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
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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
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