What is malnutrition?World Health Organization definition:

The term is used to refer to a number of diseases, each with a specific cause related to one or more nutrients (for example, protein, iodine or iron)

and each characterized by cellular imbalance between the supply of nutrients and energy on the one hand, and the body's demand for them to ensure growth, maintenance, and specific functions, on the other.

Child malnutritiondeath and disability

Inadequate DiseaseDiet

Insufficientaccess to food

Inadequatematernal and

child care

Poor water/ sanitationinadequate health

services

Causes of malnutrition

Death from malnutrition

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Undernutrition

DeficiencyPrimary deficiency :

a nutrient deficiency caused by inadequate dietary intake of a nutrient

Secondary deficiency :

a nutrient deficiency caused by something other than an inadequate intake such as a disease condition that reduces absorption, accelerates use, hasten excretion, or destroys the nutrien

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PERKEMBANGAN MASALAH GIZI

Masalah kesehatan masyarakat dianggap berat bila prevalensi pendek sebesar 30 – 39 persen dan serius bila prevalensi pendek ≥40 persen (WHO 2010). Sebanyak 14 provinsi termasuk kategori berat, dan sebanyak 15 provinsi termasuk kategori serius.

Prevalensi Balita Pendek Menurut Provinsi

2010

< 20% (0) 20%-29,9% (9) 30%-39,9% (17) 40%+ (7)Jahari A.B

Consequences of PEM throughout the Life-cycle

fetus infant

child

adolescent

Pregnancy

Older age

Birth defects Low birth weight

stuntingIncreased risk of poor health

Poor physical performance

Decreased mental capacity

High prevalence of infectionsRisk of obstructed labor

Risk of maternal mortality

. Food insecurity

. Intra-households biases

- Heavy physical labor

- Diarrheal disease

- Increased physiological needs

Hospital Malnutrition:Hospital Malnutrition:

Numerous studies on hospital malnutrition have been published.

Prevalence of malnutrition in U.S. hospitals today ranges from 30% to 50%.

Illness

Malnutrition

Example : Cancer

Altered Food

Intake

Altered Digestion and

AbsorptionAltered

MetabolismAltered Nutrient Excretion

Examples: Loss of appetite, altered food likes/dislikes, difficulty chewing and swallowing, reduced saliva secretion

Examples: radiation enteritis, surgical resection of GI tract, diarrhea

Example: increased energy needs due to altered energy use in cancer

Examples: fecal loss of fat-soluble vitamins and calcium in clients with cancers that affect enzyme secretion or bile salt production

Define: Underweight: weight for age < 80% expected Marasmus: weight for age < 60% expected Kwashiorkor: weight for age < 80% + edema Marasmic kwashiorkor: wt/age <60% + edema Wasting: weight for height Stunting: height for age

SAM: severe acute malnutrition

Underweight Define: weight-for-age less 80% expected Encompasses both wasting and stunting High correlation with stunting Prevalence directly describes the

magnitude of the problem of growth faltering and stunting in young children

Protein – energy malnutrition

1- MarasmusDefinition: It is a clinical syndrome and a form of under nutrition

characterized by failure to gain weight due to inadequate caloric intake.

Incidence: commonly in infants between the age of 6mo. - 2years (Infantile atrophy).

Marasmus Deficit in calories – “marasmus” comes

from Greek origin of word “to waste” Gross weight loss Hyper-alert and ravenously hungry Children have no subcutaneous fat or

muscle

eventually starve to death (immediate cause often is pneumonia)

Marasmus

Weight for age < 60% expected No edema Often stunted CFR=20-30%

Marasmus (low calories)

Ravenouslyhungry

Gross weightloss & no fat

Marasmus – mechanism Energy intake is insufficient for body’s

requirements – body must draw on own stores Liver glycogen exhausted in a few hours –

skeletal muscle protein used via gluconeogenesis to maintain adequate plasma glucose

When near starvation is prolonged, fatty acids are incompletely oxidized to ketone bodies, which can be used by brain and other organs for energy

Mechanism is same as anorexia

Complications of Marasmus 1. Intercurrent infection : Broncho pneumonia .

is the cause of death 2. Gastro enteritis 3. Hypothermia 4. Hypoglycemia5. Edema(marasmic kwashiorkor )

Kwashiorkor

Swollen belly

Pellagra

Decreasedmusclemass

Sparsehair

Infection

Apathy

Kwashiorkor Definition It is a clinical syndrome and a form

of malnutrition characterized by slow rate of growth due to deficient of protein intake, high CHO diet and vitamins & minerals deficiency (adequate supply of calories).

Incidence Commonly in toddlers between the

age 1-3years, following or with weaning

Kwashiorkor(Edematous Malnutrition)

Underweight with edema Irritable, difficult to feed Electrolyte abnormalities Highest mortality – 50 to 60%

Assessment 1- Essential features (cardinal

manifestation): Growth retardation :- Weight is diminished (60-80%) of

expected Edema :

It is due to hypo proteinemia. It is starts in the feet and lower parts

of the legs) then becomes generalized edema .

The cheeks become bulky, pale, waxy in appearance (doll-like-cheeks)

2-Early features (usual manifestation)

Hair changes : The hair is sparse , dys pigmentation( reddish or greyish),atrophic ,easily pickable.

G.I.T Manifestations: Anorexia ,vomiting in severe cases, diarrhea

3-Occasional or variable features

- Vitamins and minerals defection and vit.D , A,C minerals as iron, zinc, Mg,

Hepatomegaly. Skin changes (dermatitis in areas due to

pigmentation ,napkin dermatitis, petechiae over the abdomen, fissures,ulceration

Poor resistance and liability to infections

Pathogenesis:Kwashiorkor: Normal energy intake, Lack of protein Edema:1970.decrease oncotic pressure,

Recent> Increase Renin activity,N a and fluid retention.

Amino aciduria due to proximal tubular dysfunction

Failure of adaptation .Hepatomegaly due to fatty infiltration from

lipogenesis of excess CHO - Biochemical and haematological changes

Kwashiorkor (low protein)

Decreased muscle mass (failure to gain weight and of linear growth)

Swollen belly (edema and lipid build-up around the liver) Changes in skin pigment (pellagra); may lose pigment

where the skin has peeled away (desquamated) and the skin may darken where it has been irritated or traumatized

Hair lightens and thins, or becomes reddish and brittle. Increased infections and increased severity of normally

mild infection, diarrhea Apathy, lethargy, irritability

Death does not occur from actual starvation but from secondary infection

Kwashiorkor – mechanisms Occurs in reaction to emergency situations

(famine) Kwashiorkor more likely in areas where

cassava, yam, plantain, rice and maize are staples, not wheat

Increased carbohydrate intake with decreased protein intake eventually leads to edema (water) and fatty liver

STUNTING Height for age less than 90% expected

BabyLow Birth

Weight

ChildStunted

AdolescentStunted

WomanMalnourished

Pregnancy Low Weight Gain

ElderlyMalnourished

Highermortality rate

Impairedmental

developmentIncreased risk of

adult chronic disease

Untimely/inadequateweaningFrequentInfections

Inadequatecatch upgrowth

Inadequatefood, health

& care

Reducedmental

capacity

Inadequatefood, health

& care

Reducedmental

capacity

Inadequatefetal

nutritionInadequate

food, health& care

Inadequatefood, health

& care

Highermaternalmortality

Reducedcapacityto care

for baby

Start here

Mental development Lower IQ levels Poorer school performance

Behaviors of recovered severely malnourished children

shy, isolated, withdrawn decreased attention span immature, emotionally unstable fewer peer relationships/reduced social skills played less/stayed nearer to mothers

Severe Malnutrition: Consequences

Stunting – Height for Age Height for age reflects pre- and post-

natal linear growth “Stunting” refers to shortness that is not

genetic, but due to poor health or nutrition

Most standard definition < 2 S.D.

Stunting: Timing Age of onset varies, but usually in first 2-

3 years of life First few months, infants in developing

countries grow just as quickly as children in reference populationsGrowth retardation starts from 2-6 month of

life (often associated with weaning)Infants at risk during this time because of

high nutritional requirements and high rates of infections (breast fed infants often protected)

Stunting: Consequences Cross-sectional associations – Low height for

age associated with:Reduced cognitive developmentPoor motor skillsPoor neuro-sensory integrationQuiet, reserved, withdrawn, timid, passiveDifficulty making decisionsDecreased involvement with environment, toys,

tasksLess able to deal with stressor such as hunger or

parasites