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
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