Malnutrition

1. Malnutrition It is a pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients.

2. Forms of Malnutrition Under-nutrition Over-nutrition Macronutrient def. Obesity Micronutrient def

3. The main forms of Malnutrition are • Under-nutrition: • a pathological state resulting when nutrient intake does not meet the requirements. It includes: • Macronutrient deficiency e.g., protein-energy malnutrition( marasmus & kwashiorkor). • Micronutrient deficiency as iron deficiency anaemia, vitamin A deficiency, vitamin D deficiency…….etc. • Over-nutrition: • a pathologic state resulting whennutritional intake exceeds the body needs • Obesity

4. Malnutrition Primary Malnutrition due to community or family factors related to food production, distribution…. etc Secondary Malnutrition due to individual factors affecting intake , absorption or utilization of food

5. Primary malnutrition It is due to reduced intake as in case of the following 1- Insufficient food production 2- Unequal distribution of foods 3- Lack of leisure . The work of women, the duration of work outside home and the transportation time all are factors that affect the likelihood of having proper meals at home. This indicates the importance of school meals and provision of canteens at work. 4- Housing and kitchen facilities 5- Lack of transportation 6-Cultural factors

6. 6-Cultural factors • Food attitudes, habits, Values, behaviors, • Religion …. • - Celebration food • -Age group or sex linked foods • -Disease linked foods • -Modern foods ( Fast meals) • -Duration of breast feeding • -Food preparation • -Pattern of diet during pregnancy • & lactation

7. Examples of Negative poor habits : • Unconsumption of satisfactory amounts of protective foods due to: • failure to promote the habit during childhood, • local food customs, • Religious or ethnic restrictions or economic restrictions • Examples of Positive poor habits: • a) Excessive use of sweets . This replaces proteins , vitamin & and mineral source foods • b) Consumption of highly refined foods especially white flour and white sugar. • The white toxic Tirade: white Flour, Salts, sugar

8. Secondary Malnutrition • Deficient Intake: • due to anorexia, in elderly and mentally ill • Increased food requirements: • during febrile diseases and in hyperthyroidism • Malabsorption: • in patients with diarrhea or patients with gastrectomy & in elderly patients • Malutilization: • Defects in metabolism as in Liver diseases . • Increased excretion: • Chronic bleeding causes iron deficiency anemia

9. I-Macronutrient deficiency Protein Energy malnutrition (PEM) PEM is a range of pathological conditions caused by a chronic deficiency of energy and / or protein, occurring most frequently in infants and young children and commonly associated with infections.

10. Wellcome classification of PEM

11. Underweight: • A child who does not eat enough to cover his nutrient needs is “underweight`. • It is characterized • weight loss 60-80% of the standard, • low resistant to infection • associated with nutrient deficiency • ( Vitamin A, C, D, B and Minerals as Iron & calcium) • Example: The weight of the child is 8 kgm while the standard weight for age is 12 kgm • The wt % standard is: 8X 100 = 60.67 % • 12

12. Marasmus: • It occurs in any age particularly in early infancy and is characterized by • severe muscle wasting , • The Wt. % standard is < 60% • loss of subcutaneous fat,

13. Kwashiorkor: • It is the severe form of PEM • occurs principally in the • weaning and post weaning • period when the diet is • deficient in protein • and rich in carbohydrates • The Weight % standard is • 60- 80% in addition to • edema

14. Marasmic Kwashiorkor The child has the characteristics of both marasmus and Kwashiorkor. It happens when a marasmic child develops edema on top of marasmus The weight % standard is < 60% without edema

15. Health consequences of childhood Malnutrition 1-Growth failure as detected by the growth curve (e.g. slowly rising, flat or going down). 2-Lack of energy for daily activities & low scholastic achievement . 3-“apathy” the child is less interested in the world around him .He does not want to play. He sleeps more and appears miserable. 3-Lack of immunity against infection.

16. Relation between Malnutrition & infectious diseases

17. (3) Infection • (4) • Increased need for • energy& other nutrients • Decreased appetite so • less intake of nutrients • Decreased absorption • Of nutrients from gut • Weight loss • Slower growth (2) Ineffective Immune system Decreased resistance of tissue (specially lining of gut & respiratory tract (1) Malnutrition

18. Prevention of Malnutrition • Primary prevention • 1-Increas food production • 2-Establishment of an efficient food • distribution system • 3-Proper environmental sanitation and • raising the standard of living • 4-Prevention and control of infectious • diseases (vaccination) • 5- Adequate services for vulnerable groups

19. Secondary prevention: Early detection and treatment of malnutrition . This can be done through periodic nutritional surveillance .i.e. systematic collection , dissemination and analysis of data related to malnutrition in order to plan a program for prevention & control of this condition Tertiary prevention Rehabilitation services to offer health education for mothers to care and feed for the malnourished children to allow them to live normal life.

20. II-Micronutrient deficiencies Micronutrients are the nutrients that enable the body to produce enzymes, hormones and other substances essential for proper growth & development. As tiny as the amounts are, the consequences of their deficiencies are severe. Vitamin A & D, iodine and ironare the most important in global public health terms; their lack represents major threats to the health and development of populations all over the world, particularly low income countries. It affects more under five children and pregnant women

21. Vitamin A deficiency (VAD) Functions of Vitamin A a-Integrity of epithelial tissues in skin and mucous membrane which are barriers against external infections especially respiratory tract infections b-Integrity of epithelial tissues lining of urinary and biliary tracts ,conjunctiva and lacrimal glands (preventing xerosis) c- Synthesis of the visual purple (rhodopsin) from protein (opsin) and vit. A itself d- Promoting the proper growth.

22. Important sources of vitamin A I – Animal: Milk including human milk (colostrums), liver, poultry , kidney; eggs, butter & Cod liver oil are the richest source for the vitamin II- Plant:orange / yellow fruits and vegetables (mangoes, apricots, carrots) and dark green leaves.

23. Clinical features • I - For children, VAD causes: • 1-Severe visual impairment and • Bitots spots, Conjunctival & • corneal xerosis, keratomalacia & night • blindness (the most severe total blindness). • 2-Xerosis &follicular hyperkeratosis of skin • 3-Increased the severity &mortality of • illness (diarrheal diseases & measles)

25. II- For pregnant women in high-risk areas, VAD occurs specially during the last trimester when the demand by both the fetus and the mother is highest. It is demonstrated by high prevalence of night blindness during this period. These women will secrete later breast milk, which is deficient in vitamin A.

27. I - Short-term intervention: • Breast-feeding: Promoting • breast-feeding • Vitamin A supplementation

28. II- Long term approach a) Food fortification (with sugar) maintains vitamin A status especially for high-risk groups . b) Home gardens. For vulnerable rural families, growing vegetables in home gardens complements fortification

29. Iodine deficiency disorders (IDD) IDD remains a major threat to the health of populations all over the world, particularly among preschool children and pregnant women in developing countries. It is not only easy to control but it can be eliminated.

30. The main causes of IDD are: • 1-Lack of iodine in food usually in places • far from the sea. • 2- Goitrogens, which are chemical • substances in water or food leading to the • development of goiter by reducing the • amount of iodine that the thyroid gland • takes up from the blood.

31. Health consequences of IDD • Hypothyroidism • Retarded physical development • Mental dysfunction • Spontaneous abortion & still birth • Cretinism

32. Health consequences of IDD

35. What are the Measures for prevention of iodine deficiency disorders? • A-Primary prevention (Elimination of IDD): • The primary intervention strategy for elimination of IDD is “Universal Salt Iodization” (USI). • Salt was chosen because it is : • widely available and • consumed in regular amounts • low costs of iodizing.

36. B- Secondary prevention (Screening forNeonatal Hypothyroidism) Neonatal hypothyroidism is the most common disorder that should be screened. Congenital hypothyroidism leads to mental retardation , which can be prevented if medical treatment is given within the first 1-2 months of life. All the neonates are routinely screened for estimation of the level of the thyroid hormones by taking blood sample from the heel of the neonate within the first week of life.

37. Vitamin D deficiency ( Rickets and osteomalacia) Rickets is a systemic disease of the growing skeleton characterized by defective calcification of the bones during growth. The term osteomalacia is applied to the same pathological condition when it affects a skeleton that has completed its growth

38. Function of vitamin D • Vitamin D is needed at times of rapid growth that is, in infants and young children, adolescents, and pregnant women. • It has the following functions: • a) Promotion of absorption of calcium and phosphorous from the intestine. • b) Calcification of bone matrix

39. Clinical signs • Active rickets • in young children: • Epiphyseal enlargement- • Beading of ribs- • Persistently open anterior fontanelles • (after 18 months of age) • Muscular hypotnia

41. Healed rickets • in older children • Frontal or parietal • bossing, • knock knees or bow knees • Deformities of the thorax Osteomalacia (in adults women): Local or generalized skeletal deformities of the pelvis with tender bones .

42. Sources of vitamin D a-The ultraviolet rays (UVRs) activate the provitamin (7-dehydrocholesterol) in the deep layers of the skin , but it can be filtered by air pollution and glass. b- Food sources are only of animal origin e.g., milk, butter, cheese, fatty fish (salmon and sardines), eggs, liver and cod-liver oil. c- Fortified milk.

44. I- Biological factors • a- Order of the child: The later the child of an undernourished mother, the higher the probability of developing Vit. D deficiency. • b- Twins • c- Low birth weight • d- High parity will lead to osteomalacia

45. II-Dietary factors • a-Deficient intake of Vitamin D or calcium • b- Presence of phytic acid and oxalates in diet preventing calcium absorption. • c- Artificially fed babies.

46. III- Social Factors • a-Poverty • b-Ignorance of mothers about proper feeding and rearing of children • c-Cultural factors as wrapping infants and preventing exposure to sunshine, and early marriages of girls who are still in need of dietary calcium. • d-Living in squatter areas.

47. III- Environmental factors • a-Amount of sunshine and ultraviolet rays (UVRs). • In cloudy and dusty atmosphere the UVRs are absorbed . • b- High prevalence in Rural areas due to ignorance, poverty and unhealthful social habits

49. Iron deficiency anemia (IDA) • Iron deficiency is the most wide spread nutritional disorder, affecting both developed & developing countries. The main clinical manifestations are: • pale conjunctivae, • spoon shaped nails and • atrophic lingual papillae. • Easy fatigability • Hematological tests will confirm the diagnosis.

50. Hemoglobin levels in anemia