Dr.J.C.Helen Shaji
OBJECTIVES
General Objective:
After completion of the Unit-5, the students should be able
to know about malnutrition.
Specific Objectives:
After completion of the class students should be able to:
1 Define Malnutrition
2 Know the 2 division of malnutrition.
3. Various Malnutrition diseases
Food Habits
Food habits: It may either negative or positive
habits.
Negative poor habits include the non consumption
of satisfactory amounts of the protective foods:
these are foods that are provide minerals, vitamins
and protein.
Positive poor habits include: excessive use of sugar,
sweetened carbonated beverage and excessive
consumption of bread, sugar.
Malnutrition
The condition caused by an improper balance
between what an individual eats and what he requires to
maintain health.
This can result from eating too little( sub nutrition or
starvation) but may also imply dietary excess or an
incorrect balance of basic foodstuffs such as protein,
fats, and carbohydrates.
A deficiency or excess of one or more minerals, vitamins
or other essential ingredients may arise from mal
absorption of digested food or metabolic malfunction of
one or more parts of the body as well as from an
unbalanced diet.
Division of Malnutrition:
1) Primary Malnutrition – is due to:
A. Insufficient food production.
B. Unequal food distribution.
C. Housing and kitchen facilities.
D. Lack of transport.
E. Cultural factors include: food attitudes, food habits,
ignorance, religion and others socio economic factors.
F. Food attitudes: The culture pattern learned from ones
parents and associates by subconscious observation
determine for the individual the food items he eats.
G. Ignorance: Improper method of cooking vegetables
and the ignorance about the values of cereals and the
importance of cod liver oil.
H. Religion: Hindus should not eat beef.
I. Socio cultural factor:
A) Separation from the breast.
B) Length of breast feeding.
C) Food preparation and meal pattern.
D) Spacing.
Secondary Malnutrition
2 Secondary Malnutrition is due to:
A) Deficient food intake.
B) Mal absorption.
C) Increased food requirements.
D) Mal utilization
E) Increase excretion.
A- Deficient food intake:
Certain illness cause anorexia, also, in chronic
disease particularly those affecting old people, special
attention should be given, so that they eat what has
been offered to them in mental hospitals pellagra may
appear because the patient is not eating his meals.
B- Mal absorption:
As in old people, atrophy of intestinal tract may result
from an inadequate amount of vitamin B complex
resulting in poor absorption: in diarrheal disease food is
given insufficient time for for complete absorption.
C- Increased food requirements:
As during febrile disease and sulphonamides therapy.
D- Mal utilization:
As in liver disease and sulphonamides therapy.
E- Increased excretion:
As in diabetes mellitus and diabetes insipidus: chronic
bleeding may case iron deficiency anemia.
Most common causes of malnutrition in infancy
and childhood:
1-Dietary inadequacy.
2-Infections.
3-Socio cultural factors.
Important malnutrition disease:
1-Rickets
2-Iron deficiency anemia
3-Pellagra
4-Obesity
5-Beri beri
6-Marasmus
7-Kwashiorkor
8-Underweight
Rickets
Is a general disorder of metabolism affecting the bone
forming minerals, calcium and phosphorus.
Pathology: the essential changes in the bones are:
Decalcification of the normal bone already present.
Formation of imperfectly calcified new bone resulting in
widening and enlargement of the epiphyseal and of the
bone.
Rickets
Etiological Classification:
Disturbances of vitamin D metabolism(deficient intake,
absorption or utilization).
Error in the filtering on absorptive capacity of the kidney,
when the glomerular tufts on the tubular system are affected.
Other are metabolic disturbances related to formation of
bone such as hyperparathyroidism.
Rickets
Clinical Picture:
A- Symptoms:
Head sweating, irritability by day and sleeplessness by
night are the earliest symptoms that appear from the third to
the six month, delayed sitting, standing and walking are late
symptoms.
B-Signs:
Bony changes: Change in the skeleton are greatest at
the sites where growth is most rapid and the deformities are
the result of gravity and traction of muscles on the affected
bone.
Rickets
Head
1.
2.
Craniotabes is the earliest bony changes to be
observed greater incidence is from 3-6 months of age,
it is the best elicited by holding the infants head
between the palms of the hands., the thumbs over the
forehead and the finger carried out over the occipital
region, the skull yields under the finger like a ping
pong ball or egg shell.
Anterior fontanel is wider and its closure is delayed
than normal.
Rickets
3.
4.
5.
Frontal and parietal bossings are due to deposits of
ostoid tissue which is situated mainly around the
centers of ossification of these bones.
Size: The head often looks larger than normal and
shows no signs of increased intracranial tension.
Teeth eruption is usually delayed and the deciduous
teeth may show enamel defect or decay
Rickets
B- Thorax
1. Beading of the ribs at the costochondral junction is the early
2. signs. (Rachitic rosary)
3. Harrison's sulcus is a horizontal groove corresponding to the
lines of attachment of the diaphragm.
C- Extremities:
1. Epiphyseal enlargement in the wrists and ankles.
2. Marfans sign: a transverse groove felt over the tibia and fibula just
proximal to the ankle joint.
3. Deformities tibia: tibia and fibula often become curved after the
rachitic child has started to walk.
D- Pelvis:
May be permanently deformed, the anterioposterior diameter
being shortened and the outer narrowed.
Rickets
Prevention:
Infantile rickets can be prevented by exposure to
ultraviolet rays or by a daily oral dose of 400 I.U. of vitamin
D in the form of cod liver 1 teaspoon full/day. The daily
prophylactic dose of vitamin D recommended for
premature infants is 1000 units; vitamin D should be given
to the pregnant or lactating mother.
Treatment:
A daily administration of 1500 units will produce healing
in 2-4 weeks demonstrable in X-Rays, in some cases of
vitamin D deficiency rickets, massive therapy consisting of
600,00 units (15mg once monthly), one, two or three
injections may be needed.
2 . Iron Deficiency Anemia
Definition:
Iron deficiency anemia is an anemia due to inadequate intake
of iron.
It is characterized by the production of smaller, thinner red
blood cells which are deficient in hemoglobin.
 Clinical Manifestations:
1 Symptoms are variable but always include fatigue to
extreme
exhaustion.
2 In some severely depleted patients: sore tongue, diarrhea.
3 Pallor is present in more severe cases.
Iron Deficiency Anemia
Laboratory Diagnosis:
1) Hypo chromic cells with thin rims of hemoglobin, fragmented
cells and elongated of red cell.
2) Serum iron levels are generally reduced to levels below 3omg (
normal 70-130mg).
Bone Marrow:
1) Hyperplastic bone marrow.
Diagnosis:
Diagnosis is not difficult, but determination of the cause may
be in adults males on a normal diet, the presumptive cause is
blood loss, and a good search for a source of bleeding should be
made.
Iron Deficiency Anemia
Treatment:
There are many preparations as: ferrous sulphate,
ferrous gluconate and ferrous fumarate given as:
Oral( tablets or liquid
Parenteral: Indicated only in those rare situations in which
the patient can find no oral preparation that can be
tolerated or in which the absorption of oral iron is
impaired because of diarrhea or gastro intestinal shunt.
It may be given IM or IV But the IM is painful. The dose
of all Parenteral preparation depends on the amount
necessary to raise the hemoglobin to the desired levels.
3- Pellagra
A nutritional disease due to a deficiency of niacin
(Vit.B). Pellagra results from the consumption of a diet
that is poor in either niacin or the amino acid
trypthopan, from which niacin can be synthesized in
the body. It is common in corn-eating communities.
Symptoms:
Scaly dermatitis on exposed surface
► Diarrhea
► Depression
►
4. Obesity and Overweight
The condition in which excess fat has accumulated in the
body, mostly in the subcutaneous tissues. Obesity is usually
considered to be present when a person is 20% above the
recommended weight for his or her weight and build. The
accumulation of fat is caused by the consumption of more
food than is required for producing enough energy for daily
activities.
However recent evidence indicates that a genetic element is
involved. Hunger and satiety appear to be controlled by
peptide messengers, encoded by specific genes and acting on
the brain; an example is leptin. Obesity is the most common
nutritional disorder of recent years to occur on western
societies.
BODY MASS INDEX
 Formula:
 BMI = weight (kg) / [height (m)]2
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BMI
Classification
Less than 18.5
18.5 – 24.5
25 – 29.9
30 – 34.9
35 – 39.9
40 and more
-
Under wt
Healthy wt
Over wt
Obesity I
Obesity II
Obesity III
Obesity and Overweight
Management of Obesity:
1. Regular visits, at least once a fortnight.
2. Weighing the patent under the same
condition on the same scale.
3. About quarter of an hours talk with the
same practitioner each visits.
4. Opportunity to bring wife, or husband.
5. The therapist is not obese.
Obesity and Overweight
Complications of Obesity:
1. Sleep apnea
2. Cancer
3. Diabetes Mellitus
4. Hypertension
5. Cerebrovascular disease
6. Coronary Heart disease
7. Respiratory Disease
8. Gallstone Hernias
9. Arthritis
10. Varicose veins
5. Beriberi
 A nutritional disorder due to deficiency of Vit.B1
(thiamine). It is the widespread in rice eating
communities in which the diet is based on polished
rice, from which the thiamine – rich seed coat has
been removed. Beriberi takes two forms: wet beriberi,
in which there is accumulation of tissue fluid (edema),
and the dry beriberi, in which there is extreme
emaciation. There is a nervous degeneration in both
forms of the disease and dearth from heart failure is
often the outcome.
6. Marasmus
 Is the commonest serve form of protein- energy
malnutrition, the childhood version of starvation. It is
usually occurs at a younger age.
Causes:
1.
2.
3.
4.
Diet very low in both calories and protein : example
by early weaning then feeding dilute food because of
poverty or ignorance.
Poor hygiene leads to gastroenteritis
Diarrhea leads to poor appetite and more dilute foods.
Depletion leads to intestinal atrophy.
Marasmus
Symptoms:
1. Gross under weight
2. No body fat
3. Gross muscle wasting
4. Old mans face
5. No edema
6. No normal hair.
7. Kwashiorkor
 A form of malnutrition due to a diet deficiency in
protein and energy thus producing food. It develops
when, after prolonged breast feeding, the children is
weaned onto an inadequate traditional family diet.
The diet is such that it is physically impossible for the
child to consume the required quantity in order to
obtain sufficient protein and energy. Kwashoirkor is
most common in children between the ages of 1 and 3
years.
Kwashiorkor
Symptoms:
1. edema
2. Loss of appetite
3. Diarrhea
4. General discomfort
5. Apathy
6. Fails to thrive
7. Gastrointestinal infection.
Kwashiorkor
Treatment:
1. Resuscitation: Correction of dehydration, electrolyte
Disturbances, acidosis, hypoglycemia, hypothermia,
treatment of infections.
2. Start of cure: Refeeding, gradually working up the
calories(from 100-150kcal/kg) and protein (to about
1.5g/kg). There maybe anorexia, and children often have
to be hand feed, preferably in the lap of there mother or a
nurse they know. Potassium, magnesium, and a multi
vitamin mixture are needed.
3. Nutritional rehabilitation: After about 3 weeks if all
goes well the child has lost edema and its skin is healed.
The child is no longer ill and has a good appetite but is
still under weight for age. It takes many weeks of good
feeding for catch up growth to be complete.
8. Underweight


Underweight defined as a BMI of less than 18.05.
Underweight springs from poverty, poor living conditions, long-term
illness, or psychological changes.
 Infants and young children and older adults are at greatest risk. Low
weight-for-age (a measurement of malnutrition) causes more than
500% of the child deaths in developing countries.
 Very underweight children can experience long-term growth
retardation. Resistance of infection is lower , general heath is poor, and
physical strength is reduced in seriously underweight individuals of all
ages.
 Underweight older adult veterans scored lower on quality-of-life
measures relating to function, health perception, and mental and
emotional well-being than normal weight or overweight adults of the
same age.
Kinds of Malnutrition
I. Kind:
The kind of malnutrition disorder may be characterized by
the quantity or specific quality of food which lead to the
given disorders.
II. Degree:
We may classify it into the following degree:
Normal nutrition:
The state in which supplies of elements and
nutrition are sufficient for maintenance of
normal structure and function and adequate
reserve of the body.
b) Poor nutrition (subnormal)
In this state the function and structure are still normal,
but the usual needs of the body, i.e.; the poor diet may not
influence the function nor the general structure, but may
lead to subnormal growth, subnormal metabolism.
c) Latent malnutrition (sub clinical):
Where the function and structure are impaired but the
disease is not yet manifest or still in an undeveloped phase.
d) Clinical malnutrition.
In which impaired function or defective structure,
produce by malnutrition causes definite disease.
e) Over nutrition (or excess nutrition)
It results from excessive supply of one or more
nutrients to certain cells of the body e.g.; mottled
enamel of the teeth in case of excess fluorine intake
and hypervitaminosis A or D.