PROTEIN ENERGY MALNUTRITION

Result when the bodys needs for protein energy fuels or both cannot be satisfied by the diet A wide spectrum of clinical manifestations conditioned by : - The relative intensity of prot or E deficit - The severity & duration of deficiencies - The age of host

- The cause of the deficiency

- The association with other nutr / infec. disease

Dietary E& prot deficiencies usually occur together, but sometimes one predominates -Kwashiorkor -Marasmus -Marasmic Kwashiorkor

Causes

Social & Economic factors

*Poverty that result in low food

availability improper child care *Ignorance, by itself or associated with poverty

*Inadequate weaning practices

Poor infant & child rearing practices Misconceptions about the use of certain foods Inadequate feeding during illness Improper food distribution within the family

*Social problems Child abuse

Maternal deprivation Abandonment of the elderly Alcoholism & Drug *Cultural & Social practices Impose food taboos Some food & diet fads particularly among addlescents & women Migration from traditional rural settings to urban slums

Biologic Factors
*Infections

*Maternal Malnutrition Prior to and / or during pregnancy Diarrheal, measles, AIDS, TB Result in negative prot & e balance

diseases

Because of anorexia, vomiting, decreased absorb, catabolic processes

Environmental Factors
*Overcrowded & / unsanitary living conditions *Agricultural patterns, droughts, flooda, war, forced migrations *Postharvest losses of food because of bad storage conditions & inadequate food distribution system

Age of host
*Infants & young children *The elderly who are unable to care properly for themselves

*Adolescents, adult men, non pregn & non lact usually have the lowest prevalence & the mildest forms of the disease

COMPARISON OF THE FEATURES OF KWASHIORKOR & MARASMUS KWASHIOKOR 1. Wasting : present 2. Oedema : present 3. Hair changes : common 4. Mental : very common 5. Dermatosis : common 6. Appetite : poor 7. Growth failure: present MARASMUS 1. Present, marked 2. Absent 3. Less common 4. Uncommon 5. Does not occur 6. Good 7. Present

COMPARISON OF THE FEATURES OF KWASHIORKOR & MARASMUS KWASHIOKOR 8. Subcutan fat: reduce but present 9. Face : May be oedematous 10. Fatty infiltration of liver : present 11. Anaemia : severe (sometimes) MARASMUS 8. Absent 9. Monkey-like 10. Absent

11. Present, less severe

IRON DEFICIENCY ANAEMIA

IRON DEFICIENCY
IRON DEFICIENCY ANAEMIA

ANAEMIA

Iron cycle in human

Erythropoiesis & heme synthesis

Bone marrow
Intestinal absorption

Plasma & ECF

Ineffective erythropoiesis

Ery (blood)
Bleeding & other excretion

Stores (Feritin & hemosiderin

Phagocytes
Ery destruction & Hb catabolism

FUNCTIONAL CONSEQUENCES OF IRON DEFICIENCY

IRON DEFICIENCY ADVERSELY AFFECTS :
the cognitive performance, behaviour, & physical

growth of infants, preschool & school-aged children

the immune status & morbidity from infections of all age groups
the physical capacity & work performance of adolescents & adults of all age groups

IDA DURING PREGNANCY

INCREASES PERINATAL RISKS FOR MOTHER & NEONATES INCREASES OVERALL INFANT MORTALITY

COGNITIVE DEVELOPMENT
Fe play a key role in brain function (animal study)
IDA show alterations in neurotransmitters & behaviour IDA delay psychomotor development & impair cognitive performance of infants

PREGNANCY
IRON DEFICIENCY IN CHILDBEARING WOMEN INCREASES : Maternal mortality Prenatal & perinatal infant loss Prematurity

ENDOCRINE & NEUROTRANSMITTERS

Iron deficiency alters : The productions of triiodothyronine (T3) & thyroid function in general The production & metabolism of catecholamines & other neurotransmitters

HEAVY-METAL ABSORPTION
Important consequence of iron deficiency increased risk of heavy-metal poisoning in children Prevention of iron deficiency, therefore, reduces the number of children susceptible to divalent heavy metals poisoning

Classification of public health significance of anaemia in populations on the basis of prevalence estimated from blood levels of haemoglobin
Category of public health significance Severe Moderate Mild Normal Prevalence of anaemia (%) > or = 40 20,0 39,9 5,0 19,9 < or = 4,9

EPIDEMIOLOGY

AGE GENDER PHYSIOLOGICAL STATE PATHOLOGICAL STATE

Pregnancy, lactation

ENVIRONMENTAL FACTORS SOSIOECONOMIC STATUS

Infection (parasitic, malaria), genetic

Diet low Fe, low bioavailability, other nutrients

Assessment, surveillance & indicators

Individual & population-based assessment - Method of screening individual/population - Limitation of the test - Monitoring the response after 1 or 2 months of oral supplementation with Fe - In resource-adequate situations, the usual practice involves the use of further, specific & more sensitive test for individual assessment

Assessment, surveillance & indicators

Purposes of biological assessments - determine the magnitude, severity & distribution of iron deficiency & anaemia & preferably its main causes (basis of planning policies & interventions) - identify populations more affected or at greater risk (select priority areas for action) - monitor trends in prevalence & evaluated the impact of interventions

Assessment, surveillance & indicators

Selection of subjects for assessment - Vulnerability Varies greatly with each stage of the life cycle. This variation is due to changes in iron stores, level of intake & needs relating to growth or iron losses - Accessbility (for monitoring purposes) - Representativeness

Assessing iron status on the basis of resource availability in a country

Level of resource Prev of Anaemia Screening Confirmation or diagnostic Poor Severe Clinical exam Hb/Ht Clinical response to Fe adminst Intermediate Moderate Hb/Ht Hb/Ht response to Fe adminstr Adequat Mild Hb, Ht + SF, TS Hb/Ht response to Fe adminstr SF,TS,TR

PREVENTION STRATEGIES
EFFORTS SHOULD BE TARGETED TO: - Reduce poverty - Improve access to diversified diet - Improve health services & sanitation - Promote better care & feeding practices

PREVENTION STRATEGIES
FOOD-BASED APPROACHES 1.1. Dietary improvement - improve the year-round availability of micronutrient-rich food - ensure the access of households, especially those at risk, to these food 1.2. Food fortification Requires the cooperative efforts of governments, the food industry & consumers
1.

FOOD FORTIFICATION
Essential requirements for implementing fortification strategies include: 1. The identification of an appropriate food vehicle that reaches the target population 2. Centrally processed & Widely available 3. Consumed in relatively predictable amounts by vulnerable population groups 4. Not be significantly changed (quality, price) 5. The food as prepared be acceptable to the population

FOOD FORTIFICATION
CONSUMPTION : 1. High proportion of the population covered 2. Regular consumption in relatively constant quantities 3. Minimal variation patterns among individual 4. Consumption not related to socioeconomic status 5. Low potential for excessive intake

Problem associated with iron supplementation

Delivery system Adherence Awareness & motivation Quality & packaging of iron supplements Monitoring & evaluation

Possible side-effects associated with iron medication

Epigastric discomfort, nausea, diarrhoea, or constipation. suppl should be taken with meals Faeces may turn black All iron preparations inhibit the absorption of tetracyclines, sulphonamides not be given together High-dose vit C suppl should not be taken with iron tablets

Other complementary public health interventions

Malaria prophylaxis Hookworm control Immunization Environmental health Control of micronutrient malnutrition Community-based primary health care

Integration with other micronutrient control programmes

The etiology of each micronutrients deficiency Vulnerable groups Groups most appropriated for assessment & monitoring purposes (surveillance groups) Suitable intervention strategies

Iodine, iron & vit. A deficiencies

Iod Geographic Iron Vitamin A Etiology Dietary Dietary Increased losses Increased losses Vulnerable Groups Pregnant Pregnant Lactating Lactating Infant Infant < 6 mo Preschool Preschool

Entire Population

Benefit of preventing iron deficiency

Benefit to children

- improved behavioural & cognitive development - where severe anaemia is common, improved child survival

Benefit to adolescents

- improved cognitive performance - in girls, better iron stores for later pregnancies

Benefit of preventing iron deficiency

Pregnant women & their infants - Decreased LBW & perinatal mortality - Where severe anaemia is common, decreased maternal mortality & obstetrical complications To all individuals - Improved fitness & work capacity - Improved cognition - Increased immunity - Lower morbidity from infectious disease