COMMUNITY NUTRITION

DADI, S ARGADIREDJA

dr, DTM&H, MPH

Group with risk of under nutrition

• Poor community

• Old age hospitalized in the hospital

• Alcohol drinkers and drug addict.

• Community who do not have house.

Problems of under nutrition.

Biologic and social problems.

Degree of under nutrition problems.

Famine problems.

Environment problems.

Biologic and social problems

• Basic cause of this problems is deficiency of nutrient delivery to the cells • Although most of the reason is deficiency of essential nutrient, the causes are very complex such as; private, culture, psychology,

economy, politics and education.• If the influence of factors are temporary,--- Malnutrition will be acute.• If the factors are permanent , the malnutrition will be chronic.

Degree of under-nutrition 1. primary under-nutrition example ; specific essential nutrient deficiency. vit C deficiency-- scurvy vit B1 deficiency beri-beri 2. secondary under-nutrition. example : disease cause by mal- absorption of nutrient or disturbance in nutrient metabolism.

Famine problems.

• There are some questions should be asked for measuring the problems:

- Number of person suffer from malnutrition - where ? -cause of malnutrition.? -poverty? -strength ? -population? -politics

Ecology problems

• Ecology = oikos (Greek) =house• Many factors and strength come from family’s

house. Here there is inter relation

in a very complex biologic process which

can product the disease.• Very often malnutrition occur as complica-

tion of tbc, parasitic intestinal or skin sepsis.• It is known that there is synergy between

malnutrition and infection.

Ecology ..............cont

• Epidemiology Triad Variables (Agent, host, environment)

Host

Disease

Agent Environment

Hierarchy of degree of PEM• 1st degree inequality drought war

• 2nd degree poverty & social problem

• 3rd degree lack of infection neglet food• 4th degree anorexy

• 5th degree malnutrition

Sign & symptom of Malnutrition

1. protein caloric malnutrition (kwashior-

kor and marasmus )

2. Anemia.

3. Hypovitaminosis A and Xerophtalmia

4. Endemic goiter.

Protein Energy Malnutrition (PEM)

Another name : Protein caloric malnutrition (PCM) , Energy nutrient malnutrition (ENM)

Kwashiorkor( protein deficiency)Kwashiorkor (African language ) mean that there is disturbances of the development of the

child after mother stop giving breast feeding in order to have another child. Usually they substitute water and sugar which lack of protein both quantity and quality

Sign &symptom of kwashiorkor

• Development and mental retarded,apathy• Edema• Thin muscle.• Depigmentation of skin and hair.• Flaky paint dermatosis.• Hypoalbuminaemia.• Atrophy of acini gland of pancreasdiarhe• Moderate anemia• Diarrhea, deficiency vit A

Metabolism in Kwashiorkor

• ABNOMAL METABOLISM” The differences metabolism caused by protein deficiency are lack of the influence of fluid and electrolyte , protein, fat, vitamin, and mineral FLUID AND ELECTROLYT. The characteristic of kwashiorkor is specific disorder of fluid and electrolyte. Total body fluid increased. There are total reduction of body Kalium and Natrium retention. The sign of that disorder are: hypoalbuminemia, hormon disorder, depression of function of enzym cell and fenal circulation.

• PROTEIN,FAT, VITAMIN AND MINERAL METABOLISM:

Metabolic function disorder is concentrated to protein like enzym and blood plasma and also there is decrease of free amino acid from extremity.

Vitamin A concentration in blood decreased. There are disorders on fat catabolism ,fat

synthesis, and lack of essential fat. Often there are deficiency of iron and cuprum.

Etiology of kwashiorkor

• Clear indication in kwashiorkor is lack of protein, both quality and quantity of protein

which is needed for development and cell repair. Kilocalorie is enough, fulfilled by carbohydrate from foodstuffs

• Case of protein malnutrition usually occurred.

1.children 1-4 years old who stop getting

breast feeding.

2. Tropic an subtropic area where economic

social and culture become combination

factors to develop protein malnutrition.

3.children being hospitalized for surgery

and hypermetabolic

Marasmus

• Maramus is lack of protein and kilocalorie chronically.• Sign and symptoms ; - very thin body, only bone and skin. - muscle and sub cutis fat atrophic. - face like old people. - skin wrinkeled. - dry -diarrhea

• Factors of marasmus - social factors. - poverty. - infection. - micro organism pathogen diarrhea, - development velocity reduced - no dermatitis and depigmentation. - no edema - dwarf (ind= kerdil), mental and emotional disturbance.

- can not sleep well, apathy. - body temperature sub normal (subcutan fat-) - escape from the environment, - minimal metabolic activities. - heart weakness.ABNORMAL METABOLISM.There are changes in metabolism of fluid, electrolyt, protein, fat and mineral. Like in kwashiorkor, there is Natrium emptiness especially if there is persistent

diarrhea. There is no fluid resistance ,and this situation very contrast with kwashiorkor In general, thin body occurred because there is no muscle and exo- genous (from diet) and endogenous (fro muscle ). Difference with Kwashiorkor , in marasmus enzym system for fat digestion and fat transport mechanism through intestine wall and protein for fat

transportation still maintain.

there is decrease of vitamin and mineral in

the body. Vitamin A absorption sometimes

occur normally, and this in contrast with

kwashiorkor where there is depression

ETIOLOGYEtiology of Marasmus is lack of protein and

Kilocalorie in the diet for a long time

physic, emotional and mental condition decreased . In old poor person this happened because lack of high quality of

food. Other disease like TBC, GE, disentry, diarrhea infectiosa, parasitic with

out health promotion become etiology of marasmus.

Marasmus occur in children 6-18 month,in the area with socio economic problems

in tropic or sub tropic area of developing countries .Marasmus can occur also in hospitalized old person.

ASSESMENT;

Factors which have role to the occurrence of

under-nutrition 1) immunity 2) Reproductive

factor, 3) work output. 4) mental 5) social

and behavior.

• Antropometri assessment can be done in ratio of - Weight for Age: mild if W/A 75-90% standard moderate if W/A 60-75% standard severe if W/A < 60% standard % expected edema harvard std + - 80-60% kwashiorkor undernutrition < 60% marasmic kwa marasmus

-Height for Age

Standard antropometri WHO-NCHS

1) WEIGHT FOR AGE

Over nutrition > 2 SD WHO-NCHS

good nutrition -2SD + 2SD

under nutrition < -2SD

bad nutrtion < -3SD

2) HEIGHT FOR AGE Normal > or = -2SD stunted (short) < -2SD 3.) WEIGHT FOR HEIGHT Fat > 2 SD Normal -2SD+2SD Wasted (thin) < -2SD Very wasted < -3 SD

ANEMIADefinition : Anemia is defined as the state of low Haemoglobin caused by pathologic condition.Etiology ; Fe deficiency, chronic infection, folic acid deficiencyFe Deficiency = abnormal biochemistry of Fe with or without anemia, caused by; -decrease bioavailability of Fe intake. -increase need of Fe (pregnant, lactation ) -increase blood loss (ankylostoma) Anemia by Fe deficiency occur in severe anemia make

the body can not maintain body temperature and can be fatal.

IRON DEFICIENCY ANEMIA(IDA)

• Severe anemia (Hb< 4 g/dl) post delivery stressO2 function decreased

death.

In pregnant woman low birth weight,

premature.

influence also O2 transportation work

capacity and productivity decrease

in baby and children influence behavior and intelligence

Factors influence anemia

1. Lack of Fe intake: in average woman need 6,5 ug/ day. inhibitor fitat and polifenol ( in cereal, peanut, coffee, tea, vegetables.) enhancer ascorbic acid, and animal protein (cow & chicken meat, fish,) 2. Increase physiological need Increase during pregnant, for increasing blood volume, for foetus and placenta, and blood loss during delivery.

Factors.....................cont

3. excessive blood loss Blood loss can be occurred during opera tion, disease, menstruation. In average a woman lost 27 cc of blood per menstruation cycle. About 10% lost more than 80 cc. IUD increase lost of blood 2X, Pill can decrease amount of menstruation blood 1,5X.

FACTORS..................cont

Placenta praevia and placenta abruption become the risk of lost of blood after delivery process . In average during delivery a woman lost 500 cc blood . Exclusive breast feeding prolong amenorrhoe of mother. Infection /parasitic infection like hook- worm correlate positively with anemia Blooding can also occurred caused by drug consumption like adreno corticosteroid, aspirin

Factors.................cont

• Laboratory increase Hb > 1 g/dl after 1 month Fe

supplementation Fe deficiency anemia Serum ferritin < 12mg/cc Fe deficiency. Fe status analysis can use concentration of

ferritin serum, saturation transferrin, erythrocyt protophorfirin, transferrin receptor

concentration. Serum ferritin is specific indicator for Fe deficiency during low Fe level. During infectin and edema serum ferritin also increase.

Prevention and therapy of IDA

• PREVENTION : maintain equilibrium between Fe input with the need and lost of Fe. To increase Fe

input increase food consumption contain heme-iron. If not enough from diet Fe supplement

Fe supplementation need discipline of the patient. Side effect of Fe is gastric disturbance,

Prevention............cont

Fortification of cereal product is one of strategy for increasing Fe consumption in

community.SCREENING;Screening is very important to identify woman

group to be treated for reducing anemia morbidity. CDC Atlanta suggest that woman (youth and adult not pregnant)

should be screened every 5-10 years. If there is risk for developing anemia ,screening is conduct

yearly.

IODINE DEFICIENCY

• Deficiency can develop since prenatal stage until old age .

• Before known as Enlargement of Thyroid (Gondok Ind)• Can cause abortion, still birth, cretin,

hypothyroid. ECOLOGY AND DEMOGRAPHY Not all country have Iodine mineral resources.

Most of natural iodine are in the sea and in the soil.

Ecology...................cont

• Iodine in soil as I and at the sea as I.2

• In sea water 50-60ug/l, air 0,7 ug/l, rain water 1,8-8,5 ug/l • Iodine easy to evaporate and sensitive to the light.• Iodine from sea water evaporate to the

air to soil with rain or snow. If soil can not keep water to river then to the sea. In area which cannot keep water endemic area of iodine deficiency

ETIOLOGY OF IODINE DEFICIENCY

• In general nutrition problems can be divided into two :

-Primary; No equilibrium b/w the need and the input. -Secondary : Body cannot use nutrient eg caused by inborn defect metabolism. Mechanism is different with other anemia

Prevention................cont

For pregnant woman screening should be conduct during PNC.THERAPY: Anemic patient should consume 60-120 mg Fe

per day and increase consumption of Fe through diet. Check after 1 month .Hb should

increase minimal 1g/dl. Pregnant woman with mild anemia should treated

with Fe 60-120mg /day .After Hb and Haematocrit normal - 30 mg/day.

Unicef concept DISTURBANCE C/B BY IOD DEFICIENCY

LACK INPUT OF IODINE

FOOD LOW IOD SALT W/O IODINE LACK OF EDUCATION ABOUT DISEASE AND THE ADVANTAGE OF SALT WITH IODINE

RESOURCE & CONTROL Health man power Economy &organization politics, ideology, structure & economic

potential resources IODINE in soil low

Toxicity and hyperthyroid

• According to Wolf (WHO 1996) excess of Iodine can be divided into 4 groups. -moderate excess of iodine increase absorption of

iodine in thyroid gland and increase production of organic iodine.

-big enough excess of iodine will inhibit release of iodine from tyroxin in and from thyroid gland where release of iodine increased by TSH . - Big excess of iodine inhibit production of organic iodine

Goiter- Very big excess will saturate active transportation

mechanism of iodine ion

Intake more than 2000 ug Iodine/ day dangerous .Big intake from sea do not dangerous,like in Japan/china - thyroid function is normal although more or less than 30 mg/day -incidence of non-toxic diffuse goiter and toxic goiter will decreased. -incidence of Graves and Hashimoto do not influence by high income -high intake of iodine will induce hypothyroid and inhibit effect of thioamide drug.

CRETIN

-Cretin is caused by irreversible iodine deficien- cy. Most dangerous deficiency of iodine.-IQ in cretin below standard.-become a burden for a long time (until dead)-In general Cretin is developed, if during

organogenesis there is iodine deficiency.-Cretin can be seen clearly after the age of

baby more than 12 months -Prevalence in baby with breast feeding is less

than baby with formula milk.

Diagnosis

• Diagnosed based on damage of central nervous system• Symptoms : mental retardation, bilateral perceptive deaf, neuro-motoric damage.• Hypothyroid obstacle of height and weight

development• In severe hypothyroid myxoedema• In mild hypothyroid ossification inhibition

,

Early sign& symptoms

• Weak and sleepy (lethargia)• Growth problems• Constipation• Swollen face and dumb expression • Chink-eyes (ind= sipit)• Thick and big tongue• Rough and dry hair.• Fat deposit at fossa supraclavicularis and neck.• Big belly and hernia umbilicalis • Short and fat, dry skin and low body temperature• Non pitting edema.

Iodine status examination

• Biochemistry : -creatinin in urine ; normal = more than 50ug I2/g creatinin hypothyroid = 25-50 ug I2/g creatinin cretin = < 25 ug I2/ g creatinin

• Thyroid gland enlargement 2 stages stage II can be seen in normal head position stage I cannot be seen in normal head position but visible when the head in lift up position.

• Indicator for thyroid gland enlargement Total Goiter rate (TGR) and Visible Goiter Rate (VGR

TGR= Group I + Group II / children examine x 100

VGR= Group II / children examine x 100• Mild TGR 5,0 – 19,0%• Medium TGR 20,0 – 29,0%• Severe- TGR > 30%• Program : In mild area salt iodization and economic

development, in medium area salt iodization 20-40 ppm and iodine oil capsules , in severe area iodine oil capsules

Program steps

• Situation analyses of disorder cause by deficiency of Iodine.

• Communicate data to health and public health professionals .

• Plan of action by MOH.• Socialization of program in local language• Organization development and partnership

with local government.• monitoring & evaluation.

Thank you