CMED 405: COMMUNITY MEDICINE MBBS Year 4 Semester 1 & 2 Course Coordinator – Dr. Dave Whippy Week 3 – Lecture 4 February 13 2024 Malnutrition Marasmus • Malnutrition refers to undernutrition resulting from inadequate consumption or excessive loss of nutrients. INTRODUCTION • Malnutrition is the condition that develops when the body does not get the right amount of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organs function. • An individual is malnourished if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the food they eat. They are also malnourished if they consume too many calories. DEFINITON The world health organization (WHO) defines malnutrition as “the cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions.” CAUSES OF MALNUTRITON There are 3 clinical forms of acute malnutrition. • Marasmus – severe weight loss or wasting • Kwashiorkor - bloated appearance due to water retention • Marasmic-kwashiorkor – combination of wasting and bi-lateral Edema MARASMUS Severe form of protein-energy malnutrition. Caused by a deficiency of both calories and protein in the diet. KWASHIKOR Characteristics: Children appear emaciated, with little to no subcutaneous fat and severe muscle wasting. Growth is severely stunted, and they have a "skin and bones" appearance. Characteristics: Swollen belly, feet, and face due to fluid retention (edema). They may have some muscle mass and may not appear as emaciated as in marasmus. Marasmus does not typically present with edema Edema is a hallmark feature of kwashiorkor, which distinguishes it from marasmus. Primary Cause: Chronic starvation or prolonged inadequate food intake, leading to an overall energy deficit. Primary Cause: Associated with a diet lacking in protein and essential amino acids, even if enough calories are consumed. MICRONUTRIENT DEFICIENCY Inadequate intake or absorption of specific vitamins and minerals necessary for proper bodily functions. OBESITY Excessive body fat accumulation, resulting from chronic positive energy balance (calorie intake exceeds expenditure). Characteristics: These deficiencies may lead to various health issues, depending on the specific nutrient lacking. Characteristics: Obese individuals have a high body mass index (BMI) and an increased risk of various health issues such as cardiovascular diseases, diabetes, and certain cancers. Primary Cause: Micronutrient deficiencies are often related to diets lacking in diverse and nutrient-rich foods. Primary Cause: Obesity is primarily caused by consuming more calories than the body needs, coupled with a sedentary lifestyle. MARASMUS • A rapid deterioration in nutritional status in a short time can lead to marasmus • Most common form of acute malnutrition in nutritional emergencies and, in its severe form, can quickly lead to death if left untreated. • Characterized by severe wasting of fats and muscle which the body breaks down to make energy. • May occur at any age particularly in early infancy. Characterized by: - severe wasting (body weight less than 60% of the expected), the body utilizes all fat stores before using muscles - loss of subcutaneous fat - gross muscle wasting CLINICAL FEATURES PATHOPHYSIOLOGY OF MARASMUS • Marasmus is a severe form of malnutrition characterized by energy deficiency resulting from inadequate intake of both protein and calories. The pathophysiology of marasmus involves a prolonged state of energy deficit, leading to significant wasting of body tissues, including muscle and fat. • In marasmus, the body’s energy reserves are depleted due to insufficient calorie intake, often caused by factors such as poverty, lack of access to food, or prolonged illness. This results in a catabolic state where the body breaks down its own tissues, including muscle and subcutaneous fat, to meet its energy needs. • As a consequence of the energy deficit, individuals with marasmus experience severe weight loss, muscle wasting, and diminished physical strength. Their body weight drops to well below the expected weight for their age and height, leading to a characteristic appearance of “skin and bones.” • Moreover, the immune system becomes compromised, making individuals with marasmus susceptible to infections and other illnesses. They may also experience impaired growth and development, delayed wound healing, and reduced cognitive function. DIAGNOSIS • Healthcare providers will begin by physically examining the person’s body. Marasmus has some telltale physical features, the primary one being the visible wasting of fat and muscle. People with marasmus appear emaciated. The loss of fat and muscle under the skin may cause the skin to hang loose in folds. Beyond appearances, healthcare providers will measure the height or length of the person’s body and the circumference of their upper arm. Healthcare providers use a few different charts to measure a child’s or adult’s weight-to-height ratio against medical standards, depending on their age. Marasmus is defined differently on different charts, but it is always significantly below average. To use a chart more people are familiar with, marasmus would score below a 16 on the BMI (body mass index). The purpose of the scoring is mostly to confirm the diagnosis and rate how severe it is. ASSESSMENT 1. Growth retardation: • Weight is 60% of expected weight for age and sex. • Length of head and chest is also affected including abdominal circumference 2. Loss of subcutaneous fat from: • Abdominal wall leading to loss of elasticity • The limbs (thighs and buttocks) the skin becomes wrinkled and hanging into longitudinal folds. • The buccinators pad of fat is the last to disappear. This leads to the hollowing of these cheeks. 3. Marked wasting of muscles: This together with subcutaneous fat loss leads to ; • Scaphoid abdomen with marked thinning of abdominal wall. • Stick- like appearance of limbs. 4. Psychic changes: • Marasmic infants look anxious, irritable, excessively cry and sleep less. However, they look less miserable than the cases of Kwashiorkor. • Marasmic infants are usually hungry and have good appetite. Sometimes, there is anorexia and poor feeding. 5. Chronic diarrhea with or without vomitting. 6. Intercurrent infections: • Like otitis media, bronchopneumonia, UTI 7. Deficiency of iron, vitamin A and D 8. Hypothermia COMPLICATIONS • Lack of proper growth in children • Joint deformities • Severe weakness • Permanent vision loss • Organ failure • Coma MALNUTRITION AND SOCIAL DETERMINANTS • Malnutrition is a complex issue influenced by various socioeconomic factors. Social determinants of health play a crucial role in shaping individuals' and communities' access to adequate nutrition and their overall nutritional status. Here are some key factors contributing to malnutrition . 1. Income and Poverty: Low income and poverty are major contributors to malnutrition. People with limited financial resources may struggle to afford nutritious food, leading to a higher dependence on cheaper, less nutritious options. 2. Access to Food: Food security is a significant determinant of malnutrition. It refers to the ability of individuals and households to access sufficient, safe, and nutritious food for an active and healthy life. Lack of access to food can result from a combination of factors, such as limited availability of food in the area, high food prices, and inadequate transportation. Continued 3. Education: Education plays a vital role in influencing dietary habits and nutritional knowledge. People with higher levels of education are more likely to understand the importance of a balanced diet and make informed food choices. Conversely, individuals with lower education levels may lack awareness of proper nutrition, leading to dietary deficiencies. 4. Access to Healthcare: Access to healthcare services is critical for identifying and addressing malnutrition. Regular health check-ups and screenings can help identify nutritional deficiencies and provide timely interventions. Lack of access to healthcare can lead to undetected and untreated malnutrition, especially in vulnerable populations. 5. Water and Sanitation: Poor access to clean water and sanitation facilities can exacerbate malnutrition. Contaminated water sources and inadequate sanitation can lead to diarrheal diseases and other infections, which can hinder nutrient absorption and lead to malnutrition. Continued PREVENTION AND INTERVENTION STRATEGIES • Prevention and intervention strategies to combat malnutrition are crucial in addressing this widespread global issue. Malnutrition can have severe consequences on individuals and communities, leading to impaired physical and cognitive development, increased vulnerability to diseases, and even death. Here are some key strategies to tackle malnutrition: 1. Global Initiatives and Programs: Governments, international organizations, and NGOs play a vital role in developing and implementing global initiatives and programs to combat malnutrition. These initiatives should focus on creating awareness, improving access to nutritious food, and enhancing nutritional education. Collaborative efforts among nations are essential to address the multifaceted causes of malnutrition. Continued 2. Importance of Early Intervention: Early intervention is critical in preventing longterm consequences of malnutrition, especially in children. Childhood is a crucial period for growth and development, and any form of malnutrition during this time can have irreversible effects on physical and cognitive abilities. Identifying and addressing malnutrition early can prevent stunting, wasting, and other developmental issues. 3. Targeted Interventions: Different regions and communities may face specific challenges related to malnutrition. Targeted interventions are necessary to address the root causes and challenges faced by each population group. These interventions could include nutrition-specific interventions, such as providing nutrient-rich food supplements, as well as nutrition-sensitive interventions, such as improving agricultural practices and livelihood opportunities. FUTURE PERSPECTIVES AND CHALLENGES IN ADDRESSING MALNUTRITION AND MARASMUS Continued REMAINING CHALLENGES AND BARRIERS TO EFFECTIVE INTERVENTIONS • Economic Disparities: Poverty and economic disparities continue to be major barriers to combating malnutrition. Nutritious foods are often more expensive, making them inaccessible to those living in poverty. • Conflict and Political Instability: Regions affected by conflict and political instability face additional challenges in combating malnutrition. Disruptions in food supply chains, displacement of populations, and limited access to resources hinder effective interventions. • Lack of Infrastructure: Inadequate infrastructure in rural and remote areas can impede the distribution of food and healthcare services, making it difficult to address malnutrition effectively. Continued • Climate Change and Environmental Factors: Climate change can adversely impact food production and availability, leading to food insecurity and malnutrition in vulnerable populations. • Cultural and Social Norms: Deeply ingrained cultural practices and beliefs may influence dietary choices, making it challenging to introduce and adopt new nutritional interventions. THE ROLE OF GOVERNMENT, NGOs AND INTERNATION COMMUNITY IN COMBATING MALNUTRITION • Governments: Governments play a critical role in combating malnutrition by developing and implementing national nutrition policies, allocating funds for nutrition programs, and ensuring access to nutritious food for all citizens. They can also promote research and collaborate with international organizations to tackle malnutrition effectively. • NGOs: Non-governmental organizations (NGOs) are instrumental in providing on-the-ground support and implementing nutrition interventions in affected communities. They can also raise awareness, conduct research, and advocate for policies that address the root causes of malnutrition. Continued • International Organizations: International organizations, such as the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the Food and Agriculture Organization (FAO), play a crucial role in coordinating global efforts to combat malnutrition. They provide technical expertise, funding, and support to countries facing malnutrition challenges. • Public-Private Partnerships: Collaboration between governments, NGOs, international organizations, and the private sector is essential to address malnutrition effectively. Private companies can contribute through food fortification, research, and development of innovative nutritional products. • Advocacy and Funding: The international community can support efforts to combat malnutrition by advocating for increased funding and resources dedicated to nutrition programs and initiatives. Addressing malnutrition requires a collective commitment from all stakeholders, and sustained funding is crucial to achieving long-term success. CONCLUSION Malnutrition remains a critical global health issue with devastating consequences, and one of its severe manifestations is marasmus. Marasmus exemplifies the severe consequences of malnutrition, highlighting the urgent need for global cooperation and intervention to address this pressing health challenge. By implementing comprehensive and sustainable strategies, we can make significant progress in reducing malnutrition and its associated hardships, ultimately saving countless lives and fostering a healthier world for all.
