What is malnutrition?

World Health Organization definition:

The term is used to refer to a number of
diseases, each with a specific cause
related to one or more nutrients (for
example, protein, iodine or iron)
and each characterized by cellular
imbalance between the supply of
nutrients and energy on the one hand,
and the body's demand for them to
ensure growth, maintenance, and
specific functions, on the other.

Causes of
malnutrition
Child malnutrition
death and disability

Inadequate
Diet

Poor water/ sanitation

Insufficient
inadequate health
access to food
services

Disease

Inadequate
maternal and
child care

Death from malnutrition

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*
*

*
*
S

Undernutrition

Deficiency
Primary deficiency :
a nutrient deficiency caused by inadequate dietary
intake of a nutrient

Secondary deficiency :
a nutrient deficiency caused by something other
than an inadequate intake such as a disease
condition that reduces absorption, accelerates use,
hasten excretion, or destroys the nutrien

PERKEMBANGAN MASALAH GIZI

19,2
19,2

18,0
18,0

2013

Masalah kesehatan masyarakat dianggap

berat bila prevalensi pendek sebesar 30
39 persen dan serius bila prevalensi
pendek 40 persen (WHO 2010).
Sebanyak 14 provinsi termasuk kategori
berat, dan sebanyak 15 provinsi termasuk
kategori serius.

Prevalensi Balita Pendek Menurut

Provinsi
2010

< 20% (0)

Jahari A.B

20%-29,9% (9)

30%-39,9% (17)

40%+ (7)

Consequences of PEM
throughout the Life-cycle
Birth defects

Low birth weight

stunting
fetus

Increased risk of poor health

infant
. Food insecurity

child

. Intra-households biases
- Heavy physical labor
- Diarrheal disease
- Increased physiological needs

Poor physical
performance

Pregnancy

Decreased mental capacity

Older age
Risk of obstructed labor
Risk of maternal mortality

adolescent
High prevalence of infections

Hospital Malnutrition:
Numerous studies on hospital malnutrition have
been published.
Prevalence of malnutrition in U.S. hospitals today
ranges from 30% to 50%.

Illness
Example :
Cancer

Altered
Food Intake
Examples: Loss
of appetite,
altered food
likes/dislikes,
difficulty chewing
and swallowing,
reduced saliva
secretion

Altered
Digestion and
Absorption
Examples:
radiation
enteritis, surgical
resection of GI
tract, diarrhea

Altered
Metabolism
Example:
increased energy
needs due to
altered energy use
in cancer

Malnutriti
on

Altered
Nutrient
Excretion
Examples: fecal
loss of fat-soluble
vitamins and
calcium in clients
with cancers that
affect enzyme
secretion or bile
salt production

Define:

Underweight: weight for age < 80% expected

Marasmus: weight for age < 60% expected
Kwashiorkor: weight for age < 80% + edema
Marasmic kwashiorkor: wt/age <60% + edema

Wasting: weight for height

Stunting: height for age

SAM: severe acute malnutrition

Underweight

Define: weight-for-age less 80% expected

Encompasses both wasting and stunting
High correlation with stunting
Prevalence directly describes the
magnitude of the problem of growth
faltering and stunting in young children

Protein energy
malnutrition
1- Marasmus
Definition:
It is a clinical syndrome and a form of under nutrition characterized
by failure to gain weight due to inadequate caloric intake.
Incidence:
commonly in infants between the age of
6mo. - 2years (Infantile atrophy).

Marasmus

Deficit in calories marasmus comes

from Greek origin of word to waste
Gross weight loss
Hyper-alert and ravenously hungry
Children have no subcutaneous fat or
muscle

eventually starve to death (immediate

cause often is pneumonia)

Marasmus

Weight for age < 60% expected

No edema
Often stunted
CFR=20-30%

Marasmus (low calories)

Ravenously
hungry

Gross
weight
loss &
no fat

Marasmus mechanism
Energy intake is insufficient for bodys
requirements body must draw on own stores
Liver glycogen exhausted in a few hours
skeletal muscle protein used via
gluconeogenesis to maintain adequate plasma
glucose
When near starvation is prolonged, fatty acids
are incompletely oxidized to ketone bodies,
which can be used by brain and other organs
for energy

Mechanism is same as anorexia

Complications of
Marasmus
1. Intercurrent infection : Broncho pneumonia .
2.
3.
4.
5.

is the cause of death

Gastro enteritis
Hypothermia
Hypoglycemia
Edema(marasmic kwashiorkor )

Kwashiorkor
Infection

Sparse
hair

Swollen
belly

Decreased
muscle
mass
Pellagra

Apathy

Kwashiorkor
Definition
It is a clinical syndrome and a form
of malnutrition characterized by slow
rate of growth due to deficient of protein
intake, high CHO diet and vitamins &
minerals deficiency (adequate supply of
calories).
Incidence
Commonly in toddlers between the
age 1-3years, following or with weaning

Kwashiorkor
(Edematous Malnutrition)

Underweight with edema

Irritable, difficult to feed
Electrolyte abnormalities
Highest mortality 50 to 60%

Assessment

1- Essential features (cardinal

manifestation):
Growth retardation :Weight is diminished (60-80%) of
expected
Edema :
It is due to hypo proteinemia.
It is starts in the feet and lower parts
of the legs) then becomes generalized
edema .
The cheeks become bulky, pale,
waxy in appearance (doll-like-cheeks)

2-Early features
(usual manifestation)

Hair changes : The hair is sparse , dys pigmentation( reddish or greyish),atrophic ,easily pickable.

G.I.T Manifestations: Anorexia ,vomiting in severe cases, diarrhea

3-Occasional or variable
features

- Vitamins and minerals defection and vit.D ,

A,C minerals as iron, zinc, Mg,

Hepatomegaly.
Skin
changes (dermatitis in areas due to
pigmentation ,napkin dermatitis, petechiae over the
abdomen,
fissures,ulceration
Poor resistance and liability to infections

Pathogenesis:
Kwashiorkor:
Normal energy intake, Lack of protein
Edema:1970.decrease oncotic pressure,
Recent> Increase Renin activity,N a and fluid

retention.

Amino aciduria due to proximal tubular

dysfunction
Failure of adaptation
.Hepatomegaly due to fatty infiltration from
lipogenesis of excess CHO
- Biochemical and haematological changes

Kwashiorkor (low
protein)
Decreased muscle mass (failure to gain weight and of

linear growth)
Swollen belly (edema and lipid build-up around the liver)
Changes in skin pigment (pellagra); may lose pigment
where the skin has peeled away (desquamated) and the
skin may darken where it has been irritated or
traumatized
Hair lightens and thins, or becomes reddish and brittle.
Increased infections and increased severity of normally
mild infection, diarrhea
Apathy, lethargy, irritability

Death does not occur from actual starvation but from

secondary infection

Kwashiorkor
mechanisms

Occurs in reaction to emergency situations

(famine)
Kwashiorkor more likely in areas where
cassava, yam, plantain, rice and maize are
staples, not wheat
Increased carbohydrate intake with
decreased protein intake eventually leads to
edema (water) and fatty liver

STUNTING
Height for age less than 90% expected

Higher
mortality rate
Reduced
capacity
to care
for baby

Elderly
Malnourished

Inadequate
food,
health
& care

Inadequate
fetal
nutrition

Woman
Malnourished
Start here

Pregnancy
Low Weight
Gain

Higher
maternal
mortality

Impaired
mental
development

Baby
Low Birth
Weight
Inadequate
catch up
growth

Increased risk of
adult chronic disease

Child
Stunted

Untimely/inadequate
weaning
Frequent
Infections
Inadequate
food, health
& care
Reduced
mental
capacity

Adolescent
Stunted

Inadequate
food, health
& care

Reduced
mental
capacity

Inadequate
food, health
& care

Severe Malnutrition:
Consequences

Mental development
Lower IQ levels
Poorer school performance

Behaviors of recovered severely malnourished

children

shy, isolated, withdrawn

decreased attention span
immature, emotionally unstable
fewer peer relationships/reduced social skills
played less/stayed nearer to mothers

Stunting Height for Age

Height for age reflects pre- and postnatal linear growth

Stunting refers to shortness that is not
genetic, but due to poor health or
nutrition
Most standard definition < 2 S.D.

Stunting: Timing

Age of onset varies, but usually in first 23 years of life

First few months, infants in developing
countries grow just as quickly as children
in reference populations
Growth retardation starts from 2-6 month of

life (often associated with weaning)

Infants at risk during this time because of
high nutritional requirements and high rates
of infections (breast fed infants often
protected)

Stunting: Consequences

Cross-sectional associations Low height for

age associated with:
Reduced cognitive development
Poor motor skills
Poor neuro-sensory integration
Quiet, reserved, withdrawn, timid, passive
Difficulty making decisions
Decreased involvement with environment, toys,

tasks
Less able to deal with stressor such as hunger or
parasites