Dr Mohammad Hayatun Nabi MPHAus MHSMAus MBBS Dept of Public Health Introduction The prevalence of malnutrition in Bangladesh is among the highest in the world Millions of children and women suffer from one or more forms of malnutrition including low birth weight wasting stun ID: 694642
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Common Nutritional problems in Bangladesh Part I
Dr. Mohammad
Hayatun
Nabi
MPH(Aus), MHSM(Aus), MBBS
Dept. of Public HealthSlide2
Introduction
The prevalence of malnutrition in Bangladesh is among the highest in the world.
Millions of children and women suffer from one or more forms of malnutrition including low birth weight, wasting, stunting, underweight, Vitamin A deficiencies, iodine deficiency disorders and anemia.
Globally, malnutrition is attributed to almost one-half of all child deaths.
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Bangladesh has made good progress in the past decade to achieve Millennium Development Goal 1, the eradication of extreme poverty and hunger, more needs to be done.
Malnutrition rates have seen a marked decline in Bangladesh throughout the 1990s, but remained high at the turn of the decade.
Nationally, 41% of children under five years are moderately to severely underweight and 43.2% suffer from moderate to severe stunting, an indicator for chronic malnutrition.
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Common Nutritional Problems
Protein energy malnutrition
Low birth weight
Nutritional anemiaNutritional blindnessIodine deficiency disorders
Seasonal vitamin deficiency
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PEM- Introduction
Protein Energy Malnutrition (PEM) continues to be a major public health problem in many developing countries.
It affects mostly children under 5 years of age belonging to the poor underprivileged communities.
The condition is particularly serious during the post weaning stage and is often associated with infection.
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Cont…
Respiratory infection and diarrhea are the common diseases that precipitate severe PEM and death.
Apart from contributing to high mortality, severe malnutrition can lead to permanent squeal in those who survive.
These include stunted growth, poor learning ability and reduced work efficiency.
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“PEM”: Invariably reflects combined deficiencies in…
Protein: deficit in amino acids needed for cell structure, function
Energy: calories (or joules) derived from macronutrients: protein, carbohydrate and fat
Micronutrients: vitamin A, B-complex, iron, zinc, calcium, others
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Classification
Several methods have been suggested for the classification of PEM.
The choice of classification depends on the purpose for which it is used.
In clinical studies, patients with severe PEM are classified into 3 groups- kwashiorkor, marasmus and marasmic
kwashiorkor.WHO classification
Gomez classification
Wellcome
classification
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Gomez Classification
Malnutrition Body weight
(% of standard*)
Grade 1 76-90
Grade 2 60-75Grade 3 <60
*Harvard
standard
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Etiology
Protein energy malnutrition results from the interaction of several factors of which, inadequate diets and infectious diseases are the most important.
Preschool children age are most seriously affected because their nutritional requirements are relatively higher than those of adults and infections occur more frequently in this age group.
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Etiology
Diet
Free radicals
InfectionsSocio-demographic factors
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Marasmus
Clinical features:
•Severely wasted (emaciated) & stunted •“Balanced”starvation
•“Old Man”face, wrinkled appearance, sparse hair
•No edema, fatty liver, skin changes
•Too little breast milk or complementary foods
<
2yrs of age
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Too little breast milk, often after 6 mo of age
Dilute and unhygienic formula or bottle feeding
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•
Kwashiorkor
Clinical Features:
Edema, it tends to be generalised
•Mental changes
•Hair changes: the black color alters to blonde, grey
Mucosal changes: angular stomatitis
•Fatty liver
•Dermatosis (skin lesions)
•Infection
Anorexia
•High case fatality
•Low prevalence
1
st
to 3
rd
yrs of life
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Features
Marasmus
Kwashiorkor
Cause
Due to deficiency of calories and other nutrients in addition to protein
Due to protein deficiency
Essential features
1. Edema
Absent
Present in the lower legs, sometimes face or generalized
2. Wasting
Marked, all skin and bone
Less obvious, child looks flabby
3. Muscle wasting
Severe
Sometimes, less
4. Growth retardation in terms of body weight
Severe
Less than in marasmus
Differences between Marasmus and Kwashiorkor
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5. Mental changes
Usually absent
Usually present
Variable features
1. Appetite
Usually good
Usually poor
2. Skin changes
Usually none
Often, diffuse depigmentation
3. Hair changes
Slight change in texture
Often sparse- straight and silky, dyspigmentation- grayish or reddish
4. Moon face
None
Often
5. Hepatic enlargement
None
Frequent
Differences between Marasmus and Kwashiorkor
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Prevention of PEM
Prevention of Kwashiorkor
Educate mother
Advice to farmersProvide food supplements in hospitalsLegumes, nuts and seeds (locally produced)Prevention of MarasmusFamily planningImmunization program
Encourage breastfeedingMaternity and child health clinics
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Vitamin A deficiency Disorders
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Introduction
Nutritional blindness due to
xeropthalmia
is an important public health problem among young children in developing countries.The term xerophthalmia encompasses all ocular manifestations of vitamin A deficiency. It includes the structural changes affecting conjunctiva, cornea and occasionally retina, and also the biophysical disorders of retinal rod and cone functions.
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Vitamin A
Adequacy
Deficiency
Bone growth Growth retardation
Reproduction Dysfunction (M&F)Embryogenesis Teratogenesis
Rod vision
Night
blindness
Cell differentiation Epithelial
metaplasia
Immunity Impaired innate & acquired
defenses
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VITAMIN A DEFICIENCY DISORDERSHealth Consequences of VAD
Xerophthalmia: Mild to severe
Corneal blindness and disability
AnemiaStunted growthImpaired immunityIncreased severity of infection
(eg,measles, diarrhea, or malaria)Mortality
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WHO Xerophthalmia Classification (1982)
XN Nightblindness
X1A Conjunctival xerosis
X1B Bitot’s spotsX2 Corneal xerosisX3 Corneal ulcerationKeratomalaciaXS Corneal scarring
XF Xerophthalmic fundus
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Night Blindness
It is an useful screening tool and correlates with other evidence of vitamin A deficiency.
It can be elicited in the case of young children by detailed questioning of the parents or the guardians.
The children usually cannot see in dim light, either at dusk or down.The value of night blindness will depend on the care with which the questions are asked, and upon the degree to which the phenomenon of night blindness is recognized by the community.
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Magnitude
Globally it is estimated that every year about 7,00,000 children are likely to develop corneal lesions due to vitamin A deficiency.
The problem is considered to be of public health significance in 36 countries, in South East Asia, the western Pacific and Africa.
About 20-40% million children are estimated to have mild vitamin A deficiency at any point of time. Mahtab et al, 2003
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Epidemiology
Age
Vitamin
A deficiency is preponderant in children. While it is rare during infancy, preschool age children are at a greater risk
.
Sex
Xerophthalmia
is more frequent in boys than in girls.
The incidence of
keratomelacia
is similar in both the sexes.
Socio-economic Factors
Children from rural and tribal families belonging to low-income group are more vulnerable to vitamin A deficiency.
The mothers of vitamin deficient children are generally illiterate and unaware of the importance of diet in disease.
Because of food fads and false beliefs, foods like colostrums, green leafy vegetables and papaya which are rich in vitamin A are avoided.
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Seasonal Effects
The seasonal changes in vitamin A deficiency are related to times of harvest.
The highest prevalence is observed in the months of May-June and November-December.
DroughtThe extent of vitamin A deficiency is more during drought due to non-availability of leafy vegetables because of shortage of rainfall.The prevalence is higher in areas which are chronically drought prone.
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Aetiology
Inadequate dietary intake of vitamin A or its precursor (
b
-carotine) is the most important contributory factor.The common childhood infections like measles, diarrhea, respiratory tract infections, and infestations like
ascariasis and giardiasis interfere with the absorption of vitamin A.
Low purchasing power of the communities and their inability to meet the dietary requirements even after spending 80-90% of their income on food is an important factor for the widespread prevalence of vitamin A deficiency
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Prevention And Control
Vitamin A deficiency is one of the simplest preventable nutritional disorders.
Several strategies are possible for controlling
xerophthalmia and the consequent blindness:Periodic dosing SuppliesFortification
Dietary modifications to promote production and consumption of vitamin A/ beta carotene rich foods through nutrition education and/or horticulture intervention.
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Thank You
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Dr. Mohammad Hayatun Nabi