NUTRITIONAL HEALTH PROBLEMS
Malnutrition
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 & 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

Nutritional
intakes
Nutrition
needs
Nutritional
intakes
Nutritional status
The result is
Under- Nutrition

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.
DISEASEMULTI
FACTORS

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 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

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

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.

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 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

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. Rehabilitation
3. Follow up

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

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 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

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 feeding
stfeeding
Mother’s nutritionComplementary
feeding
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 years
Pregnant & Lactating women
Women 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