Moderate malnutrition contributes more to the overall disease burden than severe, as it affects many more children, even if the risk of death is lower (8). But existing prevention programmes are imperfect, especially in poorest countries or in countries undergoing an emergency crisis, and moderate plus severe malnutrition (as underweight) persists at around 25%, only falling slowly. According to recent National Family Health Survey (1.6) and UNICEF Reports (1.7), 46% of preschool children and 30% of adults in India suffer from moderate and severe grades of protein-calorie malnutrition as judged by anthropometric indicators. Currently, India is in nutrition transition with 10% rural adults and 20% urban adults suffering from overnutrition leading to an emerging double burden of malnutrition (1.8). The first step in this potential transformation came with development of new therapeutic diets. Previously, high-energy milk products had been used, even when appetite was good enough for the child to take non-liquid foods. Ready-to-use therapeutic foods (RUTF) were developed as an alternative, in the form of energy-dense pastes or biscuits containing no water so they do not support bacterial growth (which is a major drawback of milk-based liquid diets). These were shown to be efficacious in obtaining rapid weight gain (14, 15), and furthermore can be used in the community. Addition of adapted mineral and vitamin supplement to the local diet seems also to increase the efficacy of programmes based on the use of locally available nutrient rich foods, but this approach requires further research to determine its effectiveness (17)
MALNUTRITION Dr. Sunil Pal Singh.C
MALNUTRITION1.Magnitude of malnutrition2. Dimensions of malnutrition3. Measurements of malnutrition4. Prevention and control.
MALNUTRITIONIs defined as a pathological state resulting from an absolute or relative deficiency or excess of one or more essential nutrients.
MAGNITUDE OF PROBLEMIndia – one fifth population (230 million people ) is undernourished, (The State of Food Insecurity in the World, FAO, 2008)Global Hunger Index - India ranks 94th out of 119countries. (2/3rd of this score is attributable to its high child malnutrition rate)Change in the state of food and nutrition insecurity in India was main cause of rise in number of hungry persons in South Asia (FAO, 2004).
MAGNITUDE OF PROBLEM- CONTD. NFHS-3 Survey :56% women are Anemic 30% are low birth weight (LBW) babies47% children are underweight.
CAUSES OF DEATHS AMONG <5 YEAR CHILDREN IN DEVELOPING COUNTRIES Malaria * 8% Measles *Others 5% 29% Diarrhoea * 12% Malnutrition* * Approximately 60% 70% of all childhood deaths are associated Pneumonia * with one or more 20% of these fivePerinatal conditions 22% HIV/AIDS 4% Source: WHO 2002; Lancet-2003
Female unwanted Dies child DiesMalnourishedmother Poor Girl child malnourished Nutrition Mother child Dies loss Under developed adolescents
Agro-climatic factors Demographic factors Socio-economic Disasters factors• Food production • Population Drought/Floods • Religion Wars• Land Ownership • Family Size • Community• Type of land • Urbanisation • Occupation • Income• Rain fall• Geographic conditions Availability of &• Agricultural techniques Physiological participation in• Use of hybrid seeds factors developmental• Use of fertilizers • Pregnancy programmes • Lactation • PDS • Breast feeding • Rural Dev. Prog.Socio-cultural practices • Employmentfactors • Infant & child generation prog. Feeding practices• Illiteracy• Ignorance• Taboos Pathological Conditions • Infections • Diarrhoeas Environmental factors • Resp. Infections • Malaria • Environmental sanitation • Others • Personal hygiene • Infestations • Safe drinking water • Hook worms • Round worms • Giardiasis etc.,
NUTRITIONAL PROBLEMS1.Undernutrition:Macro-nutr. : Low birth weight (LBW) Protein energy malnutrition (PEM) Chronic Energy Deficiency (CED)Micro-nutr. : Vitamin A deficiency (VAD) Iron deficiency anemia (IDA) Iodine deficiency disorder (IDD) etc.2.Overnutrition: Overweight and Obesity Diet related chronic diseases Fluorosis etc.
3. IMBALANCE Imbalance can result if energy potential of fat in diet exceed 30% of total input, that of saturated fatty acids exceeds 10% or that of carbohydrates falls below 50%.
1.NUTRITIONAL ANTHROPOMETRY Height Mid Upper Arm Circumferences Head Circumferences, Chest Circumferences, Waist Circumferences and Hip Circumference Fat fold thickness at …Triceps, Biceps, Supra-Iliac, Infra-scapular regions
NUTRITIONAL ANTHROPOMETRYWeight : - Body mass - Simple, widely used - Sensitive to changes over short durationHeight : - Genetically Determined - Environmentally influenced - Reflects long duration undernutritionMUAC : - Reflects muscle/fat - Easy to measure - Independent of age (<5 years)FFT: - Measures body fat - Correlates well with total body fat - Equipment is expensive
FORMULA FOR AVERAGE WEIGHT.WEIGHT KGBIRTH 33-12 MONTHS AGE(MONTH) + 9 21-6 YEARS [AGE(YEAR) X 2] + 87-12 YEARS [AGE(YEARS) X 7] - 5 2
FORMULA FOR AVERAGE HEIGHTHEIGHT CMBIRTH 503 MONTHS 606 MONTHS 661 YEAR 752-12 YEARS [AGE(YEARS) X 6] + 77
WHO CLASSIFICATION OF MALNUTRITIONAcute and chronic malnutrition W/A H/A W/H Interpretation Decreased Normal Decreased Acute malnutrition Decreased Decreased normal Chronic malnutrition Decreased Decreased Decreased Acute-on-chronic malnutritionModerate and severe undernutrition: Feature Moderate Severe Oedema No Yes Weight-for-height(wasting) <70% 70-79% Height-for-age(stunting) 85-89% <85%
THE IAP CLASSIFICATION OFMALNUTRITION Nutritional status* Weight for age(% of expected) NORMAL >80 Grade I PEM 71-80 Grade II PEM 61-70 Grade III PEM 51-60 Grade IV PEM <50
CLASSIFICATION ACCORDING TO HEIGHT FOR AGE Height for age Waterlow’s Mclaren’s Vishweshwara rao’s(% of expected) classification classification classification Normal >95 >93 >90 First degree 90-95 80-93 80-90 Stunting/short* Second degree 85-90 - - Stunting Third degree <85 <80 <80 Stunting/dwarf**Terminology used in Mc Laren’s classification
CLINICAL SIGNS OF MALNUTRITIONHAIR: Lack of lustre, thinness and sparseness,and flag sign.Face: diffuse depigmentation, nasolabial dyssebacia.moon face.Eyes: pale conjunctiva, bitots spots,corneal xerosis., conjunctival xerosis.
Lips: angular stomatitis, angular scars, cheilosis.Tongue: scarlet and raw tongue, atrophic papillae.Teeth: mottled enamel.
TYPES OF DIET SURVEYS Food balance sheets Family diet survey Individual diet survey Food frequency Institutional diet surveys
WEIGHMENT DIET SURVEY (Households)The method involves weighing of edible portion of raw ingredients before cooking of food. Duration of the survey could be for one, three or 7 consecutive days.
24 HRS RECALL METHOD (OR) ORALQUESTIONNAIRE (OR) INDIVIDUAL DIETSURVEYThe raw equivalents of different foods consumed byan individual is computed as follows: Raw quantity of a givenfood stuff in the preparation Volume of cooked XTotal volume of food cooked Food consumed
INSTITUTIONAL LEVEL DIET SURVEY (Hostels, Industrial Canteens, Jails and Orphanages)The raw ingredients, total cooked foods and individualplate servings are weighed. Individual intake of foods &nutrients are computed.Merits : Better accuracyLimitation : Time consuming
Institutional level Diet Survey (Hostels, Industrial Canteens, Jails and Orphanages)Food stock registers are verified for a week.The average intake/caput/day= (stocks at the beginningof week - stocks at the end of week) / Total number ofinmates partaking x 7 days.
ENVIRONMENTAL FACTORS• Environmental sanitation - Solid & Liquid waste disposal - Availability & Usage of sanitary Latrines• Personal hygiene - Preparation of food, - Storage and handling of food• Safe drinking water - Access, distance of source from house - Water handling practices at home
Socio-cultural factors• Illiteracy : Total, Male, Female,• Ignorance : Knowledge, Attitude Practice• Taboos : Beliefs, Customs• Peer groups : Elders in the family
AGRO-CLIMATIC FACTORS• Food production : Type, Yield• Land Ownership : Extent of land owned• Type of land : Wet, Dry, Semi arid• Rain fall : Adequacy, scanty, delay• Geographic conditions : Desert, Hilly, Coastal• Agricultural techniques : Modern, primitive• Use of hybrid seeds• Use of fertilizers
PREVENTION AND CONTROLAGRICULTURE MEASURES: Agrarian reforms, Foodproduction, Agricultural policy.PUBLIC HEALTH MEASURES:Populationstablisation,Nutrition supplement,Health andNutrition education, primary health care.SOCIO-ECONOMIC MEASURES:POVERTYalleviation,Female emamcipation,socio-economicdevelopment.
COMMUNITY NUTRITIONALPROGRAMMES.Programmes Year MinistryVITAMIN A PROPHYLAXIS PROGRAM 1970 Health and Family WelfarePROPHYLAXIS AGAINST NUTRITOINAL 4th Five Health and Family Welfare ANAEMIA year planCONTROL OF IODINE DEFICIENCY 1962 Health and Family Welfare DISORDERSCONTROL PROGRAMMESPECIAL NUTRITIONAL PROGRAM 1970 Social WelfareBALWADI NUTRITIONAL PROGRAM 1970 Social WelfareICDS PROGRAM 1975 Social WelfareMID-DAY MEAL PROGRAM. 1961 EducationMID –DAY MEAL SCHEME 1995 Human Resources Revised Development 2004
ReferencesPark’s Textbook of Preventive and Social Medicine – 20th Edition.Foundations of community medicine-GM DHAAR,I ROBBANI -2nd edition.J.KISHORE’S National health programs of India -9th edition.GHAI Essential pediatrics-6th edition.Nutrition and child development-KE ELIZABETH 4th edition.http://www.who.int/childgrowth/training/en/