Review of different types and manifestations of undernutrition - protein-energy undernutrition (PEU) and vitamin deficiency

1. UNDERNUTRITION
PREPARED BY:
SAMAH ABDELAAL
UNDER SUPERVISION OF:
PROF.DR. SHAHIRA RAMSIS

2. MALNUTRITION
The term malnutrition addresses 3 broad groups of conditions:
Malnutrition refers to deficiencies, excesses, or imbalances in a
person’s intake of energy and/or nutrients.

3. MALNUTRITION
undernutrition, which includes protein energy
undernutrition (PEU)
micronutrient-related malnutrition, which
micronutrient deficiencies (a lack of important
vitamins and minerals) or micronutrient excess; and
overweight, obesity and diet-related
noncommunicable diseases (such as heart
disease, stroke, diabetes and some cancers).

4. CAUSES OF UNDERNUTRITION
• Primary: (Decreased intake of:)
1- Energy and/ or protein (Kwashiorkor, Marasmus)
2- one or more minerals/ vitamins (Vitamin A,
iodine,…)

5. CAUSES OF UNDERNUTRITION
• Secondary: (Normal diet)
1- Alteration of normal metabolism (infection, fever,
HIV/AIDS)
2- Malabsorption (diarrheal infections)
3- Diversion of nutrients to parasitic agents
(hookworms, malaria,…)

6. A- PROTEIN ENERGY UNDERNUTRITION (PEU)
Kwashiorkor Marasmus
Causes Proteins Calorie intake
(from all nutrients)
Age 1-4 years 6-8 months

7. Clinical Picture • Mental retardation
• Hypoglycemia
• Hypoalbuminemia
• Oedema “moon face”
• Overweight
• Muscle wasting
• Skin and hair changes
• No mental changes
• Normal sugar
• Normal albumin
• Senile look
• Underweight
• Severe muscle wasting
“skin over bone”
• Dry lusterless hair , Flag
sign
Prognosis Bad (Coma & death) Good

9. PREVENTION
OF PEU
Health education about breast
feeding and proper weaning
Growth monitoring for early
detection
Rehydration and nutrition
supplementation

10. B- MICRONUTRIENT
UNDERNUTRITION
1- Vitamin D and Calcium (Rickets)
Definition:
• Defective calcification of osteoid &
epiphyseal cartilage of growing
bone.
• Decreased vitamin D that affects
absorption, utilization & deposition
of calcium & phosphorus in bone.
Age: 6- 24 months
Prevalence: 25% in developing countries

11. RICKETS
Causes:
• Decreased intake
• Poor calcium supplementation during
pregnancy
• Repeated unspaced pregnancy
• Preterm and twin babies
• Decreased sun exposure due to dust particles,
clouds, smoke or excessive wrapping of
infants

12. RICKETS
Clinical picture:
• Muscle weakness & hypotonia
• Delayed teeth eruption
• Delayed closure of fontanelles
• Craniotabes, skull bossing
• Epiphyseal enlargement
• Bone deformities, beading of
ribs, and pigeon chest; leading
to recurrent chest infections

13. RICKETS
Prevention:
• Primary
• Sun exposure
• Nutritional education for mothers
• Proper nutrition for pregnant and baby
• Increased pregnancy spacing
• 2. Secondary
• Growth monitoring for early detection
• Vitamin D supplementation, 400 IU oral or 200,000 IU IM
• 3. Tertiary
• Treatment of complications
• Rehabilitation and social support

14. OSTEOMALACIA & OSTEOPOROSIS
Osteomalacia Osteoporosis
Definition • Softening of
bone
• Bone replaced by
soft osteoid
tissue
• Atrophy of
• Reduction of
bone density and
mass (more than 2.5
SD from mean of
reference population)

15. OSTEOMALACIA & OSTEOPOROSIS
Pathogenesis • Ca deficiency
with and without
vitamin D and Ph
deficiency
Failure to replace
bone turnover
Demineralized
tissue
• Bone mass starts
to decline after
age of 40
• Due to
resorption, Ca,
Ph & vitamin D
deficiency
formation of too
little bone

16. OSTEOMALACIA & OSTEOPOROSIS
At risk groups &
predisposing
factors
Modifiable
• Young women
with repeated
pregnancy
• Diet deficient in
Ca, Ph, and
vitamin D
• Malabsorption &
chronic renal
failure
Non-modifiable
• Postmenopausal women
• Elderly
• Delayed puberty & hypogonadism
Modifiable
• Diet deficient in Ca, Ph, and vitamin D
• Low body weight
• Sedentary life
• Smoking & alcoholism
• Malignancy and chronic renal failure
• Endocrinal diseases ad Cushing’s
syndrome
• Drugs as corticosteroids, cytotoxic
drugs

17. OSTEOMALACIA & OSTEOPOROSIS
Clinical picture • Bone ache
• Muscle weakness
• Uneven (Waddling)
gait
• May be asymptomatic
• Progressive vertebral
collapse
Persistent backache &
kyphosis
• Hip fracture
Treatment • Calcium & vitamin D
supplementation
• Early: Calcium &
vitamin D
supplementation
• Late: anti-resorptive
drugs>> Estrogen
Receptor Modulators

18. 2-IRON
DEFICIENCY
ANEMIA
Most prevalent undernutrition disorder
Causes:
• Increased demand (infant, adolescent,
pregnancy & lactation)
• Increased loss:
• Chronic blood loss, intravascular
hemolysis
• Gynecological conditions (menorrhagia,
polymenorrhagia,…)
• GI blood loss (NSAIDS, peptic ulcer, and
parasitic diseases
• Decreased intake in diet

19. 2-IRON
DEFICIENCY
ANEMIA
Decreased absorption due to:
• Malabsorption syndrome
• Iron of plant origin (less absorbable)
• Decreased intake of vitamin C
• Hypoacidity of the stomach
• Precipitation of iron by oxalates &
phosphates

20. 2-IRON
DEFICIENCY
ANEMIA
Clinical picture:
• Headache
• Pallor, brittle nails & hair loss
• Fatigue
• Dyspnea on exertion
• Angina
• Palpitation and hemic murmurs
• Decreased physical and mental abilities

21. 2-IRON DEFICIENCY ANEMIA
• Clinical picture
• Lab: decreased…
• Hemoglobin < 13 g/dl in men, 12 g/dl in women
• CBC: microcytic hypochromic anemia
• Iron profile: low serum iron, ferritin, transferrin and high
TIBC
Diagnosis:

22. 2-IRON
DEFICIENCY
ANEMIA
Prevention:
• 1- Primary
• Health education for increase of food rich in iron
• Iron supplementation
• 2- Secondary
• Screening for early detection
• Treatment with iron drugs
• 3-Tertiary
• Treatment of complications

23. 3-VITAMIN B12 (PERNICIOUS ANEMIA)
• Brain & CNS development and function
• Red cell formation and maturation
• Immune function
B12 is essential for:

24. 3-VITAMIN B12
(PERNICIOUS
ANEMIA)
Causes:
Decreased intake of animal sources (meat, poultry, fish, milk,…)
Decreased absorption
• Atrophic gastritis (decreased intrinsic factor)
• Celiac disease (gluten sensitivity >> intestinal
damage)
• Crohn’s disease
• Surgical removal of a portion of stomach or
intestine
• Drugs for : DM, acid reflux, peptic ulcer…

25. 3-VITAMIN B12
(PERNICIOUS
ANEMIA)
Clinical picture:
• Confusion, memory loss & dementia
• Numbness, cold hands & feet
• Poor appetite
• Sore mouth & tongue
• Constipation
• Pale skin
• Chest pain & palpitation

26. 3-VITAMIN B12
(PERNICIOUS
ANEMIA)
Prevention:
• 1-Primary
• Health education for increased intake of
animal sources
• 2-Secondary
• Early detection of vitamin B12 deficiency
• Treatment of causes of decreased absorption
• B12 supplementation

27. 4-FOLIC ACID
Causes:
• Decreased intake of dark
leafy vegetables, meat,…
• Increased demand
(pregnancy)

28. 4-FOLIC ACID
Clinical picture:
• Megaloblastic
anaemia
• Neural tube defect
• Spina bifida
• Anencephaly
• Low birth weight
• Preterm labor

29. 4-FOLIC ACID
Prevention:
• Primary
• Health education
• Increased intake of liver, kidney, fish, and
green leafy vegetables
• Folic acid supplementation especially
before and during the first trimester of
pregnancy.

30. 5-VITAMIN A
Protects skin and mucosa
Increased leucocyte activity
Protect against death in measles by
50% and in diarrhea by 30%

31. 5-VITAMIN A
Manifestations of
vitamin A deficiency:
Night blindness:
impaired dark
adaptation
Day sight or
nyctalopia
Xerophthalmia: due
to affection of
lacrimal glands
Bitot spots on cornea
Corneal ulceration &
keratomalacia >>
blindness
Xerosis & follicular
keratosis of skin
Increased risk of
urinary and
respiratory infections

33. 5-VITAMIN A • Primary
• Consumption of food rich in vitamin A or its
precursor B-carotene (carrots, liver, milk,…)
• Vitamin A supplementation:
• For mother … 200,000 IU
• For child … 9th month 100,000 IU, 18th
month 200,000 IU
• Secondary
• Screening for early detection and treatment
• Tertiary
• Treatment of complications (e.g. corneal
Prevention:

34. 6-VITAMIN B1 “THIAMINE” (BERI BERI)
Deficiency is common
in East Asia (diet is
mainly white rice)
Clinical picture:
• Muscle wasting and nerve
damage
Prevention:
• Increase intake of beef, whole
grains, and whole bread.

35. 7-VITAMIN B3
“NIACIN”
(PELLAGRA)
Clinical picture:
• 4Ds “Diarrhea, Dermatitis,
Dementia, and Death”
Prevention:
• Consumption of broccoli, eggs,
dates, beef, salmon, and peanuts

37. 8-VITAMIN C
(SCURVY)
Causes:
• Decreased intake
• Smoking (depletes vitamin C)
• Bottle feeding of infants
• Sailors and desert workers (consume canned
food)
• Increased demand in pregnancy and elderly

38. 8-VITAMIN C (SCURVY)
Manifestations: General weakness Muscle & joint pain
Swelling of gums,
Stomatitis &
Gingivitis
Blepharitis
Impaired wound
healing
Bleeding &
hemorrhage under
the skin
Anemia (due to
decreased iron
absorption)

39. 8-VITAMIN C
(SCURVY)
Prevention:
• Primary
• Health education for increased intake
of fresh fruits and vegetables
• Dietary supplementation
• Supplying infants during weaning with
orange and tomato juice

40. 9-IODINE
DEFICIENCY
Most important cause of preventable mental retardation in babies
Manifestations of iodine deficiency:
• Hypothyroidism & endemic goiter
• Miscarriage & stillbirth
• Cretinism: mental retardation, stunted
growth, deaf mutism
Prevention:
• Increased intake of fish, sea plants, and
vegetables grown in iodized soil.
• Iodizing salt

41. 10-ZINC
Protects skin & mucosa
Zinc supplementation decreased
length and severity of diarrhea
by 1/3 and incidence of
pneumonia by 12%
Clinical picture:
• growth retardation,
skin and eye infection
Prevention:
• Consumption of
whole grains,
legumes, meat, fish
and chicken

42. THANK YOU