7 months =Shuts mouth. Shakes head to

refuse foods. 9 months =Fingers feeding 10 months =Drinks from cup. 12 months =Holds spoon unable to get food to

mouth. 15 months =Control spoon + cups. 18 months = Plays with food.

Laboratory test

• Full blood counts• Blood glucose profile• Septic screening• Stool & urine for parasites & germs• Electrolytes, Ca, Ph & serum proteins• Mantoux test• HIV testing & malabsorption

MANAGEMENT

MANAGEMENT

1. Initial treatment (emergency treatment)2. Rehabilitation3. Follow up

INITIAL  TREATMENT 

(EMERGENCY PHASE)     USUALLY 2-7 DAYSFluids and electrolyte balance:- • Iv infusion - indicated in a severely

malnourished child with circulatory collapse (otherwise N/G feeding)

• ½ strength Darrow’s solution with 5% dextrose• Half normal saline (0.45%) with 5% dextrose• Give I/V fluid 15 ml/kg over 1 hour

MILD INFECTIONS:  Cotrimoxazole BD x 5 days

SEVERE INFECTIONS WITH COMPLICATIONS:

•    Ampicillin:50mg/kg I/M, I/V 6hr x 2days• Amoxicillin:15mg/kg oral 8hr x 5 days• Gentamicin:7.5mg/kg I/M,I/V O.D x 7days

DIETARY MANAGEMENT

For 2-3 weeks• Calorie : 120 -140 cal/kg/day• Protein :3- 5 gm/kg/day• Elemental iron: 3-6 mg/kg/day (ferrous sulphate)• Vitamin A: 300,000I.U then 1500I.U/day• Vitamin D: 4000 I.U/day• Vitamin k: 5mg I/M, I/V once only• Folic acid: 5 mg on day 1, then 1 mg/day

INITIAL REFEEDING 

• Frequent small feeds of low osmolarity & low lactose

• Oral/NG feeds (never parenteral preparation)

• 100 cal/kg/day• Continue breast feeding if the child is breast

fed.

nutritional rehabilitation• Eating well

• Improvement of mental state

• Sits, stands or walks

• Normal temperature

• No vomiting/ diarhea/ edema

• Gaining wt > 5 gm/kg body wt/day x 3 consecutive

days

o Infants <24 months fed exclusively on liquid/

semi solid food

o Older children given solid food.

FOLLOW UP

– Follow up at regular intervals after discharge

– Child should be seen after– Every 2 days for 1 wk – Once weekly for 2nd wk – At 15 days interval for 1 - 3 months– Monthly for 3- 6 months– More frequent visits if there is problem

WHO PROTOCOL OF PEMPHASE STABILISATION REHABILITATION

Day 1-2 Day 2-7+ Week 2-6 1. Hypoglycaemia 2. Hypothermia 3. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients 7. Cautious feeding 8. Rebuild tissues 9. Sensory stimulation 10. Prepare for follow-up

no iron

with iron

Prevention of Malnutrition• Primary Prevention

– Health Education to mothers about good nutrition and food hygiene through Lady Health Workers

– Immunization of children.– Growth monitoring on Growth Charts specially of all children under 

3 years of age

• Secondary Prevention– Mass Screening of high risk populations, using simple tools like 

(Weight for age) or MUAC.

• Tertiary Prevention– Good Nutritional Care, supplementary feedings and rehabilitation,–  counseling of mothers.

Interventions Proven to Reduce Malnutrition When Linked with Health Services (Essential Nutrition Actions)

Vitamin A and iron

Iodized salt

Breast feedingstfeeding

Mother’s nutritionComplementaryfeeding

Sick/severe cases

NUTRITIONAL PROGRAMMES

1. Balwadi nutrition programme (1970)

Beneficiary group Preschool children 3-5years of age.

Services 300kcal and 10gm protein for 270 days in a year.

2. Special nutrition programme

1970 Ministry of Social Welfare.

Operation in urban slums, tribal areas and backward rural areas.

Beneficiary group

Children below 6 years Pregnant and lactating women

Services

Preschool children : 300kcal and 10-12gm protein Pregnant & lactating mothers :500kcal and 25 gm protein

3.Integrated child development service(ICDS) scheme

Beneficiaries Children < 6 yearsPregnant & Lactating womenWomen in Reproductive age group (15-44 yr)Adolescent Girls.

(1975)

4.Mid-day meal programme (1961)

First started in Tamilnadu.Also known as School lunch programme.

Aim To provide at least one nourishing meal to

school going children per day

5. Akshaya patra 

• Started in 2000, feeding 1500 children in 5 schools in Bangalore.

Fight Malnutrition