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Malnutrition (Nutritional Health Problems)

  1. NUTRITIONAL HEALTH PROBLEMS Malnutrition Presented By: Dr. Kailash Nagar Department of Community health
  2. 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
  3. 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.
  4. NUTRITION The process of providing or obtaining the food necessary for health and growth.
  5. 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.
  6. NUTRIENTS Macronutrients Micronutrients
  8. 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.
  9. 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).
  10. BURDEN OF MALNUTRITION There are 170 million underweight children globally, 3 million of whom will die each year as a result of being underweight.
  11. Let this not come to you as a surprise….
  12. IT’S REAL
  13. India at the Alarming stage…
  14. The world bank Estimates that India is ranked…. 2nd in the world of the Number of children suffering from malnutrition
  15. Prevalence of underweight Children in India Is highest In the world
  16. WHO Estimates that 3 million Indian children die Before reaching age of 5 Every year.
  17. Every 5 second a child Dies.
  18. Because he or she was hungry…..
  19. Over 900 million people go to bed Hungry every day (FAO).
  20. World health report
  21. MALNUTRITION • (Bad Nourishment) • A pathological state OR resulting from Relative OR Absolute Deficiency Excess of One OR More Essential Nutrients
  22. 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
  24. UNDERNUTRITION ACUTE UNDERNUTRITION CHRONIC UNDERNUTRITION • Marasmus • kwashiorkor • Marasmic- kwashiorkor • Wasting • Stunting • Underweight
  25. 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.
  26. 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.
  27. Factors related to Malnutrition Social & Economic Biological factors  Poverty  Ignorance  Female gender Rural area Low birth weight Illiterate mother Scheduled caste/ scheduled tribe Cultural & social practices Maternal malnutrition, prematurity Birth spacing < 47 months Age of mother: 18 – 23 yrs Birth order > 3 Underweight status of mothers Infectious disease Diarrhea, TB, measles, Malaria, AIDS Environmental Unsanitary living, Droughts, floods, wars, forced migrations
  28. Nutritional intakes Nutrition needs Nutritional intakes Nutritional status The result is Under- Nutrition
  29. 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.
  30. 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. DISEASEMULTI FACTORS
  31. ntake Malnutrition in children Traditional Bio-Medical Concept Decrease immunity Recurrent ARI/GI tract infections Low birth weigh Inadequate energy intake
  32. 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
  33. Etiology of PEM PRIMARY PEM Protein + 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
  34. 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 :-
  35. • 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.
  36. Signs and symptoms of kwashiorkor kwashiorkor
  37. • 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
  38. • 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)
  39. 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.
  40. • 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
  42. • 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
  43. • 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.
  45. 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
  46. WEIGHT At 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.
  47. HEIGHT • 1 yr 72-75 cm • 2 yrs 88-90 cm • 4 yrs 100 cm.
  48. 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
  50. Gomez classification Parameter: weight for age Reference 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
  51. PHYSICAL EXAM Muscular Tone. ,muscle wasting ,delayed walking. • Abdomen- Hepatomegally. spleenomegally, • CVS -Cardiomegally ,oedema • CAN- Apathy, confusion, psychosis, depression….
  52. 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.
  53. 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
  55. MANAGEMENT 1. Initial treatment (emergency treatment) 2. Rehabilitation 3. Follow up
  56. INITIAL TREATMENT (EMERGENCY PHASE) USUALLY 2-7 DAYS Fluids 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
  57. 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
  58. 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
  59. 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.
  60. 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
  61. o Infants <24 months fed exclusively on liquid/ semi solid food o Older children given solid food.
  62. 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
  63. WHO PROTOCOL OF PEM PHASE STABILISATION REHABILITATION Day1-2 Day2-7+ Week 2-6 1. Hypoglycaemia 2. Hypothermia 3. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients 7. Cautiousfeeding 8. Rebuild tissues 9. Sensorystimulation 10. Preparefor follow-up noiron with iron
  64. 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.
  65. Interventions Proven to Reduce Malnutrition When Linked with Health Services (Essential Nutrition Actions) Vitamin A and iron Iodized salt Breast feeding stfeeding Mother’s nutritionComplementary feeding Sick/severe cases
  66. 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.
  67. 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
  68. 3.Integrated child development service(ICDS) scheme Beneficiaries Children < 6 years Pregnant & Lactating women Women in Reproductive age group (15-44 yr) Adolescent Girls. (1975)
  69. 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
  70. 5. Akshaya patra • Started in 2000, feeding 1500 children in 5 schools in Bangalore.
  71. Fight Malnutrition