Malnutrition is poor nutrition due to an insufficient, poorly balanced diet, faulty digestion or poor utilization of foods. (This can result in the inability to absorb foods). Malnutrition is not only insufficient intake of nutrients. It can occur when an individual is getting excessive nutrients as well.

1. Dr. Dalia El-Shafei
Assoc. prof., Community Medicine Department, Zagazig University
http://www.slideshare.net/daliaelshafei

2. MALNUTRITION

3. MALNUTRITION
• Poor nutrition due to an insufficient, poorly balanced diet,
faulty digestion or poor utilization of foods. (This can result
in the inability to absorb foods).
• Not only insufficient intake of nutrients. It can occur when
an individual is getting excessive nutrients as well.

5. WHO IS AFFECTED BY MALNUTRITION?
Individuals who are
dependent on others for
their nourishment
(infants, children, the
elderly, prisoners….etc)
Mentally disabled or ill
because they are not
aware of what to eat.
People who are
suffering from TB,
eating disorders,
HIV/AIDS, cancer, or
who have undergone
surgical procedures
“interferences with
appetite or food
uptake”.

6. UNDERNUTRITION

7. CAUSES OF MALNUTRITION
• Deficient in energy and /or protein (Kwashiorkor, marasmus)
• Deficiency in one or more mineral/ vitamin (e.g. vitamin A,
iodine, iron, zinc, calcium, vitamin D)
1ry causes: "Lack of food”
• Alteration of normal metabolism (during infection / fever,
HIV/AIDS)
• Prevention of nutrient absorption (diarrheal infections)
• Diversion of nutrients to parasitic agents (hookworms,
tapeworms, schistosome worm, Malaria).
2ry causes:

8. MOST IMPORTANT CAUSES OF MALNUTRITION
Poor dietary habits
Metabolic
abnormalities
Improper &or
Inadequate food intake
Inadequate food
absorption
Emotional factors Deficient food supply Food faddism Diseases

12. PREVENTION OF MALNUTRITION
• Nutrition education: requirements & values of different kinds of food and needs of individuals.
• Promotion of breast feeding
Action at the family level
• Socioeconomic development
• Survey study of malnutrition problem's prevalence.
• Study food habits, nutritional knowledge of population to prepare health education programs.
• Sanitary environment & improving health conditions.
• Prevention & control of infectious diseases.
• Supplementation & fortification of foods.
Action on community level
• Increasing agricultural production & animal husbandry.
• Supplementary feeding programs for preschool and school children.
• Prevention of nutritional deficiency disease by providing nutritive elements to pregnant &lactating women.
• Nutrition intervention programs.as immunization, environment sanitation family planning and management
of infectious and parasitic diseases.
• Nutritional surveys & early detection of cases of malnutrition.
• Fortification of bread with iron, table salt with iodine (most prevalent deficient elements in all population).
Action on the national level

13. TYPES OF UNDER-NUTRITION DISORDERS
Protein Energy
Malnutrition (PEM
or PCM)
• Kwashiorkor
• Marasmus
Micronutrient
deficiencies
• Vit D & Calcium deficiency
• Rickets
• Osteomalacia
• Osteoporosis
• Iron deficiency anemia
• Folate deficiency
• Pernicious anemia (B12-Folate deficiency Anemia)
• Vitamin A
• Bribery (Vit.B1 deficiency)
• Pellagra (Vit.B3 deficiency)
• Scurvy (Vit.C deficiency)
• Iodine Deficiency
• Zinc Deficiency
• Dental caries

17. Kwashiorkor Marasmus
Causes Deficiency in protein with excess
carbohydrates. Increased calories
more than required.
Deficiency in caloric requirement,
protein & all other nutrients
Age affected 1-4 years Infants 6-8 months
C/P Muscle wasting, oedema ‘moon
face’ & overweight. Mental
retardation, skin lacerations & hair
changes. Hypoglycemia &
hypoalbuminaemia.
Severe muscle wasting (skin over
bone), senile look, underweight. No
mental changes, flag skin, dry &
lusterless hair. Normal sugar &
albumin
Prognosis Bad (can lead to coma & death) Good
Prevention - Health education about breast feeding & proper weaning.
- Growth monitoring for early detection.
- Nutrition supplements & rehydration.

29. Prevalence is 25% in developing
countries.
Affecting children between 6-24
months.
Vit.D Deficiency negatively
affects absorption, utilization &
deposition of Ca & P in bones.
Defective calcification of osteoid
& epiphyseal cartilage of
growing bones
Also, it negatively affects the
immunity

30. CONTRIBUTING FACTORS:
Lack of sun exposure &
excessive wrapping of
infants, especially in winter.
Cloudy sky, dusty or foggy
weather, Suspended dust in
air interferes with penetrating
power of UV rays.
Chronic malnutrition,
especially PEM. Recurrent
gastroenteritis, prematurity &
LBW.
Nutrition ignorance of the
mother & non
supplementation of infant’s
diet with vit.D.
Low standard of living, poor
housing & bad sanitation
Repeated unspaced
pregnancy, poor
supplementation during
pregnancy with Ca & vit.D.

31. CLINICAL
PICTURE
Skeletal manifestations
• Craniotabes (softening of skull
bones, bossing of parietal & frontal
bones, delayed closure of anterior
fontanel)& delayed teeth eruption.
• Enlarged metaphyseal ends of
long bones (wrists & ankles).
• Deformities of long bones & pelvis.
• Chest: rachitic beads of ribs
(rickety rosary), pigeon chest &
Harrison’s sulcus.
Other manifestations
• Hypotonia
• Tetany & Convulsions
“impaired Ca absorption”
• Chest infections (due to chest
deformity & suppression of
immunity)

33. PREVENTION
Good housing &
sanitary
environment.
Health education
of mothers
highlighting
importance of
exposing the infant
to sunlight daily &
increase inter-
pregnancy spacing
Specific measures
• Vita. D “powdered milk or
drug”:
• Oral drops 400 IU daily.
• IM 200,000 IU every 6
months under medical
supervision “risk of
hypervitaminosis D”
(illiterate mothers or far
from health service).

34. CONTROL
Early case
finding by
growth
monitoring.
TTT of cases with
vitamin D (oral or IM),
Ca supplement
• Health education of the
mother for importance of
daily exposure to the sun
rays.

37. Osteomalacia Osteoporosis
Def. Bone Softening "bone replaced by
soft osteoid tissue".
Bone Atrophy "significant reduction of bone
density & mass more than 2.5 SD "
Path. Vit. D or Ca++ & Ph---deficiency →
failure to replace bone turnover →
demineralized soft osteoid tissue.
Bone mass starts to decline after age 40 ys.
due to resorption > formation → too little
bone but with normal mineral content.
RF • Young women with repeated
pregnancy.
• Indoor living conditions.
• Diet deficient in Ca++, Ph---
• Malabsorption & chronic renal
failure.
• Post menopasual women & Elderly.
• Insufficient intake “Ca++, Ph---, vit.D”
• Smoking, alcoholism
• Sedentary life
• Delayed puberty, hypogonadism
• Endocrinal diseases as Cushing's
syndrome
• Drugs “corticosteroids, cytotoxic drugs”.
• Malignancy (lymphoma), CRF
• Low body weight.

38. Osteomalacia Osteoporosis
C/P • Bone-ache, tenderness
• Uneven gait due to muscular
weakness
• May be a symptomatic
• Persistent backache due to progressive
compression & collapse of vertebrae
• Kyphosis, hip fracture.
TTT Ca++ &vit.D supplementation. Early cases: Ca++, vit.D supplementation
Late cases: antiresorptive drugs.

40. IRON DEFICIENCY ANEMIA

41. • Microcytic, hypochromic anemia.
• Decreased HG concentration than standards.
• Most prevalent single deficiency state on a worldwide basis.
• Important economically “diminishes the capability of individuals
to perform physical labor, growth and learning capacity in children”

42. CAUSES:
Decreased intake of animal
proteins
Bad dietary habits (intake of
tea after meals)
Parasitic infections
Inadequate dietary intake
especially when requirements
are high “pregnancy, rapid
growth”.
Impaired iron absorption “low
vit C intake, gastric
Hypoacidity, iron Precipitation
by oxalates & phosphates”.
Chronic blood loss.

44. DIAGNOSIS:
C/P
Pale skin, loss of appetite & apathy
Fatigue
↓ Attention, learning ability, work
performance & immune status
Dry brittle nails which later become
flat & spoon shaped.
Haemic murmurs
Blood picture
Low HG>11gm./dL.(different cut-
off(s) in different ages)
Decreased RBCs.
Small color index 0.5-0.7

46. PREVENTION & CONTROL:
Adequate dietary
intake.
Dietary supplementation
“dry milk & bread”
Prevention & control of
parasitic diseases &
pathological conditions
associated with blood
loss.
Early detection by lab testing.

47. (B12-Folate deficiency Anemia)
PERNICIOUS ANEMIA

49. MACROCYTIC MEGALOBLASTIC ANEMIA
Deficiency of vitamin B12 & Folic acid arrests the development of
erythrocytes in the bone marrow at the stage of megaloblasts.

50. AT RISK GROUPS:
Pregnant & lactating women
“↑ demand”
Vegetarians “diet lacks vit
B12”
Gastrectomy “lacking of
intrinsic factor needed for
absorption of B12”
Diphyllobothrium latum
infestation “consumes B12” Malabsorption syndrome
Medications that treat DM,
acid reflux & peptic ulcers

51. CLINICAL PICTURE:
GIT, NS, and CVS.
CVS: Chest pain or heart
palpitations
CNS: Confusion, memory
loss, Depression or dementia
GIT: Constipation, Pale skin or
jaundice, poor appetite, sore
mouth & tongue and weight loss.
Developmental delays &
failure to thrive. Fatigue or weakness Numbness or coldness of
hands & feet.

53. PREVENTION:
Balanced diet
with
considerable
intake of animal
food.
B12 & Folic
acid
Supplementation
“pregnant,
lactating women
& vegetarians”.
Atrophic gastric
mucosa or who
had gastrectomy
should be given
intrinsic factor.

54. FOLATE DEFICIENCY

55. C/p: If deficiency during pregnancy
Regulates the nerve cells of the embryonic development.
Neural tube defect &
Spina bifida
Anencephaly LBW
Preterm delivery Anemia

57. PREVENTION:
↑
Consumption
of
Liver,
Kidney,
Fish,
Green
leafy
vegetables&Beans.
Folic
acid
supplementation
if
needed.

58. VITAMIN A DEFICIENCY

59. Most important cause of blindness in developing countries.

61. MANIFESTATIONS:
Delayed growth ↓ Iron utilization
Follicular keratosis
of the skin
↑ Susceptibility to
respiratory &
urinary tract
infections (anti-
infection vit.).
Night blindness:
nyctalopia or day
sight.
Conjunctival xerosis
“affection of the
lacrimal gland”
Bitot spots in the
cornea
Xerophthalmia,
Corneal ulceration
and keratomalacia
Blindness

63. PREVENTION :
Nutritional
education
M.C.H. Services
• Mothers after labor
(200 000IU)
• Infants as drops at 9th
month (100 000IU) &
another dose at 18th
month (200 000IU)
Fortification of
foods with
vitamin A
• Margarines
• vegetable oils
• Dried skimmed milk

64. Thiamine (vitamin B1)
deficiency
“BERIBERI”

65. Common in
South East Asia
where many
diets consist
solely of white
rice.
Affects nervous &
circulatory system
C/P: muscle
wasting & nerve
damage.
Prevention: foods
such as pork, beef
and whole grain
(unrefined) breads
and grains.

67. Niacin or Vit B3 (or
Tryptophan) Deficiency
PELLAGRA “ROUGH SKIN"

69.  Prevention:
Broccoli, Eggs, Dates, Beef, Salmon, Seeds & Peanuts.

70. Vitamin C deficiency
“SCURVY”

71.  In bottle fed infants, pregnant, elderly, workers in desert who
consumed canned food.
 C/P:
General
weakness
Muscle & joint
pain
Swelling of
gums
Bleeding Blepharitis
Anemia “↓ iron
absorption”
Stomatitis,
Gingivitis
Impaired healing
of wounds.
Hge under skin
& joints
provoked by
slight trauma

73. PREVENTION:
↑ Intake of
fresh
vegetables &
fruits. (vit.C
is heat labile,
easily
oxidized &
destroyed by
storage)
Nutrition
education
Supplying
infant during
weaning by
orange &
tomato juice
Dietary
supplementation
by food rich in
vit C for the
high-risk groups
in camps or
isolated
communities

74. IODINE DEFICIENCY

77. Most important cause of preventable brain damage & mental retardation in
babies.
Lower IQ by 10-15%.
Deficiency gives hypothyroidosis & goitre.
Stillbirth & miscarriage.
Cretinism: mental retardation, stunted, hypothyroidism, deaf-mutism.
Prevention: Iodising salt, Sea fish, sea plants (vegetables grown on iodized soil).

79. DENTAL CARIES

80. Def in Ca, ph, vitamin D, and fluorine.
Ingestion of carbohydrates, sugars, & soft drinks with neglecting oral hygiene.

81. ZINC DEFICIENCY

82.  C/P: Growth retardation & increased susceptibility to
infections especially skin & eye lesions.
 Prevention: Consumption of foods as: Whole-grain
cereals, Legumes, Meat, Chicken and fish.

83. Obesity
“OVERNUTRITION”

84. Definition: it is excess adipose tissue in different parts in the body due
to excess storage of fat.
The ability to store fat is unlimited but if the amount of fat to be stored
exceeds the ability of the fat cells to expand (50 times its size), the
body forms new adipose cells. With weight loss, fat cells decrease in
size but NOT in number. Once a fat cell formed, it exists for life.

87. ETIOLOGY (OF SIMPLE OBESITY):
Imbalance between energy intake & energy
expenditure for long periods of time.

90. Obesity RF
Non-modifiable Biological
Genetics
Age
Sex
Modifiable
Behavioral
Diet
Physical inactivity
Psychological & emotional
disorders
Environmental
Family
Work
Advanced technology
Foods advertisements

91. A. Biological factors (Non-modifiable):
1. Genetics:
Brown adipose tissue (BAT): interscapular adipose tissue and
along the aorta. Thin persons have more brown adipose tissue, so
that fat oxidized more than stored.

96. Leptin “satiety factor”
It is a hormone secreted from adipocytes with central control from
hypothalamus. Suppress appetite, deplete fat stores & ↑ energy
expenditure.
In obesity there is a state of leptin resistance at cell level with
hyperleptinaemia → complications as CVDs.

97. Gremlin hormone
Hormone produced in the stomach. Its secretion stimulated by
adrenaline & nor-adrenaline which are released in response to
hypoglycemia where it promotes the appetite.

98. 2. Age: Obesity may appear at any age but obesity in
childhood is predictive to obesity later on adulthood.
3. Sex: Both sexes are exposed. Pregnancy causes ↑ in mother
weight by 4-6 pounds over her pre-pregnancy weight.
Menopause represents a risk period for extra weight gain and
redistribution of fat towards visceral regions.

99. B. Behavioral factors (modifiable factors):
Diet: Eat more than
need in Quality &
Quantity:
↑Sweets, fats, snacks &
soft drinks .
Nibbling in between
meals.
Evening overeating.
Physical inactivity:
Sedentary occupations,
preferring indoor life &
with least activity.
Psychological &
emotional disorders:
Anxiety, Stress &
Depressive illness
“emotional relieve”.

100. C. Environmental factors (modifiable factors):
Family lifestyle & feeding pattern Work problems & unemployment
Advanced technology Foods advertisements

101. ASSESSMENT OF OBESITY

102. Assessment
of
obesity
Qualitative
Pear-shaped obesity (Gynacoid).
Apple-shaped obesity (Android)
Quantitative
Body mass index (BMI)
Skinfold thickness
Relative (RW)
Waist/hip ratio (WHR)
Arm Fat Area (AFA)
Hydrostatic water weighing
(densitometry)

103. A. QUALITATIVE ASSESSMENT:
Fat distribution in the body which is of morbid significance:
Pear-shaped obesity
(gynacoid)
Females “fat in hips &
thighs”.
Apple-shaped obesity
(android)
Males “fat around waist &
abdomen”.

105. B. QUANTITATIVE ASSESSMENT:
1. BMI is not a sensitive index (BMI > 30)

106. 2. Skinfold thickness.

107. 3. Relative weight:
(RW=body weight "kg"/desirable body weight "kg" x 100)
• RW is supposed to be 100%.
• Desirable body weight for each height is obtained from
special tables.
• RW > 120% is considered obesity.

108. 4. Waist/hip ratio (WHR):
if > 85%: android obesity “more health hazards as
cardiovascular problems”.
If <85% : gynacoid obesity.

110. 5. Arm Fat Area (AFA):
It is a measure of total body fat (fat weight) and calculated from
mid-arm circumference and triceps skin fold thickness by certain
equation as :
AFA = Arm area - Arm muscle area.

111. 6. Hydrostatic water weighing
(densitometry):
It is comparing of body weight on
standard scale with the weight
underwater. By assuming that adipose
tissue is less dense than lean tissue
(muscles & bones), so the more adipose
tissue in a body, the less its underwater
weight (the more it tends to float). It is
an accurate method for estimating the
total body fat.

113. Management of obesity

114. Management of
obesity
Lifestyle
modification
Diet
Physical activity
Behavioral
modification
Medications
Surgery

115. I) Lifestyle modification:
Diet: decreasing caloric intake by about 500 Kcal./day to achieve a weight
loss of 450 gm/week. Because of the way the body uses fuel from
carbohydrates, fats and protein, a more rapid weight loss will compel the
body to use protein (muscles) instead of fat for energy. This will decrease
muscle mass with each dieting attempt and fat percentage will increase.
Other principles of healthy eating relevant to weight loss:
Eat plenty of
food rich in
starch and fibers.
Eat plenty of
fruits and
vegetables.
Avoid eating too
much fat and
sugars.
Not skip meals
“suppress
metabolism”.

116. 2. Physical activity:
 Walking or swimming are safe exercise for all persons.
 Those who are bed ridden or are in wheel-chairs can use upper arm exercises.
 Aerobic exercises require more air & tend to use the highest % of body fat for
fuel.
↓ body fat while helping
to preserve muscles
tissue tone.
Manage mental stress. ↑ energy levels Control of appetite
Improve blood sugar
control in diabetes.
↓ Blood pressure. ↑Amounts of HDL-C.
Improve bone density
where weight-bearing
exercises can slow down
bone loss after
menopause or even ↑
bone density.

117. 3. Behavioral modification:
By focusing on small, gradual behavioral changes, the
individual learns to gain control on eating behaviors with
the goal of permanent changes in eating habits.
Some basic strategies can be useful in promoting behavior changes for
sustained weight loss include:
Self-monitoring
Behavioral
contracting
Stimulus control
(precedes eating)
Cognitive
restructuring
Stress
management
Social support Physical activity
Relapse
prevention

118. II) Medications:
• Control obesity “appetite suppression or prevention of fat absorption”.
• Supplementation of vitamins & minerals
• Management of obesity complications.

119. III) Surgery:
It is used in cases of morbid obesity (BMI > 40) or in
cases of failure of other methods to control of obesity.

120. Complications of obesity

122. Cardiovascular “Main cause of death in obese”
• Coronary heart disease: Hyper-insulinaemia (insulin
resistance)& Hypertriglyceridemia (dyslipidemia).
• Hypertension ↑ renal sodium retention & catecholamines
release.
Diabetes mellitus
• Insulin resistance syndrome: due to defect in the insulin
receptors at the cell level leading to inability of the
body cells to utilize blood sugar to give the needed energy
Other complications
• Musculoskeletal disorders, gout,
• Cancer (colon, breast)
• Gall stones, hernias & Menstrual irregularities