1. BHARTI
MPH

2. CONTENTS
 INTRODUCTION
 DEFINITION OF PEM
 TYPES OF MALNUTRITION
 INCIDENCE OF PEM
 CAUSES OF PEM
 NUTRITIONAL DEFICIENCY DISEASES
 CLASSIFICATION OF PEM
 EFFECTS OF MALNUTRITION
 CHILD MALNUTRITION IN INDIA

3. INTRODUCTION
 Protein energy malnutrition (PEM) – Major
health and nutrition problem in India .
 Occurs particularly in weaklings and
children in the first years of life.
 Not only an important cause of childhood
morbidity and mortality , but leads to
permanent impairment of physical and
mental growth.

4. DEFINITION OF PEM
 Bad nutrition
 As a state in which a prolonged lack of one or
more nutrients retards physical development or
causes the appearance of specific clinical
conditions such as anaemia,goitre etc.
 As ‘a pathological state resulting from a relative
or absolute deficiency or excess of one or more
essential nutrients.’

5. TYPES OF MALNUTRITION
 Undernutrition -insufficient food is eaten
 Overnutrition -consumption of excessive
quantity of food .
 Imbalance -disproportion among essential
nutrients .
 Specific deficiency -relative or absolute
lack of nutrients.

6. World Health Report 2003.

7. DIFFERENCE BETWEEN OVER
AND UNDER NUTRITION
 Overnutrition is encountered much more
frequently than under nutrition .
 The health hazards from over nutrition are
a high incidence of obesity, diabetes,
hypertension, cardiovascular and renal
diseases.

8. PERCENTAGE OF CHILDREN
AFFECTED BY MALNUTRITION
COUNTRY STUNTING ,1980-90
(AGES 24-59 MONTHS)
WASTING,1980-90
(AGES12-23 MONTHS)
INDIA 65 27
CHINA 41 8
NEPAL 69 14
BANGLADESH 65 14
SRI LANKA 27 13
PAKISTAN 50 9

9. INCIDENCE OF PEM
India is one of the countries with highest proportion
of malnourished children in the world along with
Bangladesh, Nepal .
IN INDIA –
 Preschool age children – 1-2%
 Great majority of PEM are the
‘intermediates’ ones -80%
(i.e. the mild and moderate cases which
frequently go unrecognized)

10. CAUSES OF PEM
 An inadequate intake of food both in
quantity and quality.
 Infections notably diarrhea, respiratory
infections , measles and intestinal worms-
1. Increase requirements of calories, protein
and other nutrients.
2. While decrease their absorption and
utilization.

11. Conceptual Framework for the
Causes of Malnutrition in Society

12. NUTRITIONAL DEFICIENCY
DISEASES
1. Kwashiorkor,
2. Marasmus
3. Xerophthalmia,
4. Nutritional anaemias and
5. Endemic goiter.
(Iceberg’ of malnutrition: a much larger
population are affected by hidden
malnutrition which is not easy to
diagnose. )

13. CLASSIFICATION OF PEM
Classified according to severity, course and
the relative contributions of energy or
protein deficit
 WEIGHT FOR AGE CLASSIFICATIONS
 HEIGHT FOR AGE CLASSIFICATIONS
 WEIGHT FOR HEIGHT CLASSIFICATION

14. CONT-
(1) Weight for age classifications- Gomez’z
 Weight of more than 90 percent of expected for
that age (50th centile) as normal.
 Weights for age between 76-90% grade- l
 Weights for age between 61-75% grade -ll
 Less than or equal to 60 % are classified as
grade -III malnutrition respectively .

15. (2) Height for age classification :
 Children with less than 80% height of
expected for age as dwarf.
 Those with a height of between 80 to
93 % are classified as short and
 more than 93 % of height is seen in
normal children.

16. (3) Weight for height classification -acute or
chronic based on anthropometry.
 In acute malnutrition weight is primarily
affected .
 A proportionate reduction in weight and
height points towards a chronic courses
 A greater and disproportionate reduction
in height indicates acute on chronic PEM.

17. EFFECTS OF
MALNUTRITION
It is of two type :
(1) Direct and
(2) Indirect
Direct- the occurrence of frank and subclinical
nutrition deficiency diseases such as
 Kwashiorkor
 Marasmus
 Vitamin and mineral deficiency diseases etc.

18. Indirect- High morbidity and mortality among
young children,
 Retarded physical and mental growth and
development ,
 Lowered vitality of the people leading to lowered
productivity and reduced life expectancy .
 The high rate of maternal mortality ,
 Stillbirth and slow birth –weight are all associated
with malnutrition.

19. CHILD MALNUTRITION IN
INDIA
 World’s malnourished children-40%
 Low birth weight infants -35%
(developing world)
 Every year children die in India-2.5 million
(accounting for one in five deaths in the world)

20. CONT-
1. More than half of all preschoolers, and 75 %
suffer from iron deficiency anemia.
2. Maternal mortality in India is one of the highest
in the world, with 540 deaths per 100,000 live
births .
3. 83 % of women in India suffer from iron –
deficiency anemia, compared with 40% in Sub –
Saharan Africa.
4. Acc to GHI India ranked 117th
out of 119
countries on child malnutrition.

21. NUTRITIONAL STATUS
 In 1997 – about 170 million children under
five years of age i.e. 30% of the world’s
children are malnourished .
 It is recognized that 56%of the deaths in
under five children , in developing countries
are attributed to malnutrition .
 In India 47%of all children below 3 years of
age are undernourished.

22. ACCELERATING PROGRESS IN
REDUCING CHILD MALNUTRITION IN
INDIA
 Integrated child development services
(ICDS)
 Public Distribution System (PDS)
 The Mid –Day Meals Program
 Community public works programs
 The National Old age Pension program
 Annapurna program

23. STRATEGIC CHOICES FOR
IMPROVED CHILD NUTRITION
 SHORT-TERM STRATEGY:
1. Nutrition and health programs and policies
2. Effectively address the main nutrition
problems.
3. Combined efforts with action.
4. Strong monitoring and evaluation.
5. Research can identify gaps .

24. 5. Additional research.
6.Focused on states, districts,& communities
7. Increase attention to girls and women
health.
 LONG TERM STRATEGY :
1. Policymakers should work on economic
growth & poverty reduction policy.
2. Strong partnership b/w National agencies.

25.  Prime Minister Manmohan Singh stated, “The
problem of malnutrition is a matter of national
shame.... I appeal to the nation to resolve and
work hard to eradicate malnutrition in five years.”
This concept note focuses on international
research and policy experiences in reducing child
malnutrition and outlines how to move forward in
close cooperation with the country’s policymakers
and its nutrition community

26. REFERENCES
 Park k .Park’s text book of preventive and social medicine 17th
edn. Jabalpur:banarsidas bhanot publishers;2003.p 435
 Ghai op ,Gupta p Essential preventive medicine,1st
edn.
Jangpura , Delhi: Vikas publishing house pvt Ltd; 1999.p.142
 National Family Health Survey II, Key Findings, International
Institute of Population Sciences. Mumbai, India: IIPS Press;
l998. Vol 99. p. 17-8.
 Gopujkar PV, Chaudhari SN, Ramaswami MA, Gore MS,
Goplan C. Infant Feeding Practices with special reference to
the use of Commercial Infant Foods. Nutrition Foundation of
India, Scientific Report No.4. New Delhi: Ratna Offset; 1984.
p. 115.