NUTRITIONAL PROBLEMS

JENITA JOYCE JOHNI YEAR M.Sc., (N)

APOLLO CON, CHENNAI

INTRODUCTION

• Nutrition is the selection of foods and preparation of foods, and their ingestion to be assimilated by the body. By practicing a healthy diet, many of the known health issues can be avoided.

The diet of an organism is what it eats, which is largely determined by the perceived palatability of foods.

HISTORY OF NUTRITION• 400 B.C. -- Hippocrates, the

"Father of Medicine", said to his students, "Let thy food be thy medicine and thy medicine be thy food".  He also said  A wise man should consider that health is the greatest of human blessings. One story describes the treatment of eye disease, now known to be due to a vitamin A deficiency, by squeezing the juice of liver onto the eye. Vitamin A is stored in large amounts in the liver.

• 1747 Dr. James Lind, a physician in the British Navy, performed the first scientific experiment in nutrition. At that time, sailors were sent on long voyages for years and they developed scurvy. In his experiment, Lind gave some of the sailors sea water, others vinegar, and the rest limes.  Those given the limes were saved from scurvy. As Vitamin C wasnt discovered until the 1930s, Lind didnt know it was the vital nutrient. 

• Early 1800s It was discovered that foods are composed primarily of four elements: carbon, nitrogen, hydrogen and oxygen, and methods were developed for determining the amounts of these elements.

• 1930s William Rose discovered the essential amino acids, the building blocks of protein.

• 1940s The water soluble B and C vitamins were identified

• 1950s to the Present -- The roles of essential nutrients as part of bodily processes have been brought to light. For example, more became known about the role of vitamins and minerals as components of enzymes and hormones that work within the body

TERMINOLOGIES

• NUTRITION - The word Nutrition is the science of foods, the study of nutrients and other substances therein, their action, interaction and balance in relationship to disease.

• HEALTH – It is the state of complete physical, mental and emotional well being and not merely the absence of disease or infirmity.

• NUTRIENTS – These are the components of food that help to nourish the body. The basic nutrients are CHO, proteins, vitamins, lipids (fats), minerals and water.

• NUTRITIONAL STATUS – It is the condition of the body as it relates to consumption and utilization of food.

• Malnutrition – defined as a pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients

• Undernutrition - condition that results when insufficient food is consumed over an extended period of time

• Overnutrition – pathological state resulting from the consumption of excessive quantity of food over an extended time

• Imbalance – pathological state resulting from disproportion among essential nutrients with or without the absolute deficiency of any nutrient

• Specific deficiency – pathological state resulting from a relative or absolute lack of specific nutrients

CLA

SS

IFIC

ATIO

N O

F FO

OD

BASED ON FUNCTIONS

ENERGY YIELDING FOOD

CARBOHYDRATES

FATS

BODY BUILDING FOOD PROTEINS

PROTECTIVE FOOD

VITAMINS

MINERALS

BASED ON NUTRIENTS

MACRONUTRIENTS

MICRONUTRIENTS

CA

RB

OH

YD

RA

TES

MONOSACCHARIDES

GLUCOSE

FRUCTOSE

GALACTOSE

DISACCHARIDES

SUCROSE

MALTOSE

LACTOSE

POLYSACCHARIDES

STARCH

GLYCOGEN

DIETARY FIBER

LIPIDS (FATS)SIMPLE• FATS & OILS• WAXES

COMPOUND• PHOSPHOLIPID• GLYCOLIPIDS

DERIVED• STEROLS• FATTY ACIDS• LIPOPROTEINS

VITAMINS FAT

SOLUBLE

VITAMIN A

VITAMIN D

VITAMIN E

VITAMIN K

WATER SOLUBLE

THIAMIN B1

RIBOFLAVIN B2

NIACIN B3

PANTOTHENIC ACID B5

PYRIDOXINE B6

BIOTIN B7

FOLATE B9

CYANOCOBALAMINE B12

VITAMIN C (ASCORBIC ACID)

FOOD GUIDE PYRAMID

FATS, OILS &

SWEETSMILK & MEAT

PRODUCTS, EGGS & NUTSFRUITS &

VEGETABLE GROUP

BREAD, CEREALS AND RICE GROUP

ASSESSMENT OF NUTRITIONAL STATUS

• Clinical Examination• Anthropometry• Biochemical evaluation• Assessment of dietary intake• Vital statistics – morbidity and

mortality• Ecological factors

NUTRITIONAL PROBLEMS

NUTRITIONAL PROBLEMS

PROTEIN ENERGY

MALNUTRITION (PEM)

MICRONUTRIENT

DEFICIENCY

CHRONIC DISEASES

EATING DISORDERS

NUTRITION PROBLEMS IN INDIA

WHO IS AT RISK??

PREGNANT WOMEN LACTATING WOMEN INFANTS PRESCHOOL CHILDREN ADOLESCENT GIRLS ELDERLY

.

Vijayaraghavan

PROTEIN ENERGY MALNUTRITION• Protein–energy

malnutrition (or protein–calorie malnutrition) refers to a form of malnutrition where there is inadequate protein and calorie intake

• It is considered as the primary nutritional problem in India

• PEM is due to the “food gap” between the intake and requirement

• Causes childhood morbidity and mortality

PROTEIN ENERGY MALNUTRITION

PEM

KWASHIORKOR

MARASMUS

MARASMIC - KWASHIORKO

R

CAUSES AND RISK FACTORS

Inadequate intake of food

DiarrheaRespiratory

infectionsMeaslesIntestinal wormsInfants and pre

schoolers

CONTRIBUTORY FACTORS

Poor envt. HygieneLarge family sizePoor maternal healthFailure of lactationPremature termination

of breast feedingDelayed

supplementary feedingUse of over diluted

cow’s milk

KWASHIORKOR

Kwashiorkor is the most common and widespread nutritional disorder in developing countries. It is a form of malnutrition caused by not getting enough protein in the diet.

MARASMUS• Marasmus is a severe form of

malnutrition that consists of the chronic wasting away of fat, muscle, and other tissues in the body.

• Malnutrition occurs when the body does not get enough protein and calories.

• This lack of nutrition can range from a shortage of certain vitamins to complete starvation.

• Marasmus is one of the most serious forms of protein-energy malnutrition (PEM) in the world.

MARASMIC KWASHIORKOR

A malnutrition disease, primarily of children, resulting from the deficiency of both calories and protein. The condition is characterized by severe tissue wasting, dehydration, loss of subcutaneous fat, lethargy, and growth retardation

KWASHIORKOR AND MARASMUS – A COMPARATIVE CHART

KWASHIORKORAcute

illness/infections, measles, AGE, trauma, sepsis are some causes

Protein is principal nutrient

18 months to 3 yearsRapid, acute onsetSome weight lossHigh mortality

MARASMUSSevere prolonged

starvation, chronic/recurring infections

Calories and protein are principal nutrients

6 months to 2 yearsChronic, slow onsetSevere weight lossLow mortality unless

related to underlying disease condition

BIRTH

BREAST FEEDING

EARLY ABRUPT WEANING

DILUTE DIRTY FORMULA

REPEATED INFECTIONS

STARVATION THERAPY

NUTRITIONAL MARASMUS

MARASMIC KWASHIORKOR

LATE GRADUAL WEANING

STARCHY FAMILY DIET

ACUTE INFECTIONS

KWASHIORKOR

COMPARISON OF CLINICAL FEATURES KWASHIORKOR

Edema, pot belly, swollen legs

Mild to moderate growth retardation

Weight masked by edemaLow subcutaneous fatMuscle atrophyRound face (moon face)Dry, flaky peeling skinThin dry easily plucked

hairEnlarged liverXerophthalmiaAnemia, diarrhea, infection

MARASMUSNo edemaWeight loss upto 40%Severe growth failure

Severe emaciationSevere loss of subcut fatSevere muscle atrophyWrinkled face (old man’s

face)Rare skin changesCommon hair changesMildly enlarged liverAnemia, diarrhea, infection

ASSESSMENT OF PEM

Gomez Classification

• Weight for age (%) = Weight of child 100

Wt. of normal child of same age

Between 90 – 110% Normal Nutritional StatusBetween 75 – 89% Mild malnutrition (1st degree)Between 60 – 74% Moderate Malnutrition (2nd

degree)Under 60% Severe Malnutrition (3rd degree)

WEIGH CALCULATION FORMULAE

• Infant – Weight (Kg) = Age in months + 9 2• Pre schooler – Weight (Kg) = 2 x (Age in

years) + 5

PREVENTION• Oral rehydration therapy helps to prevent

dehydration caused by diarrhea• Exclusive breast feeding for 6 months there

after supplementary foods may be introduced along with breast feeds

• Immunization for infants and children • Nutritional supplements• Early diagnosis and treatment• Promotion and correction of feeding

practices• Family planning and spacing of birth• Periodic surveillance• Nutritional rehabilitation

LOW BIRTH WEIGHT

An LBW newborn is any newborn with a birth weight of less than 2.5kg (including 2.499kg) regardless of gestational age.

RISK FACTORSoMaternal

malnutritionoAnemia

CAUSESo Illness/infectionsoShort maternal

statureoVery young ageoHigh parityoClose birth intervalso IUGRoHard physical labor

during pregnancyoSmoking

LOW BIRTH WEIGHT

PRE TERM BABIES SGA BABIES

SPONTANEOUS PRE

TERM BIRTH

PROVIDER INITIATED PRE TERM

BIRTH

PREVENTION• Identification of mothers at risk – malnutrition, heavy work

load, infections, disease and high BP• Increasing food intake of mother, supplementary feeding,

distribution of iron and folic acid tablets• Avoidance if smoking• Improved sanitation methods• Improving health and nutrition of young girls• Early detection and treatment of medical disorders – DM HTN• Controlling infections – UTI, rubella, syphillis, malaria

MICRONUTRIENT DEFICIENCY

MIC

RO

NU

TR

IEN

TS

VITAMINS

VITAMIN A

VITAMIN B COMPLEXES

VITAMIN C

VITAMIN D

VITAMIN K

MINERALS

MAJOR MINERALS

CALCIUM

PHOSPHORUS

SODIUM

POTASSIUM

MAGNESIUM

TRACE ELEMENTS

IRON

IODINE

FLUORINE

ZINC

VITAMIN A DEFICIENCY

Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A crude population measure of obesity is the body mass index (BMI), a person’s weight (in kilograms) divided by the square of his or her height (in meters). A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight.

XEROPHTHALMIA

Xerophthalmia i.e., dry eyes refers to all the ocular manifestations of vitamin A deficiency in manIt is the most widespread and serious nutritional disorder leading to blindness

RISK FACTORSPoor SE statusFaulty feeding

practicesWeaningPEMInfections1-3 years

CLINICAL FEATURES

Corneal ulcersSoftening of corneaKeratomalaciaBitot spot

PREVENTION AND CONTROL

Administering large doses of vitamin A orally on a periodic basis

Regular and adequate intake of vitamin A

Fortification of certain food with vitamin A – sugar, salt, tea and skimmed milk

NUTRITIONAL ANEMIA

Nutritional anemia is a condition where the hemoglobin content of blood is lower than normal as a result of a deficiency of one or more essential nutrients, regardless of the cause of such deficiency.

RISK FACTORS Infants and children Pregnant women Pre menopausal

women Adolescent girls Older adults Alcoholism Chronic/ critically ill Excessive exercise

CAUSES Inadequate diet Insufficient intake of

iron Iron malabsorption Pregnancy Excessive menstrual

bleeding Hook worm

infestation Malaria Close birth intervals GI bleed

CLINICAL MANIFESTATIONS

EFFECTS OF ANEMIA

• Increases risk of maternal and fetal morbidity and mortality• Abortions, premature births, PPH, low

birth weight are associated with anemia during pregnancy

PREGNANCY

• Anemia can be aggravated by parasitic infections like malaria, intestinal parasites• Iron deficiency may repair cellular

response and immune functions

• More severe the anemia, greater the reduction in work performance

INFECTION

WORK CAPACI

TY

PREVENTIONEstimation of Hb to assess degree of

anemiaBlood transfusion in severe cases of

anemia (<8g/dL)Iron and folic acid supplementsFood fortification with ironChanging dietary habitsControl of parasitesNutritional education and awareness

IODINE DEFICIENCY DISORDERS (IDD)

IDD leads to a much wider spectrum of disorders commencing with the intrauterine life and extending through childhood to adult life with serious health and social implications

DISORDERSGoiterHypothyroidismSubnormal intelligenceDelayed motor milestonesMental deficiencyHearing defectsSpeech defectsMental retardationNeuromuscular weaknessEndemic cretinismIntrauterine death

PREVENTION• Iodized salt • Iodine monitoring• Public awareness

and education

COMPLICATIONS• Thyrotoxicosis• Iodide goiter• Iodinism• Lymphocytic

thyroiditis

ENDEMIC FLUOROSIS

In many parts of the world where drinking water contains excessive amounts of fluorine (3-5mg/L), endemic fluorosis has been observed.

ENDEMIC FLUOROS

IS

DENTAL FLUOROS

IS

SKELETAL

FLUOROSIS

DENTAL FLUOROSIS

• It occurs when excess fluoride is ingested during the years of tooth calcification – first 7 years of life

• Characterized by molting of dental enamel which has been reported above 1.5mg/L intake

• Fluorosis seen on the incisors of upper jaw

SKELETAL FLUOROSIS

• Associated with life time daily intake of 3-6mg/L or more

• Heavy deposition of fluoride in skeleton

• Crippling occurs leading to disability

PREVENTION

• Changing the water sources• Chemical defluorination• Preventing use of fluoridated

toothpaste• Fluoride supplements not prescribed

for children consuming fluoridated water

LATHYRISM• It is a paralyzing disease of

human and animals• Also referred to as Neurolathyrism

as it affects the nervous system• Lathyrus Sativus is commonly

known as ‘khesari dhal’, a good source of protein but its toxins affects the nerves

• The toxin present in lathyrus seed has been identified as BETA OXALYL AMINO ALANINE (BOAA) which has blood brain barrier

STAGES OF LATHYRISM

• Latent stage• No stick stage• One stick stage• Two stick stage• Crawler stage

INTERVENTIONS

• Vitamin C prophylaxis• Banning the crop• Removal of toxin• Education and awareness• Genetic approach – producing low

toxin variety of crop• Socio economic changes

NUTRITIONAL PROGRAMS

• Vitamin A Prophylaxis Program• Prophylaxis against Nutritional Anemia• IDD Control Program• Specific Nutrition Program• Balwadi Nutrition Program• Integrated Child Development Scheme • Mid – day Meal Program• Mid – day Meal Scheme

CHRONIC DISEASES

OBESITY

Obesity is an epidemic diseases, which consists of body weight that is in excess of that appropriate for a person’s height and age standardized to account for differences, leading to an increased risk to health related problems

Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A crude population measure of obesity is the body mass index (BMI), a person’s weight (in kilograms) divided by the square of his or her height (in metres). A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight.

EATING DISORDERS

ANOREXIA NERVOSA• Anorexia nervosa is

an eating disorder characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure, and an irrational fear of weight gain, as well as a distorted body self-perception.

BULIMIA NERVOSA• Bulimia nervosa is an eating

disorder characterized by binge eating and purging, or consuming a large amount of food in a short amount of time followed by an attempt to rid oneself of the food consumed (purging), typically by vomiting, taking a laxative, diuretic, or stimulant, and/or excessive exercise, because of an extensive concern for body weight.

CLINICAL MANIFESTATIONS• Amenorrhea• Obvious, rapid, dramatic weight loss at

least 15% under normal body weight[

• May engage in frequent, strenuous, or compulsive exercise

• Perception of self as overweight despite being told by others they are too thin

• Intolerance to cold and frequent complaints of being cold. Body temperature may lower in an effort to conserve energy

• Hypotension and/or orthostatic hypotension

• Bradycardia or tachycardia• Depression: may frequently be in a

sad, lethargic state• Solitude: may avoid friends and family;

becomes withdrawn and secretive• Swollen joints• Abdominal distension• Halitosis (from vomiting or starvation-

induced ketosis)• Dry hair and skin, as well as hair thinning• Fatigue• Rapid mood swings

CONCLUSION

Good nutritional habits and a balanced diet aren't developed in one day, nor are they destroyed in one unbalanced meal. Healthful eating means a lifestyle of making choices and decisions, planning, and knowing how to make quick and wise choices when you haven't planned.

INTERNET INFORMATION

• Metformin is a drug commonly used to treat type 2 diabetes. But new research published in the Proceedings of the National Academy of Sciences (PNAS) finds the medication may also slow the aging process and increase lifespan.

JOURNAL INFORMATION

• Overweight and obesity among children – TNNMC journal of CHN• Nutritional status of pre school

children attending balwadi – Indian Journal of nutrition and dietetics

BIBLIOGRAPHY• Dudek Susan G – Nutrition essentials for nursing

practice• K Park – Textbook of preventive and social

medicine• John Sheila – Essentials of nutrition and dietetics

for nursing• Fraser Diane, Cooper Margaret A – Myles textbook

for midwives• Swaminathan K – Nutrition and dietetics