2. Malnutrition
Malnutrition is a health problem especially in
children under 5 years of age.
Globally, there are 15 percent of world's
population, who are having problem of
malnutrition according to FAO reports.
It is a problem created by man occurring in human
societies.
3. definition
Malnutrition is a health problem occurring due to
relative or absolute deficiency or excess of
nutrients in human body and causing pathological
changes.
In other words, malnutrition can be defined as the
condition due to absence, deficiency or excess of
one or more essential nutrients.
4. Types of problem of malnutrition
Malnutrition is of four types :
Under nutrition
Over nutrition
Disproportional nutrients causing imbalance
Specific nutrient deficiency.
11. Food habits
Food habits are passed from generation to generation
because of culture.
These food habits are deeply entrenched in the culture.
The food habits of Southern states of India are different
from northern states.
Even religion plays an important role n developing food
habits such as Hindus do not eat beef and Muslims do not
eat pork.
12. Food Taboos
Food taboos also play an important role
in developing malnutrition.
Food taboos prevent people from
consuming certain foods such as
orthodox Hindus do not eat onion, Garlic
etc.
13. Personal choice for food
Personal likes & dislikes for foods,
preference for one particular type of food is
also the factor causing malnutrition.
Customs,
Beliefs,
Culture,
Attitude etc.
14. Cooking practices
Cooking practices such as :
Throwing the water in which the rice or pulses were soaked.
Peeling the vegetables such as peeling of cucumber, apple etc.
Cutting the vegetables into smaller pieces & cooking for a longer
time.
Throwing away the part of fruit or vegetables having nutritive value
such as throwing of leaves of radish.
15. Women's status
In some communities or some part of India
especially in rural Communities, women do not get
the same status as men.
They are advised to eat at last the left out food.
This affects the health by developing malnutrition
among girl children & women.
16. Lack of knowledge
The people lack knowledge
regarding the nutritive value of
foods due to which they are
unable to take appropriate
nutrition
17. Poverty
Poverty loses the purchasing power
of the individual, due to which an
individual is unable to eat food
which is required to maintain the
health.
18. Poor sanitary environment
Poor sanitary environment
causes disease to occur more
frequently, thereby
contributing to malnutrition.
19. Assessment
Various techniques are used to assess the
nutritional status of people.
These techniques will help in making
decisions to improve the nutrition. These
assessment methods are clinical examination,
anthropometry and biochemical etc.
20. Clinical Examination
Clinical examination is practical method to determine the
nutritional status.
In this method, various signs & symptoms associated with
undernutrition, over nutrition are assessed.
In case of undernutrition, the signs & symptoms related to
deficiency of proteins, vitamins & minerals are assessed as each
deficiency has its own clinical manifestations while in over
nutrition, the signs & symptoms occurring due to increased amount
of protein, mineral & vitamins causing toxicity are assessed.
21. Clinical examination
WHO Expert Committee has classified signs into
three categories in nutritional surveys
i.e. signs which are not related to nutrition
(alopecia, pyorrhoea), signs which need further
investigation (malar pigmentation) & the signs
which are of value (calf tenderness, absence of
knee jerks, enlargement of thyroid gland, Bitot's
spot).
22. Anthropometry
Anthropometric measurements are valuable measurements to
determine the nutritional status.
The parameters used are weight, height, skin fold thickness arm
circumference, head and chest circumference to assess nutritional
status.
These measurements are measured with reference standards and are
compared by using three methods
Mean or median
Weight for height and weight/height.
23. Mean or median
Median is used to assess growth and development and a
variation of +2 standard deviation is considered as within
normal limits.
__2.S.D _ +2.S.D _______
Median value
_______________________
Normal Limits
24. Weight for height
It helps in assessing whether the child is within normal
range.
An expected weight is there for height which is taken as
reference for comparison.
Reference value has been complied by WHO which guides
in assessing the weight according to height A child who is
less than 70% of expected weight for height is considered
as severely malnourished.
25. PARAMETERS USED TO ASSESS NUTRITIONAL
STATUS
Weight measurement is one of the parameter to assess physical
growth in children.
It should be measured at intervals till 5 years of age as this age
group is at risk from growth deviation due to nutrition
inadequacy.
Jelliffe has given 80 percent of median weight per age of the
reference as cut off point.
Below this cut off point, the children should be considered
malnourished.
26. INTERVAL OF CHECKING WEIGHT
Year
/Weight
From birth to 1 year 13 months to 2
years
25th month till
5 years
Weight
recording
Monthly Every two months Every 3 month
Weight
increment
0-3 4-6 7-9 10-12
200 150 100 50-75
G G G G
Per Per Per Per
Week week week week
2.5 kg in year 2.0 kg per year
27. Height for age
Height of an individual / child should be
compared with reference standard.
It should increase according to age.
Low height for age is known as nutritional stunting
which reflects the past malnutrition.
The cut off point is 90 percent of height for age
values.
28. Head & chest circumference
Head and chest circumference at birth has
shown that the head circumference is 2cm
more than chest circumference.
Within 6 to 9 months these become equal
and then afterwards chest circumference is
more than head circumference.
29. INCREASE IN HEIGHT BY AGE
At birth During 1st year During 2nd year
50 cm Increases by 25 cm Increases by 12 cm
30. HEAD CIRCUMFERENCE
Note : Measure head circumference above eyebrows and at
most prominent part of the occipital region.
At birth 6 months One year 2nd year 2- 6 years
34-35 cm 42-43 cm 46-47 cm Increases by
2cm
Increases by
2cm
31. Chest circumference
circumference Ratio
Chest head > 1
Note : If it is <1, it means chest has failed to
develop.
Measured in mid respiration on sitting posture at
level of nipples.
32. Mid arm circumference
Mid arm circumference is
measured of upper arm which
gives muscle mass &
subcutaneous tissue information.
33. Mid arm circumference
Note - * It is measured with arm hanging on side.
*It is measured between elbow and shoulder
At birth At end of 1 year From 1 year to 5 years At end of 5 year
10 Cms 16 cms 0.15 cm per year 16.75- 17 cms
34. CLASSIFICATION OF UPPER MID ARM
CIRCUMFERENCES
Circumference Normal Under developed Malnourished
Mid –upper
arm
circumference
14- 16.5 cms 13.5 to 12.5 cms < 12.5 cms
35. Biochemical Tests
Biochemical tests are required to assess the concentration of
nutrients in body fluid. These tests detect the presence of abnormal
amount of metabolites and measure the enzymes.
These biochemical tests are:
Prothrombin time
Serum folate
Serum retinol
Leucocyte ascorbic acid
36. Assess the dietary intake
Assessing the dietary intake provides the information on the food
consumption.
This can be done either by weighing the food which is cooked &
consumed and by asking the type of food with quantity eaten for the
previous 24 or 48 hours.
Then the nutritive value of the food is calculated, by which it can be
assessed that how many calories, proteins, vitamins, minerals, fats &
carbohydrate are consumed.
So, this assessment provides the information that whether the intake
is adequate or not.
37. Morbidity & mortality data
The nutritional status of population can be
assessed by morbidity & mortality in relation
to deficiency of protein & CHO ( Carbon,
hydrogen and oxygen ) (Protein, energy
malnutrition, anaemia, measles & vitamin
deficiencies.)
38. Types of Malnutrition
Protein Energy Malnutrition
It is a major public health nutritional problem and
is the most common among 1 year of life.
Protein energy malnutrition is of two types
Kwashiorkor
Marasmus
40. Clinical features
The clinical manifestation of Kwashiorkor are
Irritability.
Oedema in lower leg & usually in face & lower arms.
Poor appetite.
Sparse, silky, easily pulled out hairs.
Hepatic enlargement due to accumulation of fat.
41. Marasmus
This is a condition caused by
decreased intake of total calories.
A deficiency of total calories is
called marasmus and is often
accompanied by Kwashiorkor.
42. Clinical manifestations
Loss of subcutaneous fat
Muscle wasting present
Weight for height is low
Often have diarrhoea
Quiet & apathetic.
43. Assessment of PEM
Growth chart:-
Protein energy malnutrition can be detected by assessing the weight
for age.
If the weight for age is under the reference standard, it means the
child is losing the weight.
Health workers are maintaining growth chart for children and while
looking at this maintained growth chart, malnutrition can be
assessed.
44. Comparison of weight of child with the weight of
normal child of same age
This is based on Gomez classification.
According to this classification
Weight for age = Weight of child / Weight of
normal child of same age *100
This is measured in percentage.
45. Comparison of weight of child with the weight of normal child of
same age
By this, on the basis of percentage malnutrition is calculated as given in table.
Degree /
Percentage
90-110% 75-89% 60-74% Under 60%
Degree of
malnutrition
Normal 1st degree 2 nd Degree 3rd Degree
Severity Normal Mild Moderate Severe
46. Comparison of height of child with height of normal child at
same age
It is done to assess the development in relation to height.
It is calculated by the given formula
Height / age % = Height of child / Height of normal child of same age * 100
Nutritional status according to % Height / age
Ratio Normal Mild Moderate Severe
Height/ age > 95 87.5-95 80-87.5 < 80
47. WEIGHT /HEIGHT
It is also measured in percentage and is
calculated through the formula.
weight/Height % =Weight of child /
Weight of a normal child of same height
*100
48. NUTRITIONAL STATUS ACCORDING TO
WEIGHT / HEIGHT
Ratio Normal Mild Moderate Severe
Weight / Height > 90 80-90 70-80 < 70
49. Micronutrient malnutrition
Diseases caused by deficiency of vitamins &
mineral.
The person should take a well-balanced diet which
contains all the vitamins & minerals along with
protein, fats & carbohydrates.
In the absence of these, the individual can suffer
from a variety of diseases.
50. Deficiency of vitamin A cause disease
Bitot's spots
Conjuctival xerosis
Corneal xerosis
Keratomalacia
Night blindness
52. Vitamin E deficiency causes
No clear indication of dietary deficiency disease.
The role of vitamin E at the molecular level is little
understood.
Cytotoxic effect of vitamin E on human lymphocytes in
vitro at high concentration has been reported.
So mega dose of vitamin E should be used cautiously.
58. DEFICIENCY OF FOLATE
Its deficiency results in ;
Megaloblastic anaemia
Glossitis
Cheilosis
Gastro intestinal disturbances such as
diarrhoea, distention & flatulence
59. Deficiency of vitamin B12
Deficiency of vitamin B12 is associated with :
Pernicious anaemia
Demyelinating neurological leisons.
Infertility
60. Deficiency of vitamin C
Deficiency of vitamin C results in
scurvy which has signs of swollen and
bleeding gums, subcutaneous bruising or
bleeding into skin or joints, delayed
wound healing, anaemia & weakness.
61. Diseases Caused by Deficiency of
Minerals : -
Deficiency of calcium
No clear cut disease due to deficiency of calcium
has ever been observed but it has been established
that if the intake of vitamin D is adequate, the
problems of rickets and osteomalacia do not rise
with even low calcium intake.
62. Deficiency of phosphorous
Phosphorus plays an
important role in all
metabolisms.
Its deficiency rarely occurs.
64. Deficiency of magnesium
The principal clinical features of magnesium
deficiency are :-
Tetany
Irritability
Hyper reflexia
65. Deficiency of Iron
Deficiency of iron causes the health
problems such as –
Anaemia
Reduced resistance to infection.
Impaired cell mediated immunity
69. Other trace elements deficiency
Other trace elements deficiency such as
deficiency of zinc, copper, cobalt etc.
causes health problems such as
deficiency of copper causes neutropenia.
70. Prevention and Control of Malnutrition (A)
Undernutrition
Identification of affected individuals :-
A survey should be carried out in the community to identify the
affected individuals through clinical examination and body
measurements.
The survey will provide the data about the nutritional status of the
community.
This survey should be continued so as to plan the strategies to
reduce the number of affected people & to control & prevent the
malnutrition.
71. Special feeding programmes
The affected individuals should be rehabilitated by
focusing on special feeding programmes.
Disaster relief agencies should provide special feeding
programme in which about 400-600 kcal/person/day
should be provided
The children suffering from severe PEM may be
admitted to hospital & less severly cases treated through
special nutrition rehabilitation programmes.
72. Health education
Health education is one of the way to improve the
nutritional status of community by creating
awareness about the type of foods to be eaten &
the to calorie intakes according to energy needs of
body.
Informing & motivating the general public about
the importance of micronutrients.
73. Health education
Promotion of breast feeding and
improvement in infant and child feeding
practices
Improving the purchasing power of people.
Educating the selection of right kind of
food.
74. Health education
Correction of harmful taboos and dietary
prejudices.
Decreasing the infectious diseases by appropriate
measures.
Kitchen gardening.
Proper planning of budget with expenditure on
food.
75. Over nutrition
Due to over nutrition , obesity results.
Increased intake of energy giving food leads to prolonged
post-prandial hyperlipidemia.
Due to this, triglycerides in adipose tissue are deposited.
This results in obesity.
So obesity is defined as abnormal deposition of adipose
tissue.
The obesity is found in relation to body mass index.
76. Obesity
Obesity is a form of malnutrition which is
prevalent in developed & developing
countries.
It is a risk factor for chronic, non
communicable diseases such as hypertension,
coronary artery disease, diabetes mellitus.
77. Risk factors
Obesity is caused by multiple
factors.
The associated risk factors are :
Over eating
Physical inactivity
79. Assessment of obesity
Obesity assessment is based on
following criteria.
Body weight
Skin fold thickness
Waist circumference & waist hip ratio
80. Body weight
The indicators used for assessment of obesity are :
Body Mass Index : It is defined as the ratio of
weight in kg to square of height in metre.
The formula used is
B.M.I. = Weight (kg) /Height2(m)
81. Broca Index
Broca index is used to assess the
ideal weight, through which it can be
calculated that the individual is over
weighed or not.
Broca Index = Height in cm -100
82. Corpulence Index
It is the ratio of Actual weight to
desirable weight and it should not
exceed 1.2.
Corpulence Index = Actual
weight /Desirable weight
83. Skin fold thickness
Harpenden skin callipers are used to measure the
mid-triceps, biceps, subscapular and suprailiac
region.
For boys, the sum of these measurements should
be 40mm & for girls it should be 50mm.
Waist hip ratio : It should not be more than 1.0 in
men and 0.85 in women.
84. Prevention And Control of Over nutrition
Identification of people having obesity.
Creating awareness among public regarding dietary
habits.
Regular physical exercise.
Surgical treatment.
Health education.
Food intake according to energy requirement
85. BIBLIOGRAPHY
Neelam Kumari A Textbook of Community Health Nursing - I
,2011 Edition , Published by Pee Vee ( Regd .), Page reffered to
565- 574.
https://www.slideshare.net/saurabhsingh1153/malnutrition-
236674839
https://www.slideshare.net/LamiaaGamal/malnutrition-47406428
https://www.slideshare.net/amjadkhanafridi4all/malnutrition-
61554629