COMMUNITY NUTRITION

1. COMMUNITY NUTRITION DADI, S ARGADIREDJA dr, DTM&H, MPH

2. Group with risk of under nutrition • Poor community • Old age hospitalized in the hospital • Alcohol drinkers and drug addict. • Community who do not have house.

3. Problems of under nutrition. Biologic and social problems. Degree of under nutrition problems. Famine problems. Environment problems.

4. Biologic and social problems • Basic cause of this problems is deficiency of nutrient delivery to the cells • Although most of the reason is deficiency of essential nutrient, the causes are very complex such as; private, culture, psychology, economy, politics and education. • If the influence of factors are temporary,--- Malnutrition will be acute. • If the factors are permanent , the malnutrition will be chronic.

5. Degree of under-nutrition 1. primary under-nutrition example ; specific essential nutrient deficiency. vit C deficiency-- scurvy vit B1 deficiency  beri-beri 2. secondary under-nutrition. example : disease cause by mal- absorption of nutrient or disturbance in nutrient metabolism.

6. Famine problems. • There are some questions should be asked for measuring the problems: - Number of person suffer from malnutrition - where ? -cause of malnutrition.? -poverty? -strength ? -population? -politics

7. Ecology problems • Ecology = oikos (Greek) =house • Many factors and strength come from family’s house. Here there is inter relation in a very complex biologic process which can product the disease. • Very often malnutrition occur as complica- tion of tbc, parasitic intestinal or skin sepsis. • It is known that there is synergy between malnutrition and infection.

8. Ecology ..............cont • Epidemiology Triad Variables (Agent, host, environment) Host Disease Agent Environment

9. Hierarchy of degree of PEM • 1st degree inequality drought war • 2nd degree poverty & social problem • 3rd degree lack of infection neglet food • 4th degree anorexy • 5th degree malnutrition

10. Sign & symptom of Malnutrition 1. protein caloric malnutrition (kwashior- kor and marasmus ) 2. Anemia. 3. Hypovitaminosis A and Xerophtalmia 4. Endemic goiter.

11. Protein Energy Malnutrition (PEM) Another name : Protein caloric malnutrition (PCM) , Energy nutrient malnutrition (ENM) Kwashiorkor( protein deficiency) Kwashiorkor (African language ) mean that there is disturbances of the development of the child after mother stop giving breast feeding in order to have another child. Usually they substitute water and sugar which lack of protein both quantity and quality

12. Sign &symptom of kwashiorkor • Development and mental retarded,apathy • Edema • Thin muscle. • Depigmentation of skin and hair. • Flaky paint dermatosis. • Hypoalbuminaemia. • Atrophy of acini gland of pancreasdiarhe • Moderate anemia • Diarrhea, deficiency vit A

13. Metabolism in Kwashiorkor • ABNOMAL METABOLISM” The differences metabolism caused by protein deficiency are lack of the influence of fluid and electrolyte , protein, fat, vitamin, and mineral FLUID AND ELECTROLYT. The characteristic of kwashiorkor is specific disorder of fluid and electrolyte. Total body fluid increased. There are total reduction of body Kalium and Natrium retention. The sign of that disorder are: hypoalbuminemia, hormon disorder, depression of function of enzym cell and fenal circulation.

14. PROTEIN,FAT, VITAMIN AND MINERAL METABOLISM: Metabolic function disorder is concentrated to protein like enzym and blood plasma and also there is decrease of free amino acid from extremity. Vitamin A concentration in blood decreased. There are disorders on fat catabolism ,fat synthesis, and lack of essential fat. Often there are deficiency of iron and cuprum.

15. Etiology of kwashiorkor • Clear indication in kwashiorkor is lack of protein, both quality and quantity of protein which is needed for development and cell repair. Kilocalorie is enough, fulfilled by carbohydrate from foodstuffs • Case of protein malnutrition usually occurred. 1.children 1-4 years old who stop getting breast feeding. 2. Tropic an subtropic area where economic

16. social and culture become combination factors to develop protein malnutrition. 3.children being hospitalized for surgery and hypermetabolic

17. Marasmus • Maramus is lack of protein and kilocalorie chronically. • Sign and symptoms ; - very thin body, only bone and skin. - muscle and sub cutis fat atrophic. - face like old people. - skin wrinkeled. - dry -diarrhea

18. Factors of marasmus - social factors. - poverty. - infection. - micro organism pathogen  diarrhea, - development velocity reduced - no dermatitis and depigmentation. - no edema - dwarf (ind= kerdil), mental and emotional disturbance.

19. - can not sleep well, apathy. - body temperature sub normal (subcutan fat-) - escape from the environment, - minimal metabolic activities. - heart weakness. ABNORMAL METABOLISM. There are changes in metabolism of fluid, electrolyt, protein, fat and mineral. Like in kwashiorkor, there is Natrium emptiness especially if there is persistent diarrhea. There is no fluid resistance ,and this situation very contrast with kwashiorkor In general, thin body occurred because there is no muscle and exo- genous (from diet) and endogenous (fro muscle ). Difference with Kwashiorkor , in marasmus enzym system for fat digestion and fat transport mechanism through intestine wall and protein for fat transportation still maintain.

20. there is decrease of vitamin and mineral in the body. Vitamin A absorption sometimes occur normally, and this in contrast with kwashiorkor where there is depression ETIOLOGY Etiology of Marasmus is lack of protein and Kilocalorie in the diet for a long time

21. physic, emotional and mental condition decreased . In old poor person this happened because lack of high quality of food. Other disease like TBC, GE, disentry, diarrhea infectiosa, parasitic with out health promotion become etiology of marasmus. Marasmus occur in children 6-18 month,in the area with socio economic problems

22. in tropic or sub tropic area of developing countries .Marasmus can occur also in hospitalized old person. ASSESMENT; Factors which have role to the occurrence of under-nutrition 1) immunity 2) Reproductive factor, 3) work output. 4) mental 5) social and behavior.

23. Antropometri assessment can be done in ratio of - Weight for Age: mild if W/A 75-90% standard moderate if W/A 60-75% standard severe if W/A < 60% standard % expected edema harvard std + - 80-60% kwashiorkor undernutrition < 60% marasmic kwa marasmus

24. -Height for Age Standard antropometri WHO-NCHS • WEIGHT FOR AGE Over nutrition > 2 SD WHO-NCHS good nutrition -2SD  + 2SD under nutrition < -2SD bad nutrtion < -3SD

25. 2) HEIGHT FOR AGE Normal > or = -2SD stunted (short) < -2SD 3.) WEIGHT FOR HEIGHT Fat > 2 SD Normal -2SD+2SD Wasted (thin) < -2SD Very wasted < -3 SD

26. ANEMIA Definition : Anemia is defined as the state of low Haemoglobin caused by pathologic condition. Etiology ; Fe deficiency, chronic infection, folic acid deficiency Fe Deficiency = abnormal biochemistry of Fe with or without anemia, caused by; -decrease bioavailability of Fe intake. -increase need of Fe (pregnant, lactation ) -increase blood loss (ankylostoma) Anemia by Fe deficiency occur in severe anemia make the body can not maintain body temperature and can be fatal.

27. IRON DEFICIENCY ANEMIA(IDA) • Severe anemia (Hb< 4 g/dl) post delivery stressO2 function decreased death. In pregnant woman  low birth weight, premature. influence also O2 transportation work capacity and productivity decrease in baby and children influence behavior and intelligence

28. Factors influence anemia 1. Lack of Fe intake: in average woman need 6,5 ug/ day. inhibitor  fitat and polifenol ( in cereal, peanut, coffee, tea, vegetables.) enhancer ascorbic acid, and animal protein (cow & chicken meat, fish,) 2. Increase physiological need Increase during pregnant, for increasing blood volume, for foetus and placenta, and blood loss during delivery.

29. Factors.....................cont 3. excessive blood loss Blood loss can be occurred during opera tion, disease, menstruation. In average a woman lost 27 cc of blood per menstruation cycle. About 10% lost more than 80 cc. IUD increase lost of blood 2X, Pill can decrease amount of menstruation blood 1,5X.

30. FACTORS..................cont Placenta praevia and placenta abruption become the risk of lost of blood after delivery process . In average during delivery a woman lost 500 cc blood . Exclusive breast feeding prolong amenorrhoe of mother. Infection /parasitic infection like hook- worm correlate positively with anemia Blooding can also occurred caused by drug consumption like adreno corticosteroid, aspirin

31. Factors.................cont • Laboratory increase Hb > 1 g/dl after 1 month Fe supplementation  Fe deficiency anemia Serum ferritin < 12mg/cc Fe deficiency. Fe status analysis can use concentration of ferritin serum, saturation transferrin, erythrocyt protophorfirin, transferrin receptor concentration. Serum ferritin is specific indicator for Fe deficiency during low Fe level. During infectin and edema serum ferritin also increase.

32. Prevention and therapy of IDA • PREVENTION : maintain equilibrium between Fe input with the need and lost of Fe. To increase Fe input  increase food consumption contain heme-iron. If not enough from diet Fe supplement Fe supplementation need discipline of the patient. Side effect of Fe is gastric disturbance,

33. Prevention............cont Fortification of cereal product is one of strategy for increasing Fe consumption in community. SCREENING; Screening is very important to identify woman group to be treated for reducing anemia morbidity. CDC Atlanta suggest that woman (youth and adult not pregnant) should be screened every 5-10 years. If there is risk for developing anemia ,screening is conduct yearly.

34. IODINE DEFICIENCY • Deficiency can develop since prenatal stage until old age . • Before known as Enlargement of Thyroid (Gondok Ind) • Can cause abortion, still birth, cretin, hypothyroid. ECOLOGY AND DEMOGRAPHY Not all country have Iodine mineral resources. Most of natural iodine are in the sea and in the soil.

35. Ecology...................cont • Iodine in soil as I and at the sea as I.2 • In sea water 50-60ug/l, air 0,7 ug/l, rain water 1,8-8,5 ug/l • Iodine easy to evaporate and sensitive to the light. • Iodine from sea water  evaporate to the air to soil with rain or snow. If soil can not keep water to river then to the sea. In area which cannot keep water endemic area of iodine deficiency

36. ETIOLOGY OF IODINE DEFICIENCY • In general nutrition problems can be divided into two : -Primary; No equilibrium b/w the need and the input. -Secondary : Body cannot use nutrient eg caused by inborn defect metabolism. Mechanism is different with other anemia

37. Prevention................cont For pregnant woman screening should be conduct during PNC. THERAPY: Anemic patient should consume 60-120 mg Fe per day and increase consumption of Fe through diet. Check after 1 month .Hb should increase minimal 1g/dl. Pregnant woman with mild anemia should treated with Fe 60-120mg /day .After Hb and Haematocrit normal - 30 mg/day.

38. Unicef concept DISTURBANCE C/B BY IOD DEFICIENCY LACK INPUT OF IODINE FOOD LOW IOD SALT W/O IODINE LACK OF EDUCATION ABOUT DISEASE AND THE ADVANTAGE OF SALT WITH IODINE RESOURCE & CONTROL Health man power Economy &organization politics, ideology, structure & economic potential resources IODINE in soil low

39. Toxicity and hyperthyroid • According to Wolf (WHO 1996) excess of Iodine can be divided into 4 groups. -moderate excess of iodine increase absorption of iodine in thyroid gland and increase production of organic iodine. -big enough excess of iodine  will inhibit release of iodine from tyroxin in and from thyroid gland where release of iodine increased by TSH . - Big excess of iodine inhibit production of organic iodine  Goiter - Very big excess will saturate active transportation mechanism of iodine ion

40. Intake more than 2000 ug Iodine / day dangerous . Big intake from sea do not dangerous,like in Japan/china - thyroid function is normal although more or less than 30 mg/day -incidence of non-toxic diffuse goiter and toxic goiter will decreased. -incidence of Graves and Hashimoto do not influence by high income -high intake of iodine will induce hypothyroid and inhibit effect of thioamide drug.

41. CRETIN -Cretin is caused by irreversible iodine deficien- cy. Most dangerous deficiency of iodine. -IQ in cretin  below standard. -become a burden for a long time (until dead) -In general Cretin is developed, if during organogenesis there is iodine deficiency. -Cretin can be seen clearly after the age of baby more than 12 months -Prevalence in baby with breast feeding is less than baby with formula milk.

42. Diagnosis • Diagnosed based on damage of central nervous system • Symptoms : mental retardation, bilateral perceptive deaf, neuro-motoric damage. • Hypothyroid  obstacle of height and weight development • In severe hypothyroid  myxoedema • In mild hypothyroid  ossification inhibition ,

43. Early sign& symptoms • Weak and sleepy (lethargia) • Growth problems • Constipation • Swollen face and dumb expression • Chink-eyes (ind= sipit) • Thick and big tongue • Rough and dry hair. • Fat deposit at fossa supraclavicularis and neck. • Big belly and hernia umbilicalis • Short and fat, dry skin and low body temperature • Non pitting edema.

44. Iodine status examination • Biochemistry : -creatinin in urine ; normal = more than 50ug I2/g creatinin hypothyroid = 25-50 ug I2/g creatinin cretin = < 25 ug I2/ g creatinin • Thyroid gland enlargement 2 stages stage II  can be seen in normal head position stage I cannot be seen in normal head position but visible when the head in lift up position.

45. Indicator for thyroid gland enlargement  Total Goiter rate (TGR) and Visible Goiter Rate (VGR TGR= Group I + Group II / children examine x 100 VGR= Group II / children examine x 100 • Mild  TGR 5,0 – 19,0% • Medium  TGR 20,0 – 29,0% • Severe- TGR > 30% • Program : In mild area salt iodization and economic development, in medium area salt iodization 20-40 ppm and iodine oil capsules , in severe area  iodine oil capsules

46. Program steps • Situation analyses of disorder cause by deficiency of Iodine. • Communicate data to health and public health professionals . • Plan of action by MOH. • Socialization of program in local language • Organization development and partnership with local government. • monitoring & evaluation.

47. Thank you