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Report
Dr. Mohammad Hayatun Nabi
MPH(Aus), MHSM(Aus), MBBS
Dept. of Public Health
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The prevalence of malnutrition in Bangladesh
is among the highest in the world.
Millions of children and women suffer from
one or more forms of malnutrition including
low birth weight, wasting, stunting,
underweight, Vitamin A deficiencies, iodine
deficiency disorders and anemia.
Globally, malnutrition is attributed to almost
one-half of all child deaths.
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Bangladesh has made good progress in the
past decade to achieve Millennium
Development Goal 1, the eradication of
extreme poverty and hunger, more needs to
be done.
Malnutrition rates have seen a marked
decline in Bangladesh throughout the 1990s,
but remained high at the turn of the decade.
Nationally, 41% of children under five years
are moderately to severely underweight and
43.2% suffer from moderate to severe
stunting, an indicator for chronic
malnutrition.
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Protein energy malnutrition
Low birth weight
Nutritional anemia
Nutritional blindness
Iodine deficiency disorders
Seasonal vitamin deficiency
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Protein Energy Malnutrition (PEM) continues
to be a major public health problem in many
developing countries.
It affects mostly children under 5 years of age
belonging to the poor underprivileged
communities.
The condition is particularly serious during the
post weaning stage and is often associated with
infection.
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Respiratory infection and diarrhea are the
common diseases that precipitate severe PEM
and death.
Apart from contributing to high mortality,
severe malnutrition can lead to permanent
squeal in those who survive.
These include stunted growth, poor learning
ability and reduced work efficiency.
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Protein: deficit in amino acids needed for cell
structure, function
Energy: calories (or joules) derived from
macronutrients: protein, carbohydrate and fat
Micronutrients: vitamin A, B-complex, iron,
zinc, calcium, others
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1.
2.
3.
Several methods have been suggested for the
classification of PEM.
The choice of classification depends on the
purpose for which it is used.
In clinical studies, patients with severe PEM
are classified into 3 groups- kwashiorkor,
marasmus and marasmic kwashiorkor.
WHO classification
Gomez classification
Wellcome classification
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Malnutrition
Body weight
(% of standard*)
Grade 1
Grade 2
Grade 3
76-90
60-75
<60
*Harvard standard
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Protein energy malnutrition results from the
interaction of several factors of which,
inadequate diets and infectious diseases are the
most important.
Preschool children age are most seriously
affected because their nutritional requirements
are relatively higher than those of adults and
infections occur more frequently in this age
group.
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Diet
Free radicals
Infections
Socio-demographic factors
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•Marasmus
Clinical features:
•Severely wasted
(emaciated) & stunted
•“Balanced”starvation
•“Old Man”face, wrinkled
appearance, sparse hair
•No edema, fatty liver, skin
changes
•Too little breast milk or
complementary foods
<2yrs of age
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Too little breast milk,
often after 6 mo of age
Dilute and unhygienic
formula or bottle
feeding
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•Kwashiorkor
Clinical Features:
•Edema, it tends to be
generalised
•Mental changes
•Hair changes: the black color
alters to blonde, grey
•Mucosal changes: angular
stomatitis
•Fatty liver
•Dermatosis (skin lesions)
•Infection
•Anorexia
•High case fatality
•Low prevalence
•1st to 3rd yrs of life
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Differences between Marasmus and Kwashiorkor
Features
Marasmus
Kwashiorkor
Cause
Due to deficiency of calories Due to protein deficiency
and other nutrients in
addition to protein
Essential
features
1. Edema
Absent
Present in the lower legs,
sometimes face or generalized
2. Wasting
Marked, all skin and bone
Less obvious, child looks flabby
3. Muscle
wasting
Severe
Sometimes, less
4. Growth
retardation
in terms of
body weight
Severe
Less than in marasmus
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Differences between Marasmus and Kwashiorkor
5. Mental
changes
Usually absent
Usually present
1. Appetite
Usually good
Usually poor
2. Skin
changes
Usually none
Often, diffuse depigmentation
3. Hair
changes
Slight change in texture
Often sparse- straight and
silky, dyspigmentation- grayish
or reddish
4. Moon
face
None
Often
Variable
features
5. Hepatic
None
enlargement
Frequent
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Prevention of Kwashiorkor
Educate mother
 Advice to farmers
 Provide food supplements in hospitals
 Legumes, nuts and seeds (locally produced)
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Prevention of Marasmus
Family planning
 Immunization program
 Encourage breastfeeding
 Maternity and child health clinics
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Nutritional blindness due to xeropthalmia is an
important public health problem among young
children in developing countries.
The term xerophthalmia encompasses all
ocular manifestations of vitamin A deficiency.
It includes the structural changes affecting
conjunctiva, cornea and occasionally retina,
and also the biophysical disorders of retinal
rod and cone functions.
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Adequacy
Bone growth
Reproduction
Embryogenesis
Rod vision
Cell differentiation
Immunity
Deficiency
Growth retardation
Dysfunction (M&F)
Teratogenesis
Night blindness
Epithelial metaplasia
Impaired innate &
acquired defenses
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Xerophthalmia: Mild to severe
Corneal blindness and disability
Anemia
Stunted growth
Impaired immunity
Increased severity of infection
(eg,measles, diarrhea, or malaria)
Mortality
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XN Nightblindness
X1A Conjunctival xerosis
X1B Bitot’s spots
X2 Corneal xerosis
X3 Corneal ulceration
Keratomalacia
XS Corneal scarring
XF Xerophthalmic fundus
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It is an useful screening tool and correlates
with other evidence of vitamin A deficiency.
It can be elicited in the case of young children
by detailed questioning of the parents or the
guardians.
The children usually cannot see in dim light,
either at dusk or down.
The value of night blindness will depend on
the care with which the questions are asked,
and upon the degree to which the phenomenon
of night blindness is recognized by the
community.
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Globally it is estimated that every year about
7,00,000 children are likely to develop corneal
lesions due to vitamin A deficiency.
The problem is considered to be of public
health significance in 36 countries, in South
East Asia, the western Pacific and Africa.
About 20-40% million children are estimated to
have mild vitamin A deficiency at any point of
time.
Mahtab et al, 2003
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Age
Vitamin A deficiency is preponderant in children. While it is rare
during infancy, preschool age children are at a greater risk.
Sex
Xerophthalmia is more frequent in boys than in girls.
The incidence of keratomelacia is similar in both the sexes.
Socio-economic Factors
Children from rural and tribal families belonging to low-income
group are more vulnerable to vitamin A deficiency.
The mothers of vitamin deficient children are generally illiterate
and unaware of the importance of diet in disease.
Because of food fads and false beliefs, foods like colostrums,
green leafy vegetables and papaya which are rich in vitamin A
are avoided.
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Seasonal Effects
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The seasonal changes in vitamin A deficiency
are related to times of harvest.
The highest prevalence is observed in the
months of May-June and November-December.
Drought
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The extent of vitamin A deficiency is more
during drought due to non-availability of leafy
vegetables because of shortage of rainfall.
The prevalence is higher in areas which are
chronically drought prone.
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Inadequate dietary intake of vitamin A or its
precursor (b-carotine) is the most important
contributory factor.
The common childhood infections like measles,
diarrhea, respiratory tract infections, and
infestations like ascariasis and giardiasis interfere
with the absorption of vitamin A.
Low purchasing power of the communities and
their inability to meet the dietary requirements
even after spending 80-90% of their income on
food is an important factor for the widespread
prevalence of vitamin A deficiency
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Vitamin A deficiency is one of the simplest
preventable nutritional disorders.
Several strategies are possible for controlling
xerophthalmia and the consequent blindness:
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Periodic dosing Supplies
Fortification
Dietary modifications to promote production and
consumption of vitamin A/ beta carotene rich foods
through nutrition education and/or horticulture
intervention.
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