MALNUTRITION

AS HEALTH PROBLEMS

M. NAZIR HZ
DEPARTEMENT OF CHILD HEALTH
FACULTY OF MEDICINE, SRIWIJAYA UNIVERSITY

NUTRITION PROBLEMS IN INDONESIA (1)

1. MACRONUTRIENT DEFICIENCY
1. PROTEIN ENERGY MALNUTRION
2. MICRONUTRIENT DEFICIENCY
2.1.VITAMIN A DEFICIENCY
2.2. NUTRITIONAL ANEMIA / IDA (IRON
DEFICIENCY ANEMIA)
2.3. JODIUM DEFICIENCY
3. OVER NUTRITION (OBESITY)

NUTRITION PROBLEMS IN INDONESIA (2)

a.
b.
c.
d.
e.
f.

STUNTED < 5 YEAR 36.8%

CHRONIC MALNUTR.
PREVALENCY OF ACUTE WASTED 13.6%
ACUTE
MALNUTRITION
PREVALENCY OF LBW 11.7%
PREGNANT WOMEN
MALNUTRITION
HIGH PREVALENT OF MICRONUT DEF: NUTRITIONAL
ANEMIA, JODIUM DEF AND DEFICIENCY OF VIT. A
INCREASED INCIDENCE OF OBESITY
RE-EMERGING OF INFECTION : TBC, HIV

PROTEIN ENERGY MALNUTRITION

NUTRITIONAL
DEFICIENCY
CAUSES OF PROBLEMS

The State of the World Children , UNICEF, 1998

THE PREDISPOSSING FACTORS

1.
2.
3.
4.
5.
6.
7.

SOCIAL, ECONOMIC AND CULTURAL

CHRONIC INFECTION
MALABSORPTION
PERSISTENT/ CHRONIC DIARRHEA
CONGENITAL DISORDER
MALIGNANCY
IMMUNITY DISORDER

Infection

Nutitional deficincy
anorexia
intake <<

immunity

Macro/Micronut. def
Nutritional deficiency

Reccurent infection

Intake <<<

prolonged starvation

catabolism

atrophy

Atrophy of the intestinal epithelial cells

Disorders of digestion and absorbtion

Fatty liver

disorders of liver function

* synthesis
* secretion
* excretion
* detoxification

pneumonia
Lung tuberculose

diarrhea

Helminthiasis

THE PATHOGENESIS AND THEIR HEALTH IMPACT

CATABOLISM

DECREASED
INTAKE

PREDISPOSSING
FACTORS

ORGAN ATROPHY
ORGAN DISFUNCTION
DECREASED IMMUNITY

SYMPTOM S OF
ORGAN DIFUNCTION/
INFECTION

INFECTION

HOSPITALIZED

PNEUMONIA
DIARRHEA
SYMPTOMS
OF DEF. MACRO/
MICRO NUTR
COMPLEXS

EFFECT OF MALNUTRITION
DECREASED OF IMMUNITY
INFECTION >>
SEVERE AND LONG DURATION OF ILLNESS
ALOS (AVERAGE LENGTH OF STAY) >>
POST OPERATIVE RECOVERY >>
POST OPERATIVE COMPLICATION >>
COST OF CARE >>

THE MOST COMMON CAUSES MORBIDITY AND MORTALITY

OF CHILDREN < 5 YEAR

Malnutrition as a main cause of child

mortality (WHO, 2000)
HIV

others
Diarrhe
29%
malnutritiona 28%
(underlying
factor)
Malaria
>50%
RTI
15%

7%
woughing
cough
4 Tetanus
Neonatus
%
6%
Measle

4
%

Diarrhea
12%

others
28%
malnutrition
(underlying factor)
60%

RTI
20%

s 11%
1990
Protecting the Worlds Children, A Call for Action, 1990;
Evidence and information for Policy/WHO, Child Adolescent Health and
Development, 2001
WHO, Child and Adolescent Health and Development. On line
www.who.int/child-adolescent-health/inegr.htm

Malaria
8%

Perinata
l
22%
measles
5%

2000

15

Deficiency of Vitamin A
1. 50% (10 million) of under 5 years suffered
subclinical vitamin A deficiency (serum retinol < 20
g/L)
2. 0,33% (66.000) of under 5 years with Xeroptalmia
(bitots spot).
3. > 0,50% : Community health problem (WHO)

Survei Vitamin A (Suvita), 1992

16

Vitamin A deficiency
- one third of children < 5 yr
- to claim the lives of 70,000 children < 5 yr
- 250,000-500,000 children in dev. countries
( blind each year)
highest prevalence in Southeast Asia and Africa.

Vitamin A deficiency

NUTRITIONAL ANEMIA - IDA

Prevalency
Age Group

1995

Adolscent girl (15-19 th)

57,1%

26,5%

Pregnant

50,9%

40,1%

< 5 years

40,5%

47,0%

School age

47,2%

Survei Kesehatan Rumah Tangga (SKRT)

2001

19

Nutritional anemia/
Iron deficiency anemia (IDA)

Iron deficiency anemia (IDA) caused by:

1. An iron-poor diet
2. Body not being able to absorb iron very well
3. Long-term, slow blood loss
usually through menstrual periods
bleeding in the digestive tract (worm etc)
Rapid growth (when more iron is needed):
- in the first year of life
- in adolescence

IDA can affect school performance.

Low iron levels:
- decreased attention span,
- reduced alertness,
- learning difficulties,
in young children and adolescents.
Iron supplementation
- improves learning,
- memory,
- cognitive test performance
- the performance of athletes with IDA

JODIUM DEFICIENCY (GOITER)

45% Districts endemic:

30% mild
7 % moderate
8 % severe
87 milion people lives in endemic area
(prevalency 9.8%)
(mapping GAKY, 1998)

Prevalency Iod deficiency 11.1 %

(Survei GAKY, 2003)

23

Cretin
Cretinism : severely stunted physical and mental growth
due to untreated congenital def. of thyroid
hormones (congenital hypothyroidism
usually due to maternal hypothyroidism

OVER NUTRITION
o
o
o
o

ADULT IMT

(> 27 kg/m) 11,1%

(30 kg/m) 3,9%

(Survei IMT tahun 1997)

ADULT IMT

(Riskesdas 2007)

(> 27 kg/m) 8,8%

(30 kg/m) 10,3%

< 5 YEAR BW/A

(Susenas)

< 5 YEAR BW/BL

(>+2SD)

: 2,46% (2003)

(>+2SD)

: 3,50% (2005)
: 12,2% (2007)

(Riskesdas)

25

Immediate and longterm health problems123

Obstructive sleep disorders
Asthma
Elevated Blood Lipids/ insulin
Hypertension, Heart disease
Type 2 diabetic
Musculosceletal (Orthopedic) problems
Menstrual Irregularity
Depression and social stigmatization.
1. Kiess W, Galler A, Reich A, et al. Clinical aspects of obesity in childhood and adolescence.
Obes Rev. 2001;2(1):29 36
2. Clinton Smith J. The current epidemic of childhood obesity and its implications for future coronary heart disease.
Pediatr
ClinNorth Am. 2004;51(6):1679 1695
3. Snitker S, Le KY, Hager E, Caballero B, Black MM. Association of physical activity and body composition with insulin
sensitivity in a community sample of adolescents. Arch Pediatr Adolesc Med. 2007;161(7):677 683

TERIMA KASIH

GROWTH AND DEVELOPMENT

MONITORING

GROWTH AND DEVELOPMENT CHART

30
Sumber: materi pelatihan pemantauan pertumbuhan, Dit. Bina Gizi Masyarakat

Body weight: Increase (N1= Catch up growth)

Body weight: Increase (N2= normal growth)

Body weight: Not increase

(T1=unappropriate growth)

33

Body weight: not increase

(T2= not growing)

34

Body weight not increase

(T3=Negatif growth)

35

KMS

WHO 2005, BW/A

Boy 0-24 months

Girl 0-24 months

Boy 24-59 months

Girl 59 months

NUTRITION ASSESSEMENT

1. Analysis of intake/day:
food recall, food freq
quantity and quality
calori/ prot/ fat/ vit & mineral
RDA
2. Anthropometry:
a. Measure
: BW (kg) L/Ht (Cm) Age (y/m)
b. Index : BW/A
L-Ht/A
BW/L-Ht
c. Standart
: NCHS/ WHO, 50 %-ile =100%
d. Local Stand: Lokakarya antropometri 1975
3. Clinical finding : a. Marasmus, Kwashiorkor, M-K
b. Deficiency
4. Biochemistry/ laboratorium:

Anthropometry:
1. Age
: BW/A, Ht-L/A, MUAC/A
2. Usia (-) : BW/L-Ht, MUAC/L-Ht
3. Combine:
Waterloo (2 index): BW/L-Ht, BW/A
WHO (3 index)
: BW/L-Ht, BW/A,
L-Ht/A
4. Anthropometric index, clinical finding, Lab
Wellcome trust
Mc Laren
5. BMI (Body Mass Index): BW (Kg)
Ht (Cm)2

PEM Classification (lokakarya 1975, Puslitbang Gizi 1978)

Category

BW/A

N
Mild
Severe

100-80
<80-60
<60

L-Ht/A
100-95
<95-85
<85

Classification (BW/BL-Ht):
>150%
: Severe Obesity
135-150%: Moderate Obesity
120-135%: Mild Obesity
>120%
: Obesity
110-120%: Over nutrition

MUAC/A BW/L-Ht
100-85
<85-70
<70

90-110%
70-90%
<70%

LLA/L-Ht

100-90
<90-70
<70

: Normal
: Mild
: Severe

100-85
<85-70
<70

NUTRITION DISORDER BASED ON

ANTHROPEMETRIC MEASUREMENT

WASTED

(ACUTE MALNUTRITION)

BW/A <<<
BL/A N
BW/BL <<<

STUNTED
WASTED

BW/A N
BL/A N
BW/BL N

STUNTED

(CHRONIC AND ACUTE

MALNUTRITION)

BW/A
BL/A
BW/BL

NORMAL

<<<
<<<
<<<

BW

(CHRONIC MALNUTRITION)

BW/A
BL/A
BW/BL

N/>
<<<
N/>>

WHO CDC 2000

OK135S056

Growth Chart WHO 2005

Girl 11 months
BW 9 kg, L 73 cm
Normal nutritional status
( 50th)
Normal 3rd - 97th

Girl 11 months
BW 9 kg, L 73 cm
Normal nutritional status
Z score Median
Normal + 2 SD

B
A

A: 2 th: BW/A
Ht/A
BW/Ht
B: 4 th: BW/A
Ht/A
BW/Ht
C: 5 th: BW/A
Ht/A
BW/Ht

:
:
:
:
:
:
:
:
:

N
N
N
N
N
N
Mild
Mild
N
Stunted