Malnutrition refers to deficiencies or excesses of nutrients that can harm health. It can involve undernutrition from lack of protein, calories and micronutrients or overnutrition from excessive calorie intake. Children, pregnant women, and girls are most vulnerable to malnutrition's effects. Malnutrition's immediate causes are inadequate diet and disease, which interact to increase the risks of each. Its underlying causes include insufficient household food access, care, and sanitation. Malnutrition's basic societal causes include poverty, women's status, economic systems, and social policies. Rates remain high in South Asia and Sub-Saharan Africa. Protein-energy malnutrition (PEM) specifically involves inadequate protein and calorie intake and can manifest as marasm

1. 1
MALNUTRITION

2. Malnutrition
• A pathological state resulting from a relative or absolute
deficiency or excess of one or more essential nutrients,
• Refer to syndrome of inadequate/excess intakes of protein,
energy & micronutrients, combined with frequent infections,
resulting in poor growth & body size.
• It is an imbalance between dietary intake & body demand
2

3. Malnutrition Cont...
People are malnourished if their diet does not provide adequate
calories and protein for growth and maintenance or they are
unable to fully utilize the food they eat due to illness
(undernutrition).
They are also malnourished if they consume too many calories
(over nutrition).
3

4. Malnutrition Cont...
• Malnutrition commonly affects all groups in a community, but infants and
young children are the most vulnerable because of their high nutritional
requirements for growth and development.
• Another group of concern is pregnant women, given that a malnourished
mother is at high risk of giving birth to a LBW baby who will be prone to
growth failure during infancy and early childhood, and be at increased risk
of morbidity and early death.
• Malnourished girls, in particular, at risk of becoming yet another
malnourished mother, thus contributing to the intergenerational cycle of
malnutrition
4

5. Malnutrition Cont...
Epidemiology
• Malnutrition remains the world’s most serious health problem :Single biggest
contributor to child mortality
• WHO estimates that malnutrition contributes to 54% of child mortality world wide
(Lancet 2005)
• South Asia and Sub Saharan Africa are the most affected
•27% of children under age five are stunted & 23% are underweight in developing
countries.
•In Africa, about 24% of children are underweight & 35% are stunted
•Comparable figures for the developed world are 2.6% &1.1% for stunting &
underweight respectively 5

6. Malnutrition Cont...
6

7. Malnutrition Cont...
Trend and prevalence of malnutrition in Ethiopia (2005-
2019)
7

8. Malnutrition Cont...
0
10
20
30
40
50
60
51.4 50.2
52
41.4
33
48.6
44.1
27.3
29.8
22
36.3
44.4
Stunting rates across Regional States, EDHS 2011

9. Malnutrition…
Epidemiology…
•Malnutrition doesn’t need to be severe to pose threat to survival.
•Worldwide, more than 80% of deaths involve only mild or moderate
malnutrition.
•More than 2 billion people in the world today are estimated to be
deficient in key vitamins and minerals, particularly vitamin A, iodine,
iron and zinc
•Micronutrient deficiencies affect more than 30% of the developing
world’s population 9

10. Malnutrition…
Causes of Malnutrition
• Malnutrition, is not a simple problem with a single, simple
solution
• Multiple and interrelated determinants are involved in why
malnutrition develops, and a similarly complex series
approaches, multifaceted and multisectoral, are needed to
deal with it
10

11. Malnutrition…
Causes…
• Causes could be categorized as:
• Immediate causes
• Underlying causes, and
• Basic causes
11

12. Malnutrition…
Causes…
Immediate causes
• The immediate causes of malnutrition are an inadequate diet and disease.
• The interplay between the two most significant immediate causes of
malnutrition - inadequate dietary intake and illness - tends to create a vicious
circle:
• Children who enter the malnutrition-infection cycle can quickly fall into a
potentially fatal spiral as one condition feeds off the other
• A malnourished child, whose resistance to illness is poor, falls ill and becomes
more malnourished, which reduces his or her capacity to fight against illness
and so on. this creates a vicious cycle of infection and malnutrition. 12

13. Malnutrition…
Causes…
Immediate causes…
• Malnutrition lowers the body’s immune-response mechanisms
which leads to longer, more severe and more frequent episodes of
illness
• Infections cause loss of appetite, malabsorption and metabolic
and behavioral changes.
• These, in turn, increase the body’s requirements for nutrients,
which further affects young children’s eating patterns.
13

14. Appetite loss
Nutrient loss
Malabsorption
Altered
metabolism
Weight loss
Growth faltering
Lowered immunity
Mucosal damage
Inadequate
dietary intake
Disease:
- Incidence
- duration
- severity
Spiral of Malnutrition and Infection
The Malnutrition
Infection Cycle
Malnutrition…
14

15. Malnutrition…
Causes…
B. Underlying causes
Three clusters of underlying causes lead to inadequate dietary
intake and infectious disease:
I. inadequate household food security
II. inadequate care and health services and
III.Unhealthy house hold environment
• For an individual to be adequately nourished all the three needs to be addressed
15

16. Malnutrition…
Causes…
C. Basic causes
• It is often said that poverty at the family level is the principal cause of
child malnutrition
• Political, and cultural factors at the national and regional levels may
defeat the best efforts of households to attain good nutrition for all
members the degree to which the rights of women and girls are protected
by law and custom;
• the political and economic system that determines how income and assets
are distributed; and
• the ideologies and policies that govern the social sectors
16

17. Causes of Malnutrition
17
Malnutrition
Disability, Death
Inadequate
Food Intake
Disease
Public Health
Poor
water,sanitation
& inadequate
health services
Immediat
e Causes
Underlyin
g
Causes:H
H or
family
level
Basic Causes at
societal level
Quality & quantity of actual resources-human,
economic & organizational-and the way they
are controlled.
Potential resources: environment, technology,
people
Household Food
Security:
insufficient
access to food
Social Care and
Environment
Inadequate
MCH care
practices
Source: state of the world’s children 1998

18. Malnutrition Cont...
Forms of Malnutrition
 Over nutrition
• Excess intake of macronutrients
• Overweight/obesity
• NCDs
• Excess intake of micronutrients
• Toxicity.
18

19. Malnutrition Cont...
Forms of Malnutrition…
Under nutrition
• Inadequate intake of macronutrients
• PEM
• Inadequate intake of micronutrients
• Hidden Problèm
• VAD, IDA, IDD, ZiD, etc
• MNDs are the world’s most prevalent and most devastating
nutritional problems.
19

20. Malnutrition Cont...
Types of undernutrition:
• Acute malnutrition (wasting and bilateral pitting oedema)
• Stunting
• Underweight (combined measurement of stunting and wasting)
• Micronutrient deficiencies
20

21. Malnutrition Cont...
21

22. Protein Energy Malnutrition (PEM)
PEM is a clinical syndrome mainly due to deficiency of
macronutrients (protein and energy)
 It is manifested primarily by inadequate dietary intakes of protein
and energy, either less dietary intakes of these two nutrients than
required or the needs for growth are greater than supply.
 It is almost always accompanied by deficiencies of other nutrients.
 It is the result of poor in both quality and quantity of dietary intake.
22

23. PEM cont...
Causes of PEM
• Causes of protein energy malnutrition are multi-factorial
having a number of interwoven factors operating
simultaneously.
• The causes could be categorized as
immediate,
underlying and
basic. 23

24. PEM cont...
Causes of PEM…
24

25. PEM cont...
 Factors Associated With PEM
• ANC and PNC
• Low birth spacing
• Feeding practice
• Urban and rural distribution
• Gender
• Infection and environment
• Literacy
• Socio economic status
25

26. PEM cont...
Diagnosis of PEM
The diagnosis of PEM rests mainly on meticulous clinical
examination for the symptoms and signs of the syndrome plus
anthropometric assessments using different methods.
Additionally one may need laboratory investigation for the
assessment of complications and other health problems
associated with malnutrition.
Epidemiological considerations also contribute to the diagnosis
of malnutrition.
27

27. PEM cont...
A.Clinical diagnosis (S/S, P/E)
• The first sign of all forms of PEM is GROWTH FAILURE,
involving decline in wt & ht measurements.
• The severest clinical forms of PEM are Marasmus, kwashiorkor and
features of both called Marasmic-kwashiorkor.
• Usually deficiencies of micronutrients like riboflavin, vitamin A,
Iron and Vitamin D are also seen among the victims. 28

28. PEM cont...
Marasmus
• Marasmus, the more common syndrome, is characterized clinically by
depletion of subcutaneous fat stores, muscle wasting, and absence of
edema.
• It results from the body’s physiologic adaptation to starvation in response
to severe deprivation of calories and all nutrients.
• Most commonly occurs in children younger than 5 years because of their
increased caloric requirements and increased susceptibility to infections
29

29. PEM cont...
Marasmus…
•Is a progressive wasting of the body, occurring chiefly in young
children & associated with insufficient intake OR Malabsorption
of nutrients.
•Marasmic children have retarded growth with specific clinical
manifestations
•Marasmus is common in children <12 months of age
30

30. PEM…
•There is a failure to thrive
•Wasting of subcutaneous fats and muscle
•mood change( always irritable),
•Mild skin & hair changes
•Weight is much below the standard for age
•Temperature may be subnormal.
•Wizened monkey (old man face)
•Increased appetite
•Sunken eye ball
•Because of thinness of the abdominal
wall, peristalsis may be easily visible
•The muscles are weak & atrophic
• Drastic loss of adipose tissues
• Chronic diarrhea
• Prominent of ribs
31
Sign and symptoms

31. PEM cont...
32

32. PEM cont...
Kwashiorkor
 Kwashiorkor: disease when child is displaced from breast (Cicely
Williams, 1935, Gold Coast, W Africa)
 Is a child hood disorder caused by lack of nutrients including protein in
the diet.
 Kwashiorkor is prevalent in children age groups of 1-3 yrs
 Growth failure with wasting of muscles and preservation of
subcutaneous fat and pitting type edema
33

33. PEM cont...
Signs & symptoms of kwashiorkor
• Growth failure
• Wasting of muscle,
• preservation of subcutaneous fat
• Edema (pitting type)
• Loss of appetite
• Looks apathy & miserable
• Hair & skin color change
•Straightening of hair at the bottom &
curling on the top giving impression of
forest (forest sign) & easily pluck able hair.
•Psychomotor retardation(difficulty of
walking)
•Moon face (hanging cheeks) due to edema
•Diarrhea, vomiting, Organomegaly
•Serum protein, amylase is reduced
34

34. PEM…
35

35. PEM cont...
Marasmic_Kwash
Combines clinical feature of both kwashiorkor and
marasmus.
Muscle wasting and decreased subcutaneous fat .
When edema subsides, the patient appearance resembles
that of marasmus.
Weight for age ˂ 60% and edema.
36

36. PEM cont...
37

37. PEM cont...
B. Anthropometric assessments
• Anthropometry is the study and technique of human body measurement.
• It is used to measure and monitor the nutritional status of an individual
or population group.
• Various classifications are given
1. Gomez classification
2. Welcomes classification
3. Waterlow’s classification
4. NCHS (WHO) classification
5. MUAC
38

38. PEM cont...
39

39. PEM cont...
• The disadvantages of this classification are: -
• The cut off point 90% may be too high as many
well-nourished children are below this value,
• Edema is ignored and
• yet it contributes to weight and age is difficult to
know in developing countries.
40

40. PEM cont...
1. Well come classification :Evaluate the child for weight
for age and presence of edema
•41
Weight for Age
(Gomez)
With Edema Without Edema
60-80% Kwashiorkor underweight
< 60% marasmic-kwashiorkor marasmus

41. PEM cont...
• Shortcoming of this method is that it does not differentiate
acute from chronic malnutrition.
42

42. PEM cont...
43

43. PEM cont...
44

44. PEM cont...
Mid upper arm circumference(MUAC)
MUAC is used for children 6 -59 months
45

45. PEM cont...
C. Laboratory Investigation
Laboratory investigation for protein energy malnutrition is
to determine the level of:
• Serum protein, hemoglobin
• Co-infections due to pathologic organisms that can be
viral, bacterial or parasitic origin and
• Determination of micronutrient deficiencies
46

46. PEM cont...
C. Epidemiological considerations
• Information regarding the age, sex, birth, weight,
height, season, existence of epidemics, drought and
other natural and man made calamities will have to
be assessed critically.
47

47. PEM cont...
Case Management
Management of a case of PEM focuses on the correction of specific nutrient
deficiencies (dietary management), treatment of complications and supper
imposed Stunting (Chronic malnutrition),Wasting (Acute Malnutrition) and
infections.
• The treatment approach is classified into two phases:
The acute_ stabilization phase in which the main focus is treatment of
infection and other complications like dehydration, hypoglycaemia,
hypothermia and other electrolyte imbalances.
The rehabilitation phase focuses on the restoration of the lost tissue and
promotion of catch up growth 48

48. PEM cont...
Dietary Management
1.Acute phase
• Children are most at risk of dyeing during the acute phase.
• Dehydration, infection and severe anemia are the main dangers.
• In PEM, cardiac and renal functions are impaired and in particular
malnourished children have a reduced capacity to excrete excess
water and a marked inability to excrete Sodium
• At this phase a caution approach is required
49

49. PEM cont...
• Administration of about 100kcal/kg/day and 1-1.15g of protein/kg/day.
Small frequent feeds (as much as 12 times in 24 hours for the first two days
and gradually tapering the number of feeds.
• To be 6 in 24 hours after a week) are ideal as they reduce the risks of
diarrhea,vomiting, hypoglycemia and hypothermia.
• On this regimen, edema will disappear and the general condition will
improve.
• High energy or high protein diets should not be introduced too early or too
rapidly. Such action may precipitate the recovery syndrome' which can
prove fatal.
50

50. PEM cont...
• It is important to give additional Potassium 4mmol/kg/d, Magnesium
2mmol/kg/d, Zinc 2mg/kg/d), Copper 0.2mg/kg/d and a multivitamin
preparation and folic acid.
• High dose vitamin A should be given even if there are no eye signs of
deficiency.
• Return of a good appetite is a sign that a child is ready to progress to the
next phase (rehabilitation phase).
• Do NOT give iron early before infection is controlled.
51

51. PEM cont...
2. Rehabilitation phase
• The aim of this phase is to restore wasted tissues and
promote a rapid rate of catch-up growth through
administration of high energy and protein.
• A vigorous approach is required. In this phase there is no
danger of recovery syndrome.
• Normal rate of growth of children is such that they gain a
weight of 1gram/kg/day by taking 105 kcal/kg/d and
0.78gram of protein /kg/d.
• To increase this rate of growth by 20 times the normal, the
energy and protein intakes need to be increased to
200kcal/kg/day and 5kcal/kg/day, respectively.
52

52. PEM cont...
Where to Rehabilitate
HF/Hospitals and Health centers
• Admission of children to a hospital be targeted to those
children with severe PEM plus other admission criteria.
• In many hospitals, treatment of PEM is unsatisfactory due to
cross infection and frequent relapses
Home
• This is successful only after one week of medical care to treat
infections and other complications
• Proved to be the most cost-effective
53

53. PEM cont...
Where to Rehabilitate…
Day-care Nutrition Rehabilitation Centers(DCNRCs)
• Provide treatment for uncomplicated cases of PEM.
• Children receive 3 meals for 6 days of each week, for 3-5
months, i.e. a period sufficiently long to enable parents to
understand why' and 'how' to improve infants' feeding
practices.
Residential Nutrition Rehabilitation centers (RNRCs)
• The primary objective of this approach is preventative
rather than curative.
54

54. PEM cont...
Complications of PEM
Water, electrolyte and mineral imbalance
 Hypothermia
 Hypoglycemia
Superadded infections
Vitamin deficiency
Lactose intolerance
 Cardiac failure
Bleeding tendency
 Renal impairment
 Long term –Growth retardation, mental retardation
Others…
55

55. PEM cont...
Prevention of PEM
Dietary diversification
Nutrition education
Dietary Modification
Economic approach
56

56. Micro nutrient deficiency disorders
57

57. 1. Vitamin A Deficiency Disorders
58

58. Vitamin A
• Vitamin A is a fat-soluble vitamin
• It is provided in the diet in two forms
Retinoids (preformed vitamin A)
• Vitamin A exists in the form of an alcohol (retinol), an
aldehyde (retinal), an acid (retinoic acid) and an ester
(retinyl palmitate)
Carotenoids (provitamin A)
• Over 600 carotenoids have been identified but the principal
carotenoids found in human plasma is β-carotene
59

59. Vitamin A…
Functions of Vitamin A
• Vitamin A is an essential nutrient needed in small amounts
by humans for:
• Cornea of the eye in healthy condition…..Vision
• Cellular differentiation and maintenance of epithelial
cellular integrity
• Gene expression
• Growth and development during childhood
• Other functions - reproduction, bone metabolism,
immune system
60

60. Vitamin A…
• Functions of Vitamin A…
• In the visual system, the retina is dependent on
vit. A and its metabolites
• In the auditory system Vitamin A plays a role in
the maintenance of the middle and inner ear
• Vitamin A deficiency also leads to abnormality
in the Olfactory system.
61

61. Vitamin A…
Human requirements
• is 750 μg of retinol per day for adults;
• lactating mothers need 50 percent more, and
children and infants less
62

62. Vitamin A…
Vitamin A Food Sources
Animal sources
The best sources of vitamin A are animal sources such as
organ meats like liver, whole milk and milk products,
eggs yolks, fish liver oils
Plant sources (Beta-carotene):Leafy, dark green vegetables;
dark orange fruits and vegetables (carrots,, sweet potatoes,
pumpkin)
63

63. Vitamin A Deficiency Disorders/ VADD
• The term VADD include clinical and sub
clinical Vit A deficiencies.
• A comprehensive term that covers all effects
of the deficiency state including those on
health, survival and vision
64

64. VADD...
• “Vitamin A deficiency” (VAD) is defined as liver
stores of vitamin A
• <10 μg/dL (0.35 μmol/L) – Deficient
• < 20 μg/dL (0.7 μmol/L) – Low
• >= 30 μg/dL (1.05 μmol/L) – Normal
• Clinical signs of VAD appear when the average intake of
the vitamin is very low, which corresponds to negligible
liver reserves
65

65. VADD...
Magnitude of VADD
• According to report from WHO (WHO 2009)
• Among the most widespread and serious nutritional
problems
• Vitamin A deficiency is of public health significance in
122 countries
• One third (190 million) of the world’s preschool
children are Vitamin A deficient
• 15.3% (19.1 million) of pregnant women are vitamin A
deficient
• Highest burden being in Africa and Southeast Asia
66

66. VADD...
Causes of VADs
• Inadequate intake
Poor bioavailability
• Reduced fat intake
• Infections
• Mal absorption
• HIV, Measles, parasitic infections
• Increased needs
• Age
• Physiologic status
67

67. VADD...
Causes…
• Socio cultural factors
• Interaction with other nutrients
• Vitamin E
• Iron
• Zinc
• Copper
• Proteins
68

68. Causes…
- Age
• Varying levels of VAD can occur at any age if conditions are
sufficiently extreme
• VAD particularly severe deficiency affects children of
preschool age
• Requirements for growth in these children are high while the
dietary intake of vitamin A is low with the added burden of a
greater exposure to infection.
• The incidence of corneal xerophthalmia is most prevalent
among children age 2-4 years
• In children under 12 months of age, corneal disease is
relatively a rare event largely because breast feeding is
protective
69

69. VADD...
Causes…
- Physiologic status
• As VA needs are increased during periods of rapid
growth, younger children are the most vulnerable
group.
• The demands of VA are also increased during
gestation and lactation and so pregnant and lactating
women in underprivileged populations may be
unable to meet the increased needs during those
periods.
• Breast milk of women with poor vitamin A status
frequently is low in VA and could subsequently
contribute to increased susceptibility of the infants
70

70. VADD...
Causes…
- Diet
• The basic underlying cause of vitamin A deficiency is a diet
lacking adequate amounts of VA (preformed or provitamin A)
• In poor living conditions, the diet relies on less expensive plant
foods in which the vitamin A (as carotenoid) is less bioavailable
• Breast feeding, the quality of complementary feeding and the
quality of the childhood diet are all important factors in
maintaining vitamin A status
• Intake of yellow fruit (mango and papaya) is strongly
protective in the second and third years of life
71

71. VADD...
Causes…
-- Disease
• VAD increases the risk of infectious morbidity and
conversely infections predispose to vitamin A deficiency
• Several infections such as diarrhea, respiratory infections
and measles are associated with VAD
• Further, the frequency, duration and severity of infectious
diseases contribute either directly or indirectly to
increased vulnerability for VAD
72

72. Public health consequences of VAD….
Immune incompetence
Susceptibility to infection
Morbidity
Stunted Growth
Associations with PEM and MNDs
Mortality (infants and WRA)
73

73. 74

74. Assessing vitamin A deficiency
• Most of the vitamin A is stored in the liver in the form of
retinyl ester
• Thus, a measure of liver vitamin A stores is the best index
of vitamin A nutriture
• Unfortunately, VA is not uniformly distributed in the liver
and liver biopsies are impractical in population studies
and hence serum retinol concentrations are more often
determined
75

75. Assessing vitamin A…
• Subclinical indicators
• VAD can be assessed using specific biological
indicators
• Biological indicators of VAD can be categorized into
• Biochemical
• Histological
• Conjunctival impression cytology (CIT) or its
modification impression cytology with transfer
(ICT)
• Clinical indicators
76

76. Elimination (control) of VAD
• Four key strategies have been recommended (WHO,
UNICEF and IVACG)
Nutrition education
• Creates micronutrient awareness
• Aims at improving practices related to consumption
of vitamin A rich sources
• Has been successful in introducing home gardening
and new agricultural methods which aim at
increasing the availability of vitamin A rich food
sources in addition to providing additional income
used mainly for purchasing food
77

77. Elimination of VAD…
Diet diversification (eating a variety of foods)
• Natural way to obtain the nutrients needed for health
• It requires people to change their eating habits
• It may also involve the need to increase production,
distribution, consumption and preservation of micronutrient
crops and animal products
• Agricultural research is trying to diversify the sources and
improve the yields of foods rich in provitamin A.
78

78. Elimination of VAD…
Supplementation
• Protect individual vitamin A deficiency by building stocks in the
liver
• Protection for 3 – 6 months
• Vitamin A is safe, effective and cost effective
• Such doses are safe and expected to reduce morbidity/mortality
• It has been successfully implemented (high dose vitamin A
capsules) to reduce suffering in vitamin A deficient children
• Vitamin A supplementation reduced the prevalence of diarrhea by
36% 79

79. Elimination of VAD…
Supplementation…
• IVACG recommends the following routine high dose VAS in
developing countries
• For 0 – 5 months
• 150000 IU as three doses of 50000 IU with at least one
month interval between doses
• For 6 – 11 months
• 100000 IU should be given as a single dose every 4 to 6
months
• Children aged 12 months and older
• 200000 IU as a single does every 4 t 6 months
• Postpartum women should receive 400000 IU as two doses of
200000 IU at least one day apart as soon as possible after
delivery and not more than 6 week later or 10000 IU daily or
25000 IU weekly during the first 6 months after delivery
80

80. Elimination of VAD…
Supplementation…
• Critical contact points for vitamin A supplementation
• Delivery
• Postnatal care and family planning
• Well baby clinic and growth monitoring
• Immunization
• Sick child contacts
• Others
• National immunization days, EOS/CHD, school health
programs, informal community contacts with mothers
and children (idir, market days, etc) can be used as an
opportunity to address vitamin A deficiency
81

81. Elimination of VAD…
Food fortification
• Addition of vitamins, minerals and trace elements to staple
foods)
• Is an effective public health measure to correct nutritional
deficiencies in whole population or specific segments at risk.
• It does not require the active participation of the consumer
• Traditional food consumption patterns can be maintained.
• Costs are negligible compared with the medical and public
health costs associated with malnutrition
82

82.  Elimination of VAD…
Food fortification…
• Several advantages
• It is affordable
• It is effective
• It brings a high return on investment
• Behavioral changes are not required
• Fortification is socially acceptable and politically
attractive
• High population coverage can be achieved
• The risk of toxicity is negligible
• It is sustainable
83

83. 2. Iron Deficiency Anemia
84

84. Iron ….
Iron
• One of the essential trace elements for life
• The average iron content in a healthy adult is only about 3
to 4 g, yet this relatively small quantity is vital
• In normal circumstances, only about 1 mg of iron is lost
from the body daily by excretion into the intestines, in
urine, in sweat or through loss of hair or surface epithelial
cells.
85

85. Iron ….
• Found in the body in two different forms, namely the
1. Functional iron
Serves metabolic or enzymatic function
Mediates its physiological function through iron
containing proteins including:
86

86. Iron ….
• Iron containing nonenzymatic proteins
(hemoglobin and myoglobin)
• Iron containing Heme enzymes and
• Iron containing (None heme ) enzymes
2. Storage iron
• Primarily as ferritin and hemosiderin
• Responsible for the maintenance of iron
homeostasis
87

87. Iron ….
Functions of Iron:
• Iron plays a vital role in:
• Binding and transport of oxygen
• Electron transfer reactions
• Gene regulation
• Regulation of cell growth and differentiation
• Immune function
• Energy metabolism and
• Cognitive function
88

88. Iron ….
Dietary sources of iron
• Despite its abundance in the earth’s crust, iron deficiency occur commonly
in both the developing and developed world
• Iron in the diet comes from
• Contaminant/chemical iron
• Plants
• Non heme iron
• Leafy green vegetables, legumes, and whole and enriched grains
are good sources of non-heme iron
• Animal sources
• Heme iron
• Meat, poultry and fish are good sources of heme
89

89.  Iron Deficiency Anemia
• Occurs when hgb production is considerably reduced
leading to a fall in its levels in the blood
• Although most anemia is due to iron deficiency, the
role of other causes (such as folate and vitamin B12
deficiency or anemia of chronic disease) should be
distinguished
• Iron depletion can be categorized into three stages
90

90. IDA
Stage I: Iron depletion stage
• Characterized by a progressive reduction in the
amount of iron storage in the liver
• At this stage, the supply of iron to the functional
compartment is not compromised so levels of
transport iron and hemoglobin are normal
• However, the progressive depletion of iron stores
will be reflected by a fall in serum ferritin
concentrations
91

91.  IDA…
Stage II: Iron deficient erythropoiesis
• Also called iron deficiency without anemia
• Characterized by the deterioration of iron stores
• Iron supply to the erythropoietic cells is progressively reduced
and decreases in transferrin saturation occur
• At the same time, there are increases in serum transferrin
receptor and erythrocyte protoporphyrin concentrations
• Hgb levels may decline slightly at this stage although they
usually remain within the normal range
92

92. IDA…
Stage III: Iron deficiency anemia
• Final stage of iron deficiency
• Characterized by the exhaustion of iron stores, declining levels of
circulating iron and presence of frank microcytic, hypochromic anemia
• The main feature of this stage is a reduction in the concentration of
hemoglobin in the red blood cells arising from the restriction of iron
supply to the bone marrow
• Decrease in the hematocrit and red cell indices also occur
• Examination of a stained blood film allows confirmation of the
presence of hypochromia and micrcytosis
93

93.  Causes of iron deficiency
The main causes for failure to meet iron needs could be
Dietary
• Inadequate intake of both heme and non-heme
iron rich diets
• Regular consumption of high phytate plant-
based meals
• Inadequate intake of iron absorption enhancers
• Inadequate intake of vit A, B- 12, folic acid, &
possibly B-6
94

94. Causes of IDA..
Non dietary
• Increased physiological requirements such as
menstruation
• Frequent parasitic infections including
• Malaria
• Hookworm
• Trichuriasis
• Schistosomiasis
• Abnormal blood cell production (sickle cell)
95

95. 
Epidemiology of IDA
EDHS 2011 (Children)
• 44% were anemic
• 21% had mild anemia
• 20% had moderate anemia
• 3% had severe anemia
• Highest among children age 9-11 months (73%)
• Decreases steadily with age from 12 (63%) to 59 (31%)
months
• 45% rural children had anemia
• 35% urban children had anemia
• Regional variation of anemia in children ranges from, 33%
in Addis Ababa to 75% in Affar
96

96. Epidemiology …
EDHS 2011 (Women of RA, 15 – 49 years)
• 17% were anemic
• 13% had mild anemia
• 3% had moderate anemia
• 1% had severe anemia
• 22% anemia in pregnant women
• 19% anemia in lactating women
• 15% anemia in non pregnant and non lactating
97

97. Epidemiology …
• 18% rural women
• 11% in urban women
• Highest prevalence
• 44% from Somali
• 35% from Affar
• 29% from Dire Dawa
• Low prevalence
• 9% from Addis Ababa
• 11% from SNNP
• 12% from Tigray regions
98

98.  Who is at the greatest risk of IDA?
Children 6-24 months
Special risk infants: low birth weight, premature, and/or
from anemic mothers
Women of reproductive age, especially pregnant women
Adolescents (especially females)
PLWHA
99

99.  Assessment of Iron Nutritional Status
• Iron nutritional status can be assessed by the following
biochemical and hematological tests
• Hemoglobin
• Hematocrit
• Serum iron concentration
• Total iron binding capacity
• Transferrin saturation
• Protoporphyrin
• Serum ferritin
• Transferrin receptors
100

100. Assessment …
Hemoglobin
• Oxygen carrying pigment of RBCs
• Iron is an essential component of Hgb
• Each Hgb is a conjugate of a protein (globin) and
four molecules of heme
• Measurement of Hgb is probably the most widely
used test for IDA
101

101. Assessment …
102
Hemoglobin…

102. Assessment …
• IDA, develops only during the third stage of iron deficiency
when iron stores are exhausted and the supply of iron to the
tissues is compromised
• Hgb is therefore an insensitive measure of iron deficiency as the
concentrations only fall during this late stage
103

103. Assessment …
 Serum iron
• In IDA, serum iron may either be low or even normal
• There is a considerable diurnal variation
1. Levels are highest in the morning and lowest during the night
2. It is reduced in inflammation and malignancy and during
menstruation
3. Thus, this test cannot be really considered as of real diagnostic
value
104

104. Assessment …
 Total iron binding capacity
• TIBC and transferrin saturation indicate iron supply tissues
• TIBC is lowered in chronic disease and raised in iron
deficiency
105

105. Assessment …
Transferrin saturation
• This is a ratio (expressed as a percentage) of serum iron
and TIBC
• In iron deficiency, there is a decreased saturation, while
in chronic diseases the saturation is normal
• TS (%) = (Serum iron/TIBC)*100%
106

106. Assessment …
 Protoporphyrin
• Is the precursor of heme
• Free red blood cell (RBC) protoporphyrin is raised
when there is an insufficient supply of iron for heme
synthesis
• It is also high in IDA, caused by lead toxicity and
other sideroblastic anemias
107

107. Assessment …
Serum ferritin
• Serum ferritin reflects the status of total body iron stores
• It is generally considered as the test of choice for estimating iron stores
• The levels of ferritin are raised in inflammation, infection and liver
disease
• The effect of infections on serum ferritin often limits the usefulness of
serum ferritin as a sensitive indicator of iron stores particularly in areas
where the incidence of infections is very high as in developing countries
of south east Asia
108

108. Assessment …
Transferrin receptors
• sTfR become elevated on cell surfaces and in
plasma whenever there is insufficient iron supply
to cells or iron depletion
109

109. Assessment …
• Diagnostic criteria for IDA
• The ratio of transferrin to ferritin may be a good discriminator between iron
deficiency and anemia of chronic inflammation
• Because of the cost implications for multiple biochemical tests, the
parameter used to indicate iron stats in population studies of IDA is
measured by hgb
110
Indicator Cut off guideline
Serum iron (µg/dl) <60
Total iron binding capacity (µg/dl) > 300
Transferrin saturation (%) <15
Erythrocyte protoporphyrin (µg/dl) > 100
Serum ferritin (µg/dl) <12

110. Classification of anemia as a problem of public health
significance
111

111.  Public health implications of IDA
Consequences of Anemia:
Adults
• Adult productivity reduced
• 10% decrease in hemoglobin = 15% decrease in
productivity
Women
• Increased risk of maternal mortality
• Reduced ability to survive bleeding during & after childbirth
• Severe anemia is direct cause of 3-7% of maternal deaths
worldwide (others estimate it is direct or indirect cause of 20-
40 percent maternal deaths)
• Even with mild/moderate anemia there is an associated
increased risk of dying
112

112. Public health implications…
• Increased risk of:
• Premature birth
• Inter-uterine growth retardation
• Low birth weight
• Children
• Increased infant mortality (thru low birth weight)
• Learning deficits (iron deficiency anemia lowers IQ by 10
points
• Fatigue & poor growth
• Iron deficiency affects iodine uptake, thus increasing risk of
Iodine Deficiency Disorders
113

113.  Prevention and control of IDA
• The basic principles in the prevention of IDA are t ensure
regular consumption of iron to meet the requirements of the
body and to increase the content and bioavailability of iron in
the diet
• There are four main approaches
• Provision of iron supplements
• Fortification of commonly consumed foods with iron
• Nutrition education
• Horticulture based approaches to improving the iron bioavailability of
common foods
114

114. Prevention and control of IDA…
Iron supplementation
• The essential principle of management of IDA is iron
replacement therapy and treatment of the underlying
causes such as parasitic infections or gastrointestinal
bleeding
• Oral iron therapy is the preferred form of treatment
• Ferrous sulfate is the most inexpensive and widely
used oral iron preparation
• A total dose equivalent to 60 mg of elemental iron
(300 mg of ferrous sulfate) per day is adequate for
adults and should be given between meals either in
the morning or at bedtime
115

115. Prevention and control of IDA…
Iron supplementation…
• In the case of infants and young children, 30 mg/day of
elemental iron would be adequate
• In general, over a period of 4 weeks a hgb rise of about 2
g/dl would be expected
• It is important to continue iron therapy for about 3
months, even after the hgb level becomes normal
• Common side effects of iron supplementation are
nausea, constipation, black stools and even diarrhea
• Poor compliance is the major reason for failure to
respond to iron therapy
116

116. Prevention and control of IDA…
Iron supplementation…
• Pregnant women in developing countries are
supplemented with iron supplementation to meet
their iron needs
• Provide iron or IFA to pregnant women &
children 6-24 months
• If resources permit, provide IFA to other
vulnerable groups such as lactating women,
school-age children & adolescents
117

117. Prevention and control of IDA…
 Guidelines for iron supplementation (WHO/UNICEF/INACG)
Pregnant women
Prevention
60 mg iron + 400 μg folic acid daily for 6 months in pregnancy
 Treatment of severe anemia
120 mg iron + 400 μg folic acid daily for 3 months
Children 6-24 months
Prevention
• 12.5 mg iron + 50 μg folic acid daily from 6-12 month of age or from 2-
24 months of age if LBW
Treatment of severe anemia
•25 mg iron + 100-400 μg of folic acid daily for 3 months
Children 2-5 yrs
20-30 mg iron
Deworming
Children and mothers
Where hookworm is endemic, give anthelminthic 118

118. Prevention and control of IDA…
 Fortification
• Foods successfully used as vehicles for food fortification are
wheat, bread, milk powder, salt, infant formula and sugar
• Sweden: wheat flour (65 mg/kg)
• USA : wheat flour (44 mg/kg)
• India: common salt
Nutrition education
The only sustainable solution to IDA is to help the communities to
• Consume regularly foods that are rich in iron
• Encourage intake of promoters of iron absorption such as
vitamin C
• Discourage high consumption of inhibitory factors
119

119. Iodine Deficiency Disorders (IDD)
120

120. Iodine
• Traces of the iodine ion (called iodide) are indispensable to
life.
• Present in minute amounts (15-20 mg) in the body
• > 90 % of iodine storage is in the thyroid gland
• Iodine is an essential micronutrient for the biosynthesis of
thyroid hormones produced by the thyroid gland
121

121. Iodine…
122

122. Iodine…
Functions of Thyroid Hormones
1. Calorigenic/thermogenic: no shivering thermogenesis
2. Respiratory metabolism: increase oxygen consumption
(need oxygen for ATP production)
3. Intermediatary metabolism: mobilize glucose for use
(glycogenolysis to make ATP)
4. Development: brain development and neurogenesis are
regulated by thyroid hormones (axonal maturation,
myelin formation, dendritic outgrowth).
5. Growth: THs are essential for skeletal growth by
synergizing with GH (also stimulate GH synthesis)
6. Reproduction – THs play a permissive role in sexual
maturation
123

123. Iodine…
Dietary sources of iodine
• The richest dietary sources of iodine are seafood,
seaweed and iodized salt
• Foods of animal origin including meat and milk can
also constitute a significant source of iodine if animals
have grazed on iodine sufficient soils
• Similarly, crops from iodine sufficient soils may supply
some dietary iodine
• Iodine fortified foods like salt, bread and milk
124

124. Iodine deficiency disorders (IDDs)
• The term Iodine Deficiency Disorders (IDDs) was introduced by
Hetzel in 1983, Encompass the wide spectrum of the effect of
suboptimal iodine nutrition on health, including
• Physical impairment
• Mental retardation
• Iodine deficiency is the leading cause of preventable brain damage in
childhood
• The most devastating outcomes of iodine deficiency are increased
perinatal mortality and mental retardation
• Iodine deficiency is characterized by a:
• Slowdown of metabolic processes, which in children translates
into a deficit of growth and development
125

125. IDDS….
126

126. Epidemiology of IDDs
Ethiopia
• Ethiopia is still one of the most severely iodine deficient countries in
the world
• FMOH 2009 press release
• Less than 5% of Ethiopian households utilize adequately iodized
salt
• Estimated productivity loss due to the negative impact on health,
poor physical growth, compromised intellectual capacity and
lower educational attainment associated with IDD in Ethiopia will
be 64 billion ETB between 2006 and 2015
127

127. Epidemiology of IDDs…
An accompanying press release from MI
• Severe iodine deficiency in Ethiopian women
leads to 50,000 stillbirths annually
• The country’s goiter rate has worsened from 26%
in the 1980s to about 40% (2009)
128

128. Causes of IDD
– Soil devoid of iodine
• Erosion of the land owing to the mountainous topography
especially in Ethiopia
• Crops growing in this type of soil are deficient in iodine
• Animal products from animals grazing grass growing in this
soils are deficient in iodine
• Water will also be deficient
– Poor consumption of sea foods
– Increased consumption of goitrogens
• Foods that contain goitrogenic factors include cabbage,
cassava, beetroot, bamboo shoot
129

129. Health consequences of iodine deficiency
• Inadequate intake of iodine leads to iodine deficiency disorders
(IDD)
• The term IDD encompasses all consequences of IDD which can be
prevented by optimal iodine nutrition
• The most damaging effect of inadequate intake of iodine is on the
developing brain
• Cretinism is an extreme form of neurological damage due to severe
iodine deficiency or fetal hypothyroidism
• Cretinism is a congenital disease characterized by mental and
physical retardation and commonly caused by maternal iodine
deficiency during pregnancy. 130

130. Health consequences…
• Iodine deficiency alone lowered mean IQ scores by 0.9 SD
or 13.5 IQ points
• Iodine deficiency can induce thyroid enlargement at any
period in life. Goiter reflects an attempt of the thyroid gland
to adapt to increased need to produce thyroid hormones
• Impaired reproductive outcomes
• Child mortality
• High degree of apathy
• Reduced work productivity in the adult population living in
severely iodine deficient areas, leading to economic
stagnation of communities.
131

131.  Intervention strategies of IDDs
• One or a combination of strategies may be decided to
eradicate iodine deficiency
• Strategies decided upon depend:
• The severity of IDD
• The accessibility of the target population
• The resources available
132

132. Intervention stra..of IDDs..
• Programs may include one or both of the following
strategies:
• Food based approaches
• Fortification
• Nutrition education
• Nutraceutical approach (supplementation)
133

133. Intervention stra..of IDDs..
 Fortification
• Fortification of salt
• Common in many countries
• Iodination of water
• Iodination of irrigation water in China
• Fortification of infant formulas
• Level of fortification in terms of final concentration in the
prepared formulas should be 200 µg/L and 100 µg/L for
preterm and starting formulas, respectively
• Fortification of foods consumed by animals
• Lead to increased iodine status of humans consuming
animal products such as meat, dairy products and egg
134

134. Intervention stra..of IDDs..
Fortification…
• Salt fortification (USI)
• Has been the most effective way to combat IDD
• Salt is the best vehicle for iodine fortification as it is
consumed on a daily basis and centrally produced
• Salt mining in Ethiopia
• Afdera from Afar Region
• God Usbo (Afder zone, Hargelle Wereda) from Somali
Region
135

135. Intervention stra..of IDDs..
Fortification…
• A joint policy from the WHO, UNICEF and ICCIDD
recommends that in order to provide approximately 120
– 140 µg/day of iodine the iodine concentration in salt at
the point of production should be within the range of 20
– 40 mg of iodine per kg of salt
136

136. Intervention stra..of IDDs..
Fortification…
• This recommendation assumes that 20% of the iodine will be lost
from the production site to the household and another 20% lost
during cooking and that the average salt intake is 10 g per person
per day
• Either KIO3 or KI may be used for fortification
• But KIO3 is more suitable in hot and humid climates because of
its greater stability
• Iodine losses and requirements under local conditions should be
determined and health officials should ensure that proper
monitoring of iodized salt is regularly conducted
137

137. Intervention stra..of IDDs..
 Nutrition education emphasizing on:
• The consequences of IDD
• IQ loss of 13.5
• Every year China loses 60-70 million IQ points due to IDD
• Newton's IQ was 190 and China is losing 368,000 Newtons
every year
• Consumption of iodized salt
• Increased consumption of sea food when accessible
• Decreased consumption of goitrogenous foods and employ food
processing methods able to detoxify goitrogens
138

138. Intervention stra..of IDDs..
 Nutraceutical approach
Use of iodized oil
• Under circumstances where other iodine supplementation
strategies have failed or are not practical, treating iodine
deficiency with iodized oil is very effective
• Oil can also be a vehicle in the form of capsule or intra
muscular injection but a bit costly as compared to iodized
salt
• Intestinal parasites have been found to inhibit the
absorption of iodized oil
139

139. Intervention stra..of IDDs..
• Thus, when using iodized oil to control iodine deficiency,
deworming before dosing will increase the duration of
effectiveness of iodized oil
• No studies have been carried out to assess the effect of
worm load or deworming on increasing iodine
requirements or reducing the effectiveness of iodized salt
in controlling iodine deficiency
140

140. Intervention stra..of IDDs..
Use of KI solution
• 10% KI solution is an easily prepared, readily
available, simple and cheap alternative approach
when the main methods (iodized salt and iodized
oil) used to prevent and control iodine deficiency
are not immediately available
• Iodide doses of approximately 30 mg every month
or 8 mg every 2 weeks can be delivered
conveniently as a simple solution using a dropper
bottle
141

141. Intervention stra..of IDDs..
• Iodized Oil Supplementation
• Target Group:
• Women during pregnancy
• 1st year post-partum
• Children
• When/Where:
• IDD moderate-severe
• Cretinism/neonatal hypothyroidism
• No universal salt iodization for 1-2 yr
• Iodized oil
• Effective in high risk groups
• Administered every 6 to 12 months
142

142. Category Intake (µg/day)
Infants, 0 – 59 months 90
School children, 6 – 12 years 120
Children > 12 years and adults 150
Pregnant and lactating women 200
Recommended intakes (WHO/UNICEF/ICCIDD, 2001)
At a level that assures 150 µg/day is safe for all populations (WHO, UNICEF, FAO, ICCIDD, IAEA)
Intervention stra..of IDDs..
143

143. Iodine Nutrition Assessment
 Target population
• School-age children are considered an appropriate target group
because
• They fulfill the desired criteria for determining iodine deficiency
due to their
• Susceptibility to iodine deficiency
• Accessibility as a study group
• Representativeness of society as a whole
• Pregnant women are a prime target group for IDD control activities
because they are especially sensitive to marginal iodine deficiency
and are relatively accessible given their participation in antenatal
clinics
144

144. Assessment…
 Iodine status assessment Methods
Urinary iodine excretion
• The most widely used biochemical method of
assessing iodine status is to determine urinary
iodine excretion either in 24 hr urine samples
or casual urine specimens
• Good indicator of recent iodine intake
145

145. Assessment…
Thyroid size
The size of the thyroid gland changes inversely in
response to alterations in iodine intake
For many years thyroid size has been determined by
inspection and palpation.
This method appears attractive because it enables
observers to examine a large number of people in a
short time with out the use of an expensive equipment
However, there is concern about the accuracy of
diagnosis with this method
146

146. Assessment…
 Thyroid size by palpation
• Requires careful training and experienced observer
• Size of the thyroid gland is categorized into one of the
following grades
• Grade 0: No palpable or visible goiter
• Grade 1: A mass in the neck that is consistent with an
enlarged thyroid that is palpable but not visible when the
neck is in the normal position but moves upwards in the
neck as the subject swallows; nodular alterations can
occur even when the thyroid is not visibly enlarged
147

147. Assessment…
Thyroid size by palpation…
Grade 2: A swelling in the neck that is visible when the neck is
in normal position and is consistent with an enlarged thyroid
when the neck is palpated
• The total goiter rate (TGR) is calculated as the sum of grades 1
and 2
• When this rate exceeds 5% in 6 – 12 years in school children
the population is said to have a public health problem, except in
the short term after the introduction of an iodization program.
• Usually the iodine deficiency is corrected rapidly with an
effective iodization program but the goiter rates take longer to
return to an acceptable level. 148

148. Assessment…
 Thyroid size by ultrasonography
• Ultrasonography provides a more accurate and
objective method of determining thyroid size than
palpation
• Ultrasonography is a safe, non invasive, specialized
technique
• Requires an expensive equipment
• Practically useful in distinguishing between goiter
grades 0 and 1
149

149. Assessment…
TSH
• TSH concentrations increase in iodine deficiency as part of the feed
back system, however the increase is not great unless the deficiency is
moderate or severe.
• Thus, the TSH concentration in school aged children and adults is not
a good indicator for iodine deficiency and its use in school based
surveys is not recommended
• Measurement of TSH in serum is used as a screening test for
detecting congenital hypothyroidism in neonates because the neonatal
thyroid has limited iodine stores and even mild iodine deficiency may
increase TSH secretion 150

150. Assessment…
 Thyroglbulin
• Some investigators claim that thyroglobulin
concentrations are sensitive marker of iodine
status
• When the thyroid is enlarged in iodine deficiency
larger amounts of thyroglobulin are released
increasing the thyroglbulin levels in the
circulation
151

151. Assessment…
 T3 or T4
• Levels of T3 or T4 in serum are sometimes also
used although they are relatively insensitive,
generally only falling below the normal range
when iodine deficiency is very severe
• In iodine deficiency the serum T4 is lower and
the serum T3 is higher than in normal
populations but the overlap reduces the
usefulness of these hormones in assessing IDD
152

152. Assessment…
 Cognitive function
• Determination of cognitive function in children has
sometimes been used as a non invasive functional
measure of iodine status
153

153. Assessment…
Incidence of cretinism
• Provides an indication of the magnitude of IDD
• The condition is comparatively rare and
difficult to diagnose, cases are often hidden
away and since the life expectancy of cretins
varies, incidence data may be more appropriate
than prevalence data
154

154. oEndemic goiter
• An area is said to be endemic if 10% or more of child population
has goiter
• Grades of severity of IDD (WHO/ICCIDD)
155
Indicator Mild IDD Moderate IDD Severe IDD
Goiter prevalence 5 – 19% 20 – 29% >= 30%
Cretinism 0 0 0 – 5
Urinary Iodine, ppm 50 – 100 25 – 49 < 25
Assessment…

155. Zinc
A trace element required as a cofactor by more than 100 enzymes.
All cells contain zinc, but the highest concentrations are found in
muscle and bone.
A cofactor is a substance that works with an enzyme to facilitate a
chemical reaction.
156

156. Zinc…
Functions of Zinc
It supports the work of numerous proteins in the body, which are
involved in a variety of metabolic processes, including:
Make parts of the genetic materials
:DNA and RNA
Manufacture heme for hemoglobin
Participate in essential fatty acid metabolism
Release vitamin A from liver stores
157

157. Zinc..
Functions of Zinc….
Metabolize carbohydrates
 Synthesize proteins
Metabolize alcohol in the liver
Zinc interacts with platelets in blood clotting, influences behavior
and learning performance
It is needed to produce the active form of vitamin A (retinal) in
visual pigments and the retinol-binding protein that transports
vitamin A.

158. Zinc…
It is essential to normal taste perception, wound
healing, the making of sperm, and fetal development.
A zinc deficiency impairs all these and other
functions, underlining the vast
159

159. Zinc..
Food Source of Zinc
 Breast milk, beef, poultry are good sources
 Phytates, fiber and lignin reduce bioavailability of
zinc from cereals, legumes and tubers
 Calcium and casein may reduce bioavailability of
zinc from cow’s milk.
 Diarrhea causes excess losses
160

160. Zinc…
It is essential to normal taste perception, wound
healing, the making of sperm, and fetal development.
A zinc deficiency impairs all these and other
functions, underlining the vast
161

161.  Factors suggesting zinc deficiency in a population
 High phytate staple foods
 Low intake of “flesh”food
 Prevalent stunting
 High rate of diarrhea
 Nutritional iron deficient
162

162.  Clinical spectrum of human zinc deficiency
Severe zinc deficiency
• Hypogonadism, growth retardation, dermatitis, alopecia, mental
disturbances, infections, death
Mild-moderate zinc deficiency
• Hypogonadism, growth retardation, decreased immune function,
infections
163

163. 164