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Major nutritional problems in vulnerable groups

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Vulnerable groups: …

Vulnerable groups:
-Infancy
-Pre-school age group
-Adolescence
-Pregnancy
Infancy- problems in weaning: obesity, underweight, refusal of food intake, food allergy, lactose intolerance, feeding problem: underfeeding, diarrhoea, constipation, colic, some inborn metabolism error.
PRESCHOOL AGE GROUP: PEM, Vitamin-A deficiency, INCREASED SUSCEPTIBILITY TO INFECTION, Anaemia.
Adolescence: Obesity, eating disorders,under nutrition, adolescent pregnancy, anaemia, malnutrition due to early marriage.
PREGNANCY & LACTATION: General dietary problems, complications.
OLD AGE: osteoporosis, obesity, anaemia, malnutrition, constipation.

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  1. MAJOR NUTRITIONAL PROBLEMS IN VULNERABLE GROUPS Presented By: Supta Sarkar HHM/2013/010 M.Sc FN, 1st Yr.
  2. SEE INSIDE….. Introduction Infancy Pre-school age group Adolescence Pregnancy & lactation Old age Conclusion
  3. Introduction • Vulnerable groups: -Infancy -Pre-school age group -Adolescence -Pregnancy -Lactation -Old age
  4. Infancy  Infancy is the first year of life. - 0-6months: Exclusive breast feeding -6-12months: Weaning food is provided  In this period the capacity of the stomach of the infant & the ability to digest various components changes rapidly.
  5. PROBLEMS IN WEANING 1.OBESITY  Many infants are overfed by over zealous parents who mistake acceptance of food for appetite.  Too early & too much quantity of feeding or too concentrated food can lead to over weight of the infant.  Commercially available processed foods when overfed may lead to obesity.
  6. 2.UNDERWEIGHT: • Too less quantity of food & less concentrated foods can lead to underweight. • Bulky adult food, when consumed by an infant gives satiety without meeting calorie requirement.
  7. 3.REFUSAL TO TAKE NEW FOOD:  The form of the food can be modified or should be mixed with the food he likes & should be tried again after a week or so.  Frequently a child may spit out the first spoon of food but usually this means that he doesn't know how to swallow the non-liquid food.
  8. 4.FOOD ALLERGY: • Food sensitive enteropathis occur principally during first six months of life & mostly limited to early childhood. • Predisposing factors may be malnutrition, infection & genetic background. • Increased gut permeability, low level of secretory IgA & enzymatic immaturity put the infant at higher risk for allergy. • The foods most frequently in infant allergies are wheat, milk, egg & citrus juices.
  9. • Rice is probably the most hypoallergenic of the commonly eaten cereals. • The consumption of wheat is best delayed until after the 6th month. • Egg white, which is a potent sensitizer is usually deferred until the 10th month. • Egg yolk is less allergenic & heat denaturation renders egg yolks non reactive. • The pure orange juice doesnot arouse allergic reactions in infants or children. Improperly prepared orange juice may contain excessive amounts of peel oil or of seed proteins which have leached into the juice from broken seeds and may therefore cause reactions in susceptible children.
  10.  Allergy to milk is the most serious of the commonly encountered food allergies since milk supplies the basic nutritional requirements in early infancy.  In most cases the allergic reaction is due to the presence of lactoglobulins & to some extent lactoalbumin. The infant can be fed evaporated milk in which these proteins are denatured.  Artificial flavours & colours have been associated with respiratory allergic disorder.  In most cases, food protein allergy is transitory. Tolerance is achieved in 50% by the end of first year & 80% after 3years.
  11. LACTOSE INTOLERANCE • Lactose intolerance is the inability to digest lactose, the sugar primarily found in milk and dairy products. • It is caused by a shortage in the body of lactase, an enzyme produced by the small intestine, which is needed to digest lactose. • While lactose intolerance is not dangerous, its symptoms can be distressing. • Change from a cow's milk formula to a soy milk formula until the symptoms disappear. • Milk and dairy products may be slowly reintroduced at a later time.
  12. There is a lot of confusion between the terms milk allergy and milk or lactose intolerance:  Milk allergy is when the baby's immune system reacts to proteins in milk. It is the most common childhood allergy, affecting between 2% and 7% of babies. Babies who have eczema are more likely to suffer from it.  Lactose intolerance is when your baby has difficulty digesting the lactose, or the sugar, found in milk. This is much rarer than milk allergy
  13. FEEDING PROBLEMS 1. UNDERFEEDING:  It is suggested by restlessness & crying & by failure to gain weight adequately despite complete emptying of the breast or bottle.  It can also result from failure to take sufficient quantity of food even when offered.  Constipation, failure to sleep, irritability & excess crying can result due to underfeeding.
  14. 2.DIARRHOEA:  It is unusual in breast fed infants  It can generally cause due to overfeeding  Mild diarrhoeal disturbances can lead to temporary decrease or cessation of feeding.  Withholding all solid foods as well as one or several milk feedings & substituting boiled water or a balanced electrolyte solution is required.
  15. 3.CONSTIPATION: • May be caused by insufficient amount of food or fluid • It may also result from diet too high in fat or protein or deficient in bulk • Increasing the amount of fluid or sugar in the formula may be corrective in the first few months of life. • After this age, better results are obtained by adding or increasing the amounts of cereals, vegetables & fruits.
  16. 4.COLIC: • A frequent symptom complex of paroxysmal abdominal pain, presumably of intestinal origin & of severe crying • Occurs usually in infants younger than 3months • Prevention should be sought by improving feeding techniques, including burping, providing a stable emotional environment, identifying allergenic foods in the infant’s or nursing mother’s diet & avoiding under or overfeeding.
  17. Some inborn metabolic errors: 1.Glutaric aciduria type 1 Glutaric acidemia type 1 (or "Glutaric Aciduria", "GA1", or "GAT1") is an inherited disorder in which the body is unable to break down completely the amino acids: lysine, and tryptophan. Excessive levels of their intermediate breakdown products (glutaric acid, glutaryl-CoA, 3-hydroxyglutaric acid, glutaconic acid) can accumulate and cause damage to the brain and also other organs. Mental retardation may also occur.
  18. 2.Hypermethioninemia  Hypermethioninemia is an excess of a particular protein building block (amino acid), called methionine, in the blood.  This condition can occur when methionine is not broken down or metabolized properly in the body.  Infants with hypermethioninemia often do not show any symptoms.  Some individuals with hypermethioninemia exhibit intellectual disability and other neurological problems; delays in motor skills such as standing or walking; sluggishness; muscle weakness; liver problems; unusual facial features; and their breath, sweat, or urine may have a smell resembling boiled cabbage.  It can also result from liver disease or excessive dietary intake of methionine from consuming large amounts of protein or a methionineenriched infant formula.
  19. Pre-school age group The years between 1 to 6 is known as pre-school age. There is an increased need for all nutrients.
  20. The peak prevalence : kwashiorkor in 2-3 years & marasmus in 1-2 years.   C.Gopalan, in 1971 did systematic diet survey & brought out the ‘theory of adaptation’  Child reacts to the stress of PEM & secretes cortisol which mobilises protein from muscle & subcutaneous tissue  Marasmus is said to be well adapted to the stress of deficit in protein & calories
  21. • In Dysadaptation the child will ultimately land up in kwashiorkor as adrenal is unable to release cortisol. • The prevalence rate of severe degree of PEM in our community is 3-5%. • For every 3 to 5 cases of PEM, we can detect 80-90 cases of mild to moderate PEM. • Systematic study of the habitual diets of these children indicated that the concentration of protein in their diets was adequate, but they were suffering from energy or food inadequacy. • The average energy deficit was found to be 300kcal/day.
  22. The following are the causes for underweight for age which may precipitate into PEM:  Poverty  The starchy gruels resulting in ‘dietary bulk with a low caloric density’.  Abrupt weaning, late weaning, ignorance of importance of weaning  Less consumption of food.  Chronic infections may result in anorexia  Infestation like ascariasis particularly giardiasis may lead to anorexia.
  23. SYMPTOMS OF DIFFERENT TYPES OF PEM 1.KWASHIORKOR: • ‘Moon faced’ • Oedema of the face & lower limbs • Failure to thrive • Anorexia • Diarrhoea • Apathy • Dermatosis • Flaky paint appearance • Sparse, soft & thin hair • Angular stomatitis • Cheilosis • anaemia
  24. 2.MARASMUS  ‘Monkey faced’  Failure to thrive  Weight is less than 80% of ideal weight for age  Diarrhoea is frequent with acid stools  There is little or no subcutaneous fat  Frequent dehydration  Temperature is subnormal
  25. 3.MARASMASIC KWASHIORKOR: These children exhibit a mixture of some of the features of both marasmus & kwashiorkor 4.NUTRITIONAL DWARFING: Weight & height are both reduced resembling a child of 1 year or more younger 5.UNDERWEIGHT CHILD: Reduced weight for height. These chilren grow up smaller than their genetic potential
  26. Classification features of different types of PEM: Classifications Body weight as % of standard Oedema Deficit in weight for height kwashiorkor 80 - 60 + + Marasmic kwashiorkor < 60 + + + Marasmus < 60 0 + + Nutritional dwarfing < 60 0 Minimal Underweight child 80 - 60 0 + TABLE: CLASSIFIACTION OF PEM (FAO/WHO)
  27. According to United Nations Report 2007: 46% of children under the age of five suffer from undernutrition. As many as 35% of the world’s undernourished children live in India. I. Under the age of 5yrs 54 46 II. World's undernourished children Undernutrition Proper nutrition 35 India 65 Other countries
  28. According to NFHS-1 (1992-93) and the NFHS-2(1998-99) obtained information on child anthropometry:  Child underweight rates vary from a low of 24-28% in the Northeastern states and Kerala to 51-55% in the states of Bihar, Rajasthan, Uttar Pradesh, Madhya Pradesh and Orissa  Likewise, the decline in child underweight rates over time has also varied greatly across states.  In Punjab, for instance, the child underweight rate fell at an annual rate of 7.6% between 1992-93 and 1998-99, while Rajasthan saw an increase of 2% per annum in the child underweight rate during the same period.
  29. Trends in Child Nutritional Status Percent of children age under 3 years NFHS-3 NFHS-2 51 45 43 20 Stunted (Low height for age) 40 23 Wasted (Low weight for height) Source: NFHS-3, India, 2005-06 Underweight (Low weight for age)
  30. Source: NFHS-3, India, 2005-06
  31. VITAMIN-A DEFICIENCY: A. XEROPHTHALMIA: The WHO recommends the following: 1.Night blindness (XN): • The speed with which the eye recovers its full powers after exposure to bright light is directly related to the amount of vitamin A that is available to form RHODOPSIN • The recovery process is known as dark adaptation. • When vit A is deficient the formation of rhodopsin is impaired giving rise to night blindness. • Night blindness is an early symptom of vit A deficiency • It responds well to treatment • It is a usefull screening tool & correlates closely with other evidence of vit A deficiency.
  32. CAUSES: • The major cause is roughage which include few animal sources of pre-formed vitamin A. In addition to dietary problems, there are other causes of vitamin A deficiency. Irondeficiency can affect vitamin A uptake. Excess alcohol consumption can deplete vitamin A, and a stressed liver may be more susceptible to vitamin A toxicity. People who consume large amounts of alcohol should seek medical advice before taking vitamin A supplements. In general, people should also seek medical advice before taking vitamin A supplements if they have any condition associated with fat malabsorption such as pancreatitis, cystic fibrosis, tropical sprue & biliary obstruction.
  33. Prevalence of vitamin A deficiency Source: WHO
  34. 2.CONJUNCTIVAL XEROSIS (XIA)  It manifests dry patches of nonwettable conjunctiva  It may b associated with various degrees of thickening, wrinkling & pigmentation of the conjunctiva  The pigmentation(muddy colouring) gives a smoky appearance
  35.  It is more an extension of the xerotic process  These spots are raised, muddy & dry triangular patches.  Bitot’s spot are not easily diagnosable  In older children or young adults the lesions may be due to physical factors like exposure to excess sunlight or dust.
  36. 6 Time trends of Vitamin A deficiency (bitot’s spots) among pre-school children by States at different time points: 5.6 5 4.2 4 1985-87 1998-99 2007-08 3 2.3 2 1.9 1.8 1.7 1.4 1 1 0.4 0.2 0.4 0.9 0.6 0.4 0.1 0.2 1.2 0.9 0.1 0 Ker TN Kar AP Mah 00 MP 0.1 0.1 Ori 0.4 WB
  37. PREVALENCE OF CLINICAL SIGNS OF VITAMIN-A DEFICIENCY:
  38.  When dryness spreads to the cornea there is a dull hazy lack lustre appearance.  This is due to keratinisation which is the result of vit A deficiency on all epithelial surfaces.  The characteristic feature is a loss of substance (erosion) of a part or the whole of the corneal thickness.  If there is secondary infection there is inflammation.  The lesion only heals by scarring. If properly managed the corneal changes usually heal leaving useful vision. Corneal xerosis may progress suddenly & rapidly to keratomalacia.  
  39. 5.KERATOMALACIA (X3B) Softening & dissolution of the cornea occurs If not treated, perforation of the cornea leads to prolapse of the iris, extrusion of the lens & infection of the whole eyeball which almost invariably occurs. Healing results in scarring of the whole eye & frequently in total blindness.
  40. Sign % Prevalence Night blindness (XN) >1.0 Bitot’s Spot (X1B) >0.5 Corneal Xerosis (X2, X3A & X3B) >0.01 Corneal scar (XS) >0.05 Serum retinol level less than 10ug/dl >5.0
  41. Indian Scenario:  Survey on pre-school children by the National Nutrition Monitoring Bureau (2007) found that they did not get sufficient amount of nutrients such as vitamin, folic acid, iron & calcium. Aspects Prevalence % Low birth weight 30 Kwashiorkor/Marasmus 1-2 Bitot’s spot 3 Iron deficiency anaemia 50 Underweight (weight for age) 53 Stunting (height for age) 65 Source: Dietary guidelines for Indians, 1999, NIN, ICMR, Hyderabad
  42. Indian scenario: In India NNMB & ICDS indicate that prevalence of bitot’s spots in pre-school children (1-5yrs) ranges between 1-5% in different parts of the country. The corneal xeropthalmia has been reported to be 0.05-0.1 per 100 pre-school children in South India. It is estimated that over 50,000 children become blind every year in India due to vit A deficiency.
  43. O NNMB survey: 0.04% of blindness in India is due to vit A deficiency which can be prevented. O NIN study(2003-04): prevalence of night blindness was 0.3% & Bitot’s spot was 0.8% among preschool children. O The prevalence of bitot spot was >0.5%,a cut off level recommended by WHO to indicate public health significance, in all the states except kerala & Orissa.
  44. B. INCREASED SUSCEPTIBILITY TO INFECTION: O The action of cilia of the epithelial cells is involved in protecting the body against infection by sweeping the cell surfaces clear of invading microorganisms. O In Vit A deficient keratinised cells, the cilia are lost & the body is more vulnerable to infection
  45. ANAEMIA
  46. Anaemia among Children Age 6-35 Months Percent 90 80 74 79 70 60 50 40 30 20 4 10 5 0 Any anaemia NFHS-2 Severe anaemia NFHS-3
  47. Anaemia Is Widespread throughout India Children age 6-59 months Anaemia Prevalence Anaemia prevalence more than 70 percent Anaemia prevalence Less than 50 percent State Bihar Madhya Pradesh Uttar Pradesh Haryana Chhattisgarh Andhra Pradesh Karnataka Jharkhand Goa Manipur Mizoram Kerala DATA SOURCE: Table 9.13 (NFHS-3 Chapter)
  48. Children in All Groups Have High Anaemia Prevalence Percent of children with any anaemia • Urban (63%) • Wealthiest households (56%) • Children whose mother’s have 12+ years of education (55%) • Girls (69%), boys (70%)
  49. ADOLESCENCE • According to WHO, individuals between 10-19 years are considered as adolescents. • The period of transition from childhood to adulthood is called adolescence. • During this phase, a child is going through many changes in his/her body- changes occur in hormones, height, weight, skin, etc. • The growth velocity is maximum for girls between 10-13yrs whereas for boys at 12-15yrs. The growth spurt of boys is
  50.  The child often observes the physical changes & makes amendments in his/her eating habits without appropriate guidance.
  51. • But the caloric needs increase with the metabolic demands of growth & energy expenditure. • The protein intake generally meets growth needs for pubertal changes in both sexes & for developing muscle mass in boys.
  52. • Calcium requirement increase dramatically from about the age of 11yrs which is known as prepubertal growth spurt. A lack of calcium can lead to many problems like permanent bone deformity or disease of bones like osteoporosis.
  53.  Iron is important for growth, brain development & the immune system, however it is commonly deficient in adolescents.  Teenage girls in particular are affected by poor iron status due to increased iron losses during menstruation that are not replaced through the diet which can lead to iron deficiency anaemia.
  54. NUTRITIONAL PROBLEM:
  55. 1.OBESITY • At this age group peer pressure is very high, the need to be in step with the trends & belong to the peer group leads the adolescents to eat non-nutitious foods like pizza, burger, aerated drinks, chocolates & other roasted junk foods.
  56. • Also the children are exposed to high calorie, high fat foods that are readily available & heavily advertised on TV, radio, magazines, news paper, etc. • Moreover, the lifestyle, the type of activities & sports preferred at the present age which involves more of TV, computer, & other gadgets have reduced the activity level of the adolescents which is also an adding reason to the obesity.
  57. 2.EATING DISORDERS  Awareness about one’s body & its appearance becomes the top priority. Generally adolescent girls perceived their diet in the light of appearance & body shape while boys are more concerned about fitness.  Anorexia nervosa, an eating disorder is more common among young girls which include forced starvation to remain thin.  Whereas, bulimia nervosa is over eating. It is also an eating disorder which includes eating large meal but without gaining weight  And binge eating disorder is a disorder when one is eating to escape from emotions. It is generally characterised by frequent binge eating or eating when not happy.
  58. 3.UNDER NUTRITION • Under nutrition in terms of stunting & thinness, catch-up growth, & intrauterine growth retardation in pregnant adolescent girls is one major problem worldwide. • Under nutrition during adolescence, confounded by childhood marriages leads to higher mortality & morbidity among women & young children, thus perpetuating the vicious cycle of under nutrition.
  59. 4. Adolescent pregnancy Pregnancy at an early age has an adverse effect on both mother & child. The mother are at high risk for complications such as premature labor, maternal mortality, etc whereas the child is also at higher risk for LBW & low immunity.
  60. 5. ANAEMIA  It is common in teens because they undergo rapid growth spurts when the body has a greater need for nutrients like iron due to increased iron losses during menstruation.
  61. 6. MALNUTRITION DUE TO EARLY MARRIAGE: Child growth failure Low weight & height in teens Low birth weight baby Small adult women Fig: Early marriage & consequent early pregnancy is detrimental to the health of the mother & the baby
  62. Pregnancy & Lactation • A woman who has been well nourished before conception begins her pregnancy with reserves of several nutrients so that the needs of the growing foetus can be met without effecting her health. • The effects of undernutrition during reproduction will vary depending upon the nutrients involved, the length of time it is lacking & the stage of gestation at which it occurs. • Mother’s diet should produce adequate nutrients so that maternal stores do not get depleted & produce sufficient milk to nourish her child after birth. • The nutritional demands are highly increased in an adolescent mother.
  63. PREGNANCY: GENERAL DIETARY PROBLEMS: 1.Nausea & Vomiting: 2.Heart burn 3.Beliefs, avoidances, cravings & aversions 4.Weight gain during pregnancy
  64. COMPLICATIONS: 1.ANAEMIA: • According to WHO/UNICEF/UNO,1998, a pregnant woman is anaemic if the haemoglobin level is below 11.0g/dl or haematocrit per cent is below 33%. • Factors implicated in etiopathogenesis of anaemia during pregnancy & LBW are: maternal age, weight, height, parity, literacy, income, infection s, pregnancy related complications, nutritional stress, cultural beliefs, taboos & inappropriate food practice. • Too little space between births or too many infections & too little intake of nutrients involved in erythropoiesis during pregnancy leads to anaemia.
  65. • Severe anaemia in pregnant woman increases maternal morbidity & mortality & involves a higher risk of the foetus • A significant fall in birth weight due to increase in prematurity rate & intrauterine growth retardation has been reported to occur when maternal haemoglobin level falls below 8g/dl. • Diet should include iron & folic acid rich foods. • Regular consumption of iron rich foods such as GLVs, cereals such as wheat, ragi, jowar & bajra,pulses & jaggery.in addition meats & organ food can also be a good source. • Vit C which promotes absorption of iron must be promoted.
  66. Prevalence of anaemia among pregnant women in India. More than 85% are anaemic with different degrees Prevalence 13.1 0 12.5 33.6 Normal 40.8 Haemogl obin g/dl Mild Normal > = 11 Moderate Mild 9-11 Severe Moderate 7-9 Severe <7
  67. Anaemia Prevalence among Pregnant Women: NFHS-3, India, 2005-2006 70 59 60 50 40 31 30 26 20 10 2 0 Mild Moderate Severe Any anaemia
  68.  The pressure of the enlarging uterus on the lower portion of the intestine, in addition to the hormonal muscle relaxant effect of placental hormones on the gastrointestinal tract.  Increased fluid & use of natural laxative foods.  Regular exercise & sleep are also essential.
  69.  Mild, physiological oedema is usually present in the extremeties in the third trimester.  It is caused by the pressure of the enlarging uterus on the veins returning fluid from the legs.  Although this normal oedema requires no sodium restriction or other dietary changes.
  70. 4.PREGNANCY INDUCED HYPERTENSION (TOXAEMIA)  Severe pregnancy induced hypertension (eclampsia) are associated with higher incidence of vitamin A & protein deficiencies resulting in poor pregnancy outcome.  Symptoms include: hypertension, abnormal & excessive oedema, albuminuria, convulsions or coma.  Adequate salt & sources of vitamins & minerals are needed for correction & maintenance of metabolic balance.  PIH is seen in 10-20% of all pregnant women in India.
  71. 5.DIABETES MELLITUS Also known as gestational diabetes. Glycosuria is common because of increased circulating blood volume & its load of metabolites.
  72. LACTATION Nutritional requirement during this period is maximum as compared to any other age group in a woman’s life.
  73. MAJOR NUTRITIONAL PROBLEM: 1. Weight loss: If the mother loses weight rapidly while breast-feeding, her calorie intake is to be increased. 2.Obesity: When the baby is weaned, the mother must reduce her food intake in order to avoid obesity. 3.Inadequate lactation: 4.Anaemia: 5.Calcium deficiency:
  74. NUTRITIONAL RISK: A lactating woman is likely to be at nutritional risk if: • She is under 17yrs of age • She is economically deprived • Her usual diet is nutritionally restrictive or includes unsound nutrition practices • She is on a modified diet for chronic systemic diseases • Her weight is less than 85% of ideal weight • She has multiple gestation • She has had poor weight gain during pregnancy • She has had rapid weight loss while breast feeding • She is pregnant while breast feeding • She has a history of an eating disorder.
  75. Old age • Old age is best defined as the age of retirement that is 60years & above. • In India, the elderly constitute about 7% of the total population & by 2016,the number is likely to increase to 10%. • The number of old people is expected to cross 177
  76. 1. Osteoporosis  Bones are at their thickest and strongest in early adult life and are constantly renewed and repaired through a process called bone turnover. However, as age increases this process is no longer balanced and bone loss increases.  Women are at greater risk of developing osteoporosis than men. This is because changes in hormone levels can affect bone density. The female hormone oestrogen is essential for healthy bones. After the menopause, the level of oestrogen in the body falls, and this can lead to a rapid decrease in bone density.
  77. 2. Obesity • It is generally caused because their consumption of calories has not decreased though there is steady decrease in calorie requirement • Sedentary life style may also be an contributing factor • Obese are more susceptible to diabetes & mortality rate may be higher.
  78. 3. Anaemia  It is a common result of inadequate iron  Characterised by feelings of fatigue, anxiety, lack of energy & sleeplessness  Pernicious anaemia is seen chiefly in middle ages & elderly persons (women aged between 45-65)  Plasma vitamin B12 is below 160ng/dl while plasma folate is normal  Hydroxy cobalamin should be given in a dosage of 1,000mcg.
  79. 4. Malnutrition • The important cause: cumulative effects of chronic diseases necessitating multiple medications • NIN (2000) studies: the average daily intake of majority of nutrients bearing calcium, iron, vitamin A, thiamin, riboflavin & vitamin C were below the recommended levels as evidenced by low levels of consumption of protective foods. • NIN (2004): the prevalence of Chronic Energy Deficiency is significantly higher among the elderly than their adult counterpart.
  80.  Reduced elasticity of intestinal wall muscles affecting peristaltic movement, fewer meals, low fluid & fibre intake & depression can result in constipation.  The natural contractions or rhythms of the colon might be disturbed due to loss of tone, stress, medication, illness, resisting the urge to defecate, pain from haemorrhoids or tissues, lack of exercise, a low fibre diet or not drinking enough fluids.
  81. Conclusion

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