This document discusses various types of malnutrition including protein energy malnutrition (PEM) in Nepal. It outlines the immediate, underlying, and basic causes of PEM as inadequate dietary intake and infections which interact in a vicious cycle. Preventive measures proposed include promoting optimal infant and young child feeding practices, vaccination, food fortification, and treating diarrhea and intestinal parasites. The document also discusses iodine deficiency disorders, iron deficiency anemia, vitamin A deficiency and their prevention through salt iodization, food fortification, and supplementation programs.

1. BY : Dhirendra Nath
National Open College
Sanepa lalitpur
Malnutrition

2. Malnutrition
 Malnutrition has been defined as "a pathological state
resulting from a relative or absolute deficiency or
excess of one or more essential nutrients".
 It comprises four forms –under-nutrition, over-
nutrition, imbalance and the specific deficiency.

3. PEM
 as a major health and nutrition problem in Nepal
(weaklings and children in the first years of life)
 also to permanent impairment of physical and
possibly, of mental growth of those who survive.
 its clinical forms - kwashiorkor and marasmus
 two different clinical pictures at opposite poles of a single
continuum.

4. PEM is primarily due to
(a) an inadequate intake of food (food gap) both in
quantity and quality, and
(b) infections, notably diarrhoea, respiratory tract
infections, measles and intestinal worms
 increase requirements for calories, protein and other
nutrients,
 decreasing their absorption and utilization.
 It is a vicious circle - infection contributing to
malnutrition and malnutrition contributing to
infection, both acting synergistically

5. Malnutrition/infection cycle

6.  Other contributory factors in the web of causation, viz.
 poor environmental conditions,
 large family size,
 poor maternal health,
 failure of lactation,
 premature termination of breast feeding, and
 adverse cultural practices relating to child rearing and
weaning such as
 the use of over-diluted cow's milk and
 discarding cooking water from cereals and
 delayed supplementary feeding

7. Impact of malnutrition
 High Morbidity and mortality
 survival
 Academic performance of children
 Socio-economic
 National Devlopment
 Drug action
 Health and Devlopment

8. Cont..
 Quality of life in elderly
 Pregnant Women

9. .

13. Causes of Malnutrition and Death
Manifestations
Immediate Causes
Underlying Causes
Basic Causes
Malnutrition and Death
Inadequate
Dietary Intake
Disease
Insufficient
Household
Food Security
Inadequate
Maternal and
Child Care
Insufficient Health
Services & Unhealthy
Environment
Formal and Non-
Formal Institutions
Potential
Resources
UNICEF
Framework

14. Preventive measures
 There is no simple solution to the problem of
PEM.
 Many types of actions are necessary.
 The following is adapted from the 8th FAO/WHO
Expert Committee on Nutrition for the prevention
of PEM in the community

15. Early detection of PEM
 The first indicator of PEM is under-weight for age
 The most practical method to detect this, is to
maintain growth charts
 These charts indicate at a glance whether the child is
gaining or losing weight.

16. (a) Health promotion
1. Measures directed to pregnant and lactating women
(education, distribution of supplements)
2. Promotion of breast feeding.
3. Development of low cost weaning foods : the child
should be made to eat more food at frequent intervals
4. Measures to improve family diet

17. Cont……
5. Nutrition education - Promotion of correct feeding
practices.
6. Home economics
7. Family planning and spacing of births
8. Family environment

18. (b) Specific protection
1. The child's diet must contain protein and energy-
rich foods. Milk, eggs, fresh fruits should be given if
possible.
2. Immunization
3. Food fortification

19. Early diagnosis and treatment
1. Periodic surveillance
2. Early diagnosis of any lag in growth
3. Early diagnosis and treatment of diarrhoea
4. Development of programmes for early rehydration
of children with diarrhoea.
5. Development of supplementary feeding
programmes during epidemics.
6. De-worming of heavily infested children

20. Rehabilitation
1. Nutritional rehabilitation services
2. Hospital treatment
3. Follow-up care

21. Policy:
To reduce PEM in under 5 years and reproductive
aged women
Strategies:
 Protect, promote and support optimal feeding
practice for infants and young children (capacity
building on IYCF)
 Increase coverage of GM
 BCC for changing dietary practices
 Strengthen Nutrition Rehabilitation Homes
 Community Based Management of Acute
Malnutrition
 Improve maternal nutrition and low birth weight of
baby through improved maternal nutrition practices

22. IDD
 IDDs are spectrum of the disorders that occur
due to deficiency of iodine & associated
hypothyroidism, commencing from intrauterine life
& extending through infancy, childhood,
adolescent to adult life with serious implications

23. Prevention and Control
 Strengthen the implementation of Iodized Salt
Act, 2055 for regulation and monitoring of Iodized
salt trade to ensure that all edible salt is iodized
 Increase the accessibility and market share of
iodized packet salt with ‘two‐child’ logo

24.  Create awareness about the importance of use
of iodized salt for the control of IDD through
social marketing campaign
 Celebrate month of February as an iodine month

25. Government action on IDD:
 Universal Iodization of Salt, 50 ppm at the point of
production to 30 ppm at retail and 15 ppm at
household level
 Distribution of iodized salt in remote area at
subsidized rates
 Monitoring of the iodized salt at the entry point and in
the market
 Iodized salt warehouse construction in various part of
the country
 Increase accessibility of 2- child logo iodized salt
 Social marketing of 2-child logo iodized salt
 BCC for use of iodized salt

26. Iron Deficiency Anemia
 It is a condition that results a lowering of
hemoglobin levels below which is considered to
be normal for a specific demographic group
 It occurs at all stages of the lifecycle but is more
prevalent in women especially pregnant women
and young children
 This is frequently worsened by infectious
diseases i.e. malaria, TB, hookworm infestations

27. Cause of IDA
 Some underlying causes
 Inadequate BF
 Incorrect or incomplete complementary feeding
 Low level of family education
 Poor intra family distribution of food at H/H level
 Poor cooking/processing, storage, preservation at
H/H level
 Food fad(trend) and faulty food habits

28. Cause of IDA
 Poor health and agricultural services
 Lack of institutional capacity/trained manpower
 Low production of iron rich foods
 Lack of H/H gardening
 Insufficient marketing infrastructures
 Poorly developed commercial food processing
industry

29. Prevention and Control
 Health Promotion
 Adequate nutrition, household gardening
 Nutrition education to improve dietary habits
 Health education specially to pregnant mothers
about hazards of anemia and their prevention
 Periodical deforming specially among children and
at least once during second trimester of pregnancy

30. Prevention and Control
 Specific Protection
 Food fortification with iron
 Salt, sugar, wheat flour & other foods for fortifications
 Supplementation with iron and other nutrients:
 Early Diagnosis and Prompt Treatment
 ED:
 By history of headache, giddiness, fatigue, loss of appetite
etc
 By clinical signs
 By lab investigations

31. Prevention and Control
 Disability Limitation
 It can be done by giving intensive treatment in
hospital by blood transfusion
 If severe anemia is associated with cardiac
failure(high output failure), packed cell transfusion is
given under the umbrella of digoxin, lasix &
potassium salts
 Rehabilitation
 If treatment is given correctly & completely, the
person will not become handicapped

32.  Objective
To reduce the prevalence of anemia among women and
children.
 Target:
To reduce the prevalence of iron deficiency anemia to
less than 40% by the year 2017.

33. Control of Anemia
 Increase coverage and compliance of iron/folic
supplementation for pregnant and breast feeding
women
 Reduce the burden of parasitic infestations
(Helminthes, Malaria and Kala‐azar)
 Identify and implement food fortification to
increase the dietary iron intake focusing on
commercial as well as small‐scale community
based fortification initiatives

34. Control of Anemia
 Promote dietary diversification to improve the
quality of food consumed with an emphasis on
bio‐available iron
 Promote maternal care practices and services to
improve health and nutritional status of mother
and babies

35. Control of Anemia
 Identify and implement the effective modalities to
address iron deficiency in adolescents and
non‐pregnant women of reproductive age
 Advocate for equity among genders in access
and control over household foods

36. Vitamin A Deficiency
 When there is deficiency of Vitamin A in the body,
several complications results in the body which is
called as VAD

37. Causes of VAD
 Some Immediate Causes
 Low intake of Vit A rich foods
 High incidence (of measles, diarrhea, ARI)
 Interference with the absorption of Vit A in the small
intestine(obs jaundice, giardiasis, ascariasis)
 Conversion of caretenoids to vitamin A in liver(in
certain diseases like chronic pancreatitis)
 Interference in transport(in liver disease)

38. VAD Control
 Objective
To virtually eliminate Vitamin A
deficiency disorder and sustain the
elimination
 Target
To virtually eliminate Vitamin A
deficiency disorder by the year 2017

39. VAD Control
 The Nepal vitamin A supplementation (VAS)
programme for young children is held up as a
global success story
 It was started in 1993 in 8 districts following a
meeting in Kathmandu that considered three
major research projects in Nepal in the late
1980s which all concluded that periodic
dosing of children 6‐60 months with high dose
vitamin A resulted in significant reductions in
child mortality

40.  By the end of 1997 the programme was
implemented in 32 districts and by 2002 it had
expanded to all 75 districts
 FCHVs distribute the capsules to young children
twice a year through a ‘campaign‐style’ activity

41. Government action on VAD:
 Bi-annually mass supplementation of Vitamin A to under
five children, 100000 IU for 6-12 months and 200000 IU
for 12-60 months children
 Vitamin A supplementation to postpartum mothers, 200000
IU within 6 weeks of delivery
 Treatment of clinical cases (eye problems, malnutrition,
measles, chronic diarrhea etc.)
 BCC for changing dietary practices
 Promote vitamin A fortification
 Nutrition education
 Support for home gardening to increase production of
Vitamin A rich fruits and vegetables
 Training on improved methods for production, preparation
and preservation of Vitamin A rich foods

42. Recommendation
 Proper monitoring of activities.
 Implementation plan should be prepared properly.
 Staff should be increased for education program .
 Train FCHV about BCC.
 Proper monitoring and evaluation of BFHI program.

43. Cont….
 Lack access of iron and folic acid fortified food in
community level ,increase access and
awareness.