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MAJOR NUTRITIONAL PROBLEMS
IN VULNERABLE GROUPS
Presented By:
Supta Sarkar
HHM/2013/010
M.Sc FN, 1st Yr.
 Introduction
 Infancy
 Pre-school age group
 Adolescence
 Pregnancy & lactation
 Old age
 Conclusion
SEE INSIDE…..
• Vulnerable groups:
-Infancy
-Pre-school age group
-Adolescence
-Pregnancy
-Lactation
-Old age
Introduction
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.
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.
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.
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.
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.
• 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.
 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.
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.
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
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.
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.
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.
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.
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.
Some inborn metabolic errors:
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 methionine-enriched infant formula.
Pre-school age group
The years between 1 to 6 is known as
pre-school age.
There is an increased need for all
nutrients.
 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
• 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.
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.
• ‘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
SYMPTOMS OF DIFFERENT TYPES OF PEM
1.KWASHIORKOR:
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
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
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)
 46% of children under the age of five suffer from under-
nutrition.
 As many as 35% of the world’s undernourished children
live in India.
According to United Nations Report 2007:
46
54
I. Under the age of 5yrs
Under-
nutrition
Proper
nutrition
35
65
II. World's undernourished
children
India
Other
countries
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.
Source: NFHS-3, India, 2005-06
Trends in Child Nutritional Status
40
23
45 43
20
51
Underweight
Wasted
Stunted
NFHS-3 NFHS-2
Percent of children age under 3 years
(Low height
for age)
(Low weight
for height)
(Low weight
for age)
Source: NFHS-3, India, 2005-06
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.
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.
Prevalence of vitamin A deficiency
Source: WHO
 It manifests dry patches of non-
wettable conjunctiva
 It may b associated with various
degrees of thickening, wrinkling
& pigmentation of the
conjunctiva
 The pigmentation(muddy
colouring) gives a smoky
appearance
2.CONJUNCTIVAL XEROSIS (XIA)
 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.
0.4
5.6
1.4
0.2
4.2
0
1.9
2.3
0.2
1.7
0.4
0.6
1.8
0 0.1
0.9
1
0.4
0.1
0.9
0.1
1.2
0.1
0.4
0
1
2
3
4
5
6
Ker TN Kar AP Mah MP Ori WB
1985-87
1998-99
2007-08
Time trends of Vitamin A deficiency (bitot’s spots)
among pre-school children by States at different time
points:
PREVALENCE OF CLINICAL SIGNS OF
VITAMIN-A DEFICIENCY:
 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.
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.
5.KERATOMALACIA (X3B)
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
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
 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.
Indian scenario:
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.
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
ANAEMIA
74
79
4 5
0
10
20
30
40
50
60
70
80
90
Any anaemia Severe anaemia
NFHS-2 NFHS-3
Anaemia among Children Age 6-35
Months
Percent
Anaemia Prevalence State
Anaemia prevalence
more than 70 percent
Bihar
Madhya Pradesh
Uttar Pradesh
Haryana
Chhattisgarh
Andhra Pradesh
Karnataka
Jharkhand
Anaemia prevalence
Less than 50 percent
Goa
Manipur
Mizoram
Kerala
Anaemia Is Widespread
throughout India
Children age 6-59 months
DATA SOURCE: Table 9.13 (NFHS-3 Chapter)
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%)
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
 The child often observes the physical changes &
makes amendments in his/her eating habits
without appropriate guidance.
• 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.
• Calcium requirement increase dramatically from
about the age of 11yrs which is known as pre-
pubertal growth spurt. A lack of calcium can lead
to many problems like permanent bone
deformity or disease of bones like osteoporosis.
 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.
NUTRITIONAL PROBLEM:
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.
• Also the children are
exposed to high calorie,
high fat foods that are
readily available & heavily
advertised on TV, radio,
magazines, newspaper,
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.
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.
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.
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.
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.
6. MALNUTRITION DUE TO EARLY MARRIAGE:
Child growth
failure
Low weight &
height in
teens
Small adult
women
Low birth
weight baby
Fig: Early marriage & consequent early pregnancy is detrimental to
the health of the mother & the baby
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.
PREGNANCY:
GENERAL DIETARY PROBLEMS:
1.Nausea & Vomiting:
2.Heart burn
3.Beliefs, avoidances, cravings &
aversions
4.Weight gain during pregnancy
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, infections, 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.
• 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.
12.5
40.8
33.6
13.1
Prevalence
Normal
Mild
Moderate
Severe
Prevalence of anaemia among pregnant women in
India.
More than 85% are anaemic with different degrees
Haemogl
obin
g/dl
Normal > = 11
Mild 9-11
Moderate 7-9
Severe < 7
26
31
2
59
0
10
20
30
40
50
60
70
Mild Moderate Severe Any anaemia
NFHS-3, India, 2005-2006
Anaemia Prevalence among Pregnant
Women:
 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.
 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.
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.
 Also known as
gestational
diabetes.
 Glycosuria is
common
because of
increased
circulating blood
volume & its load
of metabolites.
5.DIABETES MELLITUS
Nutritional requirement
during this period is
maximum as compared
to any other age group
in a woman’s life.
LACTATION
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:
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.
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
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.
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.
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.
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.
 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.
Conclusion
Nutritional Problems in Vulnerable Groups: Infancy, Pre-School, Adolescence

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Nutritional Problems in Vulnerable Groups: Infancy, Pre-School, Adolescence

  • 1. MAJOR NUTRITIONAL PROBLEMS IN VULNERABLE GROUPS Presented By: Supta Sarkar HHM/2013/010 M.Sc FN, 1st Yr.
  • 2.  Introduction  Infancy  Pre-school age group  Adolescence  Pregnancy & lactation  Old age  Conclusion SEE INSIDE…..
  • 3. • Vulnerable groups: -Infancy -Pre-school age group -Adolescence -Pregnancy -Lactation -Old age Introduction
  • 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. 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. Some inborn metabolic errors:
  • 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 methionine-enriched 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. • ‘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 SYMPTOMS OF DIFFERENT TYPES OF PEM 1.KWASHIORKOR:
  • 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.  46% of children under the age of five suffer from under- nutrition.  As many as 35% of the world’s undernourished children live in India. According to United Nations Report 2007: 46 54 I. Under the age of 5yrs Under- nutrition Proper nutrition 35 65 II. World's undernourished children India 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.
  • 30.
  • 31. Source: NFHS-3, India, 2005-06 Trends in Child Nutritional Status 40 23 45 43 20 51 Underweight Wasted Stunted NFHS-3 NFHS-2 Percent of children age under 3 years (Low height for age) (Low weight for height) (Low weight for age)
  • 33. 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.
  • 34. 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.
  • 35. Prevalence of vitamin A deficiency Source: WHO
  • 36.  It manifests dry patches of non- wettable conjunctiva  It may b associated with various degrees of thickening, wrinkling & pigmentation of the conjunctiva  The pigmentation(muddy colouring) gives a smoky appearance 2.CONJUNCTIVAL XEROSIS (XIA)
  • 37.  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.
  • 38. 0.4 5.6 1.4 0.2 4.2 0 1.9 2.3 0.2 1.7 0.4 0.6 1.8 0 0.1 0.9 1 0.4 0.1 0.9 0.1 1.2 0.1 0.4 0 1 2 3 4 5 6 Ker TN Kar AP Mah MP Ori WB 1985-87 1998-99 2007-08 Time trends of Vitamin A deficiency (bitot’s spots) among pre-school children by States at different time points:
  • 39. PREVALENCE OF CLINICAL SIGNS OF VITAMIN-A DEFICIENCY:
  • 40.
  • 41.  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.
  • 42. 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. 5.KERATOMALACIA (X3B)
  • 43. 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
  • 44. 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
  • 45.  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. Indian scenario:
  • 46. 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.
  • 47. 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
  • 49. 74 79 4 5 0 10 20 30 40 50 60 70 80 90 Any anaemia Severe anaemia NFHS-2 NFHS-3 Anaemia among Children Age 6-35 Months Percent
  • 50. Anaemia Prevalence State Anaemia prevalence more than 70 percent Bihar Madhya Pradesh Uttar Pradesh Haryana Chhattisgarh Andhra Pradesh Karnataka Jharkhand Anaemia prevalence Less than 50 percent Goa Manipur Mizoram Kerala Anaemia Is Widespread throughout India Children age 6-59 months DATA SOURCE: Table 9.13 (NFHS-3 Chapter)
  • 51. 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%)
  • 52. 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
  • 53.  The child often observes the physical changes & makes amendments in his/her eating habits without appropriate guidance.
  • 54. • 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.
  • 55. • Calcium requirement increase dramatically from about the age of 11yrs which is known as pre- pubertal growth spurt. A lack of calcium can lead to many problems like permanent bone deformity or disease of bones like osteoporosis.
  • 56.  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.
  • 58. 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.
  • 59. • Also the children are exposed to high calorie, high fat foods that are readily available & heavily advertised on TV, radio, magazines, newspaper, 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.
  • 60. 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.
  • 61. 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.
  • 62. 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.
  • 63. 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.
  • 64. 6. MALNUTRITION DUE TO EARLY MARRIAGE: Child growth failure Low weight & height in teens Small adult women Low birth weight baby Fig: Early marriage & consequent early pregnancy is detrimental to the health of the mother & the baby
  • 65. 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.
  • 66. PREGNANCY: GENERAL DIETARY PROBLEMS: 1.Nausea & Vomiting: 2.Heart burn 3.Beliefs, avoidances, cravings & aversions 4.Weight gain during pregnancy
  • 67. 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, infections, 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.
  • 68. • 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.
  • 69. 12.5 40.8 33.6 13.1 Prevalence Normal Mild Moderate Severe Prevalence of anaemia among pregnant women in India. More than 85% are anaemic with different degrees Haemogl obin g/dl Normal > = 11 Mild 9-11 Moderate 7-9 Severe < 7
  • 70. 26 31 2 59 0 10 20 30 40 50 60 70 Mild Moderate Severe Any anaemia NFHS-3, India, 2005-2006 Anaemia Prevalence among Pregnant Women:
  • 71.  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.
  • 72.  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.
  • 73. 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.
  • 74.  Also known as gestational diabetes.  Glycosuria is common because of increased circulating blood volume & its load of metabolites. 5.DIABETES MELLITUS
  • 75. Nutritional requirement during this period is maximum as compared to any other age group in a woman’s life. LACTATION
  • 76. 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:
  • 77. 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.
  • 78. 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
  • 79. 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.
  • 80. 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.
  • 81. 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.
  • 82. 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.
  • 83.  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.