NUTRITIONAL PROBLEMS

By:- firoz qureshiDept. psychiatric nursing

INTRODUCTION Under nutrition is widely recognized as a

major health problem in the developing countries of the world ,food is a major concern of the mankind beginning from the time of conception & extending through the entire life span of the individual.

Food supply the energy for physical activity & other metabolic for maintaining growth of the individual & for repair of the ageing tissues.

DEFINITION Nutritional problem or malnutrition

is the condition of improper or inadequate food intake or inadequate absorption of food. And it manifests in so many diseases.

CONT….. It comprises four forms under

nutrition, over nutrition, imbalance and the specific deficiency.

 

NUTRITIONAL DISORDER   Malnutrition – Kwashiorkor Marasmus

A-vitaminosis- B vitamins - B1-Beriberi B2- Ariboflovinosis B3 –Pellagra B6 – Pyridoxine deficiency

CONT… B7 – Biotin deficiency B9 – Folate deficiency B12- Vitamin B 12 deficiency

Other Vitamins deficiency-A- Bitot spots C- Scurvy D- Ostiomalacia/ Rickets

3)Hyper alimentation – Hypervitaminosis A Hypervitaminosis E Hypervitaminosis D

METHODS OF ASSESSMENTS

Assessment of dietary intake by details history of dietary patterns, specific food consumed and its amount, quality and adequacy in relation of nutrient value.

Anthropometric examinations of the child including weight, length/height, mid upper arm circumference, skin fold thickness, are valuable indicators of nutritional status. In young children, head circumference and chest circumference are also measured to assess patterns of growth and development and deviation from average size.

Clinical examination of the child to assess deficiency signs and associated problems. Through head to foot examination is done to detect the classical signs of various deficiency states.

CONT… Assessment of associated problems like

tuberculosis, mal-absorption syndrome, any infection or infestations should be made to find out the probable cause of nutritional deficiency.

Laboratory investigations to be done to exclude the underlying cause including routine examination of stool, urine, blood and x- rays. Estimation of HB, serum proteins, enzymes, blood level of nutrients like vitamins, iron, amino acid, etc. to be done whenever indicated.

CAUSES OF NUTRITIONAL PROBLEM Assessments of ecological factors, morbidity and mortality

patterns in the community help to detect the nutritional status of the particular community, as these situations influence the nutritional status of an individual. 

Causes of Nutritional Problem – Poverty Low birth weight Infection Population growth Feeding habits Social factor 

PROTEIN ENERGY MALNUTRITION 

Protein–energy malnutrition (PEM) or protein–calorie malnutrition refers to a form of malnutrition where there is inadequate calorie or protein intake.

Types include: Kwashiorkor (protein malnutrition

predominant) Marasmus (deficiency in calorie intake)Marasmic Kwashiorkor (marked protein deficiency and marked calorie insufficiency signs present, sometimes referred to as the most severe form of malnutrition)

DISCRIPTION PEM is also referred to as protein-calorie

malnutrition. It develops in children and adults whose consumption of protein and energy is insufficient to satisfy the body's nutritional needs. While pure protein deficiency can occur when a person's diet provides enough energy but lacks the protein minimum. PEM may also occur in persons who are unable to absorb vital nutrients or convert them to energy essential for healthy tissue formation and organ function.

CONT… Although PEM is not prevalent among the

general population of the United States, it is often seen in elderly people who live in nursing homes and in children whose parents are poor.

PEM occurs in one of every two surgical patients and in 48% of all other hospital patients.

PEM is fairly common worldwide in both children and adults and accounts for 6 million deaths annually.

CLASSIFICATION WHO classification: - WHO recommended three terms: stunting,

under weight and wasting for assessing the magnitude of malnutrition in under five children. The classification is based on deficit in body weight for age and presence or absence of edema. Children weighing b/w 60-80% percent of their expected weight for age with edema are classified as kwashiorkor.

CONT…Protein calorie malnutrition is lacking of

calorie and other nutrients in child as they are growing.

Main two protein deficiency problems are :-Kwashiorkor Marasmus 

KWASHIORKOR It is a clinical syndrome that results from a severe deficiency

of protein and an inadequate caloric intake characterized by edema, irritability, anorexia, and an enlarged liver with fatty infiltrates. Either from lack of intake or from excessive losses of or increases in metabolic rate caused by chronic infections secondary vitamin and mineral deficiency may contribute to sign and syndrome.

CONT… It is most serious and prevalent form of

malnutrition in the world today. Especially in the industrially underdeveloped countries.

The term "kwashiorkor" comes from a word used in Ghana that means a "disease of a baby deposed from the breast when the next one is born." Kwashiorkor usually happens when a baby is weaned from protein-rich breast milk (for any reason) and switched to protein-poor foods. In impoverished countries, protein-rich foods are difficult to acquire.

CLINICAL MANIFESTATIONS

Early PEM manifest vague but does include: Lethargy Apathy Irritability Inadequate growth Lack of stamina Loss of muscular tissue Increased susceptibility for infection. Edema. Secondary immunodeficiency is one of the most serious and

constant complication. Failure to gain weight. Anorexia.

CONT… Loss of muscle tone. Hepatomegaly. Renal functions decreases. Dermatitis. Hairs often sparse and thin and loses its

elasticity. Dispigmentations of hairs. Dark hairs changes in

streaky red or gray color. Vomiting and diarrhea. Mental changes like irritability and apathy are

common, stupor, coma and death may follow.

LABORATORY DATA Decrease in concentration of serum albumin is the

most characteristics change. Ketonuria is common in early stage but frequently

disappears by later stage. Blood glucose level is low, but glucose tolerance curve

may be diabetic in type. Plasma values of essential amino acid are decrease

and increased aminoaciduria. Serum cholesterol level is low. Bone growth is usually delayed. Growth hormone secretion may be increased.

PREVENTIONS

Diet containing an adequate quantity of protein of good biological quality.

Adequate dietary instructions and food distribution are urgently needed in endemic areas.

TREATMENT Immediate management of acute problems such as

severe diarrhea, renal failure or shock. Replacements of missing nutrients. All symptoms must be treated. For dehydration intravenous fluid must be administer. Ringer lactate solution may be life saving. Effective antibiotic should be given parenterally for 5-

10 days. Yogurt and cow’s milk for lactose intolerant child. Vitamins and minerals, especially vita A, potassium and

magnesium are necessary from the outset of treatment. Iron and folic acid usually corrects the anemia.

 MARASMUSE Marasmus is a from of under nutrition caused

by inadequate caloric intake occurring chiefly during the first year of life.

Marasmus is a form of severe malnutrition characterized by energy deficiency. A child with marasmus looks emaciated.

CONT… Both kwashiorkor and Marasmus are common in

underdeveloped countries and in areas in which dietary amino acid content is insufficient to satisfy growth requirements. Kwashiorkor typically occurs at about age 1, after infants are weaned from breast milk to a protein-deficient diet of sugar water, but it can develop at any time during the formative years.

Marasmus affects infant’s ages 6 to 18 months as a result of breast-feeding failure, or a debilitating condition such as chronic diarrhea.

ETIOLOGY Inadequate caloric intake.. Disturbed parent child relationship. Congenital malformation. Metabolic abnormality... Severe impairment of any body system

CLINICAL MANIFESTATIONS

Failure to gain weight. Loss of skin turgor . Distend abdomen or flat. Atrophy of the muscle. Hypotonia. Subnormal temp, slow pulse Diminished appetite. Usually constipated. Tongue abnormality Short Hight Muscle wasting

CONT… Weight loss Muscle Weakness Immune deficiency Red cell production reduced Others symptoms: Edema, Skin change Impaired growth, Fatty liver characterize this. There is typical appearance of a Pot belly which

gives a false impression of health or over nutrition.

TREATMENT

The best treatment for improving digestive power is to give regular massage with Vata palliating oils like bala oil, narayan oil, and dhanvantari oil every day and exposure to early morning sun for 15 minutes. Herbs of choice are bala , shatavari , ashwgandha , and guduchi . These should be given in dose of 1 gram times day with milk or water. Balarishta 10 ml. 3 times a day for 1 month with chyavan 1 teaspoon 3 times a day.

COMPLICATION: Anorexia Nervosa Eating disorders. 

AVITAMINOSIS

B1 - BERIBERI Beriberi is a vitamin deficiency disease in which the

body does not have enough thiamine (vitamin B1). Causes-> There are two major types of beriberi: Wet beriberi affects the cardiovascular system. is an

adult with difficulty in walking Tingling or loss of sensation (numbness) in hands and feet.

Dry beriberi and Wernicke-Korsakoff syndrome (with both neurologic and psychiatric symptoms) with dyspnea (shortness of breath) on exertion.

SYMPTOMS Pain Tingling Loss of feeling (sensation) in hands and feet Muscle damage with loss of muscle function or paralysis of the lower legs Vomiting Mental confusion/speech difficulties Difficulty walking Coma Death Swelling of the lower legs Increased heart rate Lung congestion Enlarged heart related to congestive heart failure Shortness of breath with activity Awakening at night short of breath

TREATMENT This is done with thiamine supplements. Thiamine

supplements are given through a shot (injection) or taken by mouth.

Other types of vitamins may also be recommended. Blood tests may be done after the person is given

thiamine supplements to see how well they are responding to the medicine.

Complications  Psychosis Coma Congestive heart failure Death

B2 - ARIBOFLAVINOSIS Ariboflavinosis is the medical condition caused

by deficiency of riboflavin (vitamin B2). Ariboflavinosis is most often seen in association with protein-energy malnutrition and also in cases of alcoholism.

Signs and symptoms Sore throat with redness and swelling of the mouth Throat mucosa, cheilosis and angular

stomatitis(cracking of the lips and corners of the mouth),

Glossitis Decreased red blood cell count with normal cell size

and hemoglobin content

B3 - PELLAGRA

Pellagra is a vitamin deficiency disease most frequently caused by a chronic lack of niacin

The symptoms of pellagra include: High sensitivity to sunlight Aggression Dermatitis alopecia, Smooth, beefy red glossitis Red skin lesions Insomnia Weakness Mental confusion Diarrhea The main results of pellagra can easily be remembered

as "the four D's": diarrhea, dermatitis, dementia, and death.

B6 – PYRIDOXINE DEFICIENCY Signs and symptoms Irritability and neurologic symptoms, such as

confusion, are common place. Anemia has also been documented as a symptom.

Treatment Treatment of pyridoxine deficiency lies with

replacing the missing vitamin. Penicillamine or hydrazides, such as isoniazid, are rarely used due to their ability to provoke deficiency symptoms.

B7 - BIOTIN DEFICIENCY Biotin deficiency is quite rare. Bacteria in the intestines make

biotin, or vitamin B7, is a water soluble vitamin. Many foods also contain biotin, such as liver, cauliflower, carrots, soy products.

Symptoms : Dry skin Fungal infections Rashes including red, patchy ones near the mouth Hair loss or total baldness (alopecia) Treatment: Biotin deficiency is easily corrected by biotin tablets, which

are inexpensive and readily available.  

FOLATE-DEFICIENCY ANEMIA Folate deficiency is the lack of folic acid (one of the B vitamins) in the

blood, which can cause a type of anemia known as megaloblastic (pernicious) anemia.

Symptoms The following are the most common symptoms of folate-deficiency anemia.

However, each individual may experience symptoms differently.Symptoms may include the following: abnormal paleness or lack of color in the skin decreased appetite irritability lack of energy or tiring easily (fatigue) diarrhea smooth and tender tongue The symptoms of folate-deficiency anemia may resemble other blood

conditions or medical problems. Always consult your physician for a diagnosis.

CONT… Treatment Specific treatment for folate-deficiency anemia will be

determined by your physician based on: your age, overall health, and medical history extent of the disease your tolerance for specific medications, procedures, or therapies expectations for the course of the disease your opinion or preference

Treatment may include: vitamin and mineral supplements change in diet medication treatment of the causative disease

B12 DEFICIENCE Vitamin B12 deficiency, also known as

hypocobalaminemia.Symptoms

Osteomalacia: widespread bone pains and sometimes muscle weakness. Fractures can occur.Rickets: aches and pains, and sometimes visible enlargement of bones at joints, such as the wrists.

Treatment Regular daily supplements of vitamin D and calcium are usually used for people with simple vitamin D deficiency.

VITAMIN C - SCURVY vitamin C deficiency can occur as part of general

undernutrition, but severe deficiency (causing scurvy) is uncommon.

Symptoms Dark purplish spots on skin; especially the legs, spongy

gums; often leading to tooth loss, bleeding from all mucous membranes,

Pallor, Bleeding gums, Sunken eyes, Opening of healed scar , nosebleeds, non-stopping

diarrhea, and nail loss.

CAN VITAMIN C DEFICIENCY BE PREVENTED?

Vitamin C deficiency can be prevented by making sure that you have a healthy, balanced diet that contains plenty of fruit and vegetables including those high in vitamin C that are listed above. As a rough guide, one large orange a day will provide you with enough vitamin C.

HYPERVITAMINOSIS A

Hypervitaminosis A, or vitamin A toxicity, occurs when you have too much vitamin A in your body.

Symptoms:- Birth defects Liver problems, Reduced bone mineral density that may result in osteoporosis Coarse bone growths Skin discoloration Hair loss Excessive skin dryness/peeling

CONT…

SignS:- Nausea and Vomiting, Headache, Dizziness, Blurred vision, and Loss of muscular coordination

Treatment:- Treatment involves simply stopping supplements (or rarely,

foods) that contain vitamin A.

 

HYPERVITAMINOSIS D Hypervitaminosis D is a rare but potentially serious condition.

It occurs when you take in too much vitamin D. It’s usually the result of taking high-dose vitamin D supplements.

Too much vitamin D can cause abnormally high levels of calcium in the blood. This can affect bones, tissues, and other organs. It can lead to high blood pressure, bone loss, and kidney damage without treatment.

Symptoms of vitamin D poisoning include: Dehydration Vomiting Decreased appetite(anorexia) Irritability Constipation Fatigue

WHAT IS THE TREATMENT FOR HYPERVITAMINOSIS D?

Your doctor will likely advise you to stop taking vitamin D supplements immediately. They may also recommend that you reduce the amount of calcium in your diet temporarily. In some cases, corticosteroids or bisphosphonates may suppress the release of calcium from your bones.

Your doctor will monitor your vitamin D levels frequently until they return to normal

HYPERVITAMINOSIS E

Hypervitaminosis E is a state of vitamin E toxicity. Since vitamin E can act as an anticoagulant and may increase the risk of bleeding problems,V

It is a state of Vitamin E toxicity. Because vitamin E can act as an anticoagulant and may increase the risk of bleeding problems, many agencies have set an upper tolerable intake level for vitamin E at 1,000 mg .

SIGNS AND SYMPTOMS

Blotchy skin Increased bleedingDecreased production of

thyroid hormonesDecreased activity of vitamin K Increased bleeding from aspirin or anti-

coagulant medications

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