1. Nutritional diseases & Programs
Dr Asif Rehman

2. Nutrition Nutrition may be defined as
“The science of food and its relationship to health” (K Park, 2012)
The word Nutrient is used for specific dietary constituents and are organic and inorganic complexes contained in food such as:
Proteins
Vitamins
Minerals etc

3. Caloric Requirement Male: 2600 Kcal Females: 2100 Kcal
Infants: 110 Kcal
Children: (4-6yrs): 1700 Kcal.
Food caloric value
One Apple: 50 Kcal
One bottle of Pepsi: 110 Kcal
100 gm of beef: 200 Kcal
1 cup of tea (2 Tea spoon sugar): 95 Kcal

4. Nutrition
Poor nutrition – Can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.

5. Nutrients
There are about 50 different nutrients which are normally supplied through the foods we eat. Each nutrient has specific function in the body. These may be divided into
Macronutrients: (Proteins, Fats, Carbohydrates)
Micronutrients: ( Vitamins and Minerals)

6. Vitamins Fat soluble: (Vitamin A, D, E, K)
Water soluble: (Vitamin B & C)
Each vitamin has specific function to perform and deficiency of any particular vitamin may lead to specific deficiency disease.

7. Vitamin A In 1960 the term “Retinol” was introduced for Vitamin A.
The international unit (IU) of vitamin A is equivalent 0.3 microgram of Retinol.
Sources:
Animal Food: (liver, eggs, butter, cheese, whole milk, fish & meat)
Plant Food: (spinach, mangos, carrots)
Fortified Food: ( Ghee, margarine, milk)

8. Vitamin A Vitamin A deficiency can causes: Night blindness:
Conjunctional Xerosis: (Conjunctiva becomes dry and non wettable)
Corneal Xerosis: (cornea appears dull, dry and non wettable)
Keratomalacia: (Liquefaction of the cornea: one of the major cause of blindness in India)

9. Treatment & Prevention of Vitamin A Deficiency
Nearly all of the early stages of Xeropthalmia can be reversed by administration of massive dose of IU or 110 mg of Retinol orally on two successive days.
Prevention:
The recommended daily intake is 600 microgram for adults.
Diet improvement by regular and adequate intake of food rich in Vitamin A
Reducing contributory factors e.g Diarrhea Measles.

10. Vitamin D
The nutritionally important forms of vitamin D in man are Calciferol vitamin D2 and cholecalciferol vitamin D3.
Sources:
Vitamin D is found in animal fats and fish live oil.
It is also derived from exposure to UV rays of the sunlight.
Also found in Butter, Eggs and Milk

11. Function of Vitamin D and its Metabolites
Intestine: promotes intestinal absorption of calcium and phosphorus
Bone: stimulates normal mineralization, enhances bone resorption, affects collagen maturation.
Kidneys: Increase tubular reabsorption of phosphate.

12. Vitamin D deficiency can causes:
Rickets:
Usually observed in young children between 6 month to 2 yrs.
Reduce calcification of growing bone
Characterized by growth failure, bone deformity, muscular hypotonia (reduce muscles strength), tetany (involuntary contraction of muscles) and convulsion due to hypocalcaemia.
The bone deformities includes curved legs, deformed pelvis, Pigeon chest, Harrison Sulcus, etc
Osteomalacia:
Occurs mainly in women specially during pregnancy & lactation when requirement in increased.

13. Prevention
Educating parents to expose their children regularly to sunshine.
Vitamin D fortification food, specially Milk.
Periodic dosing of young children with Vitamin D.
The daily requirement for adult is 100 IU (2.5 microgram)

14. Vitamin
Function
Source
Deficiency
Vitamin K
Helps coagulation of blood
Cabbage, cauliflower
Delayed blood coagulation
Vitamin B1 (Thiamine)
Carbohydrate metabolism
Legumes, nuts
Beriberi, loss of appetite, fatigue
Vitamin B2
Forms parts of several enzymes system
Liver, cheese, eggs
Lips cracks at corner of the mouth, soreness of tongue
Vitamin B6
Metabolism in amino acids
Liver, wheat, yeast
Nervousness, irritability, weakness
Vitamin B12
Participate in hematopoieses in nucleic acid synthesis
Liver, Kidney
Pernicious anaemia
Vitamin C
Regulates calcium metabolism
Helps in healing
Green veg, oranges,
Scurvey, bleeding gums, dental caries, anaemia.

15. Food Fortification Food Fortification
According to WHO Food Fortification is defined as “the process whereby nutrients are added to food (in relatively small amount) to maintain and improve the quality of diet of a group, a community or population”
Food adulteration:
Mixing/substitution/concealing the quality/miss branding/adding toxicants

16. Malnutrition Definition
A pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrient.
Primary Malnutrition:
due to external factor like Food non availability
Secondary malnutrition:
due to abnormal digestion/absorbtion/utelization

17. Etiology of Primary Malnutrition
Failure of Lactation.
Improper Weaning Practices
Poverty
Food Taboos
2 or more children under 5 years of age in same household
Death of Mother
Incompetent/ Ignorant Mother.
Lack of Family Planning

18. Etiology of Secondary Malnutrition
Lack of Immunization
Congenital Diseases: ASD, VSD, cleft palate etc.
Malabsorption: Celiac Disease, Lactose intolerane, Giardiasis, Cystic Fibrosis
Metabolic: Inborn errors of Metabolism, CRF, Renal tubular Acidosis etc.
Infections: Tuberculosis ( very common in Pakistan)

19. Rates of G. Acute Malnutrition (Defining Crisis)
Severity
Prevalence of GAM
Acceptable
< 5 %
Poor
5 – 9 %
Serious
10 – 14 %
Critical
> = 15 %

20. Forms of Malnutrition
Under nutrition: this results when insufficient food is eaten over an extended period of time e.g (PEM)
Over nutrition: Pathological condition resulting from consumption of excessive quantity of food over an extended period of time.
Imbalance: pathological state resulting from a disproportionate among essential nutrients with or without absolute deficiency of any nutrient.
Specific deficiency: relative or absolute lack of an individual nutrient e.g Vitamin A

21. Protein Energy Malnutrition (PEM)
PEM is defined as A range of pathological conditions arising from simultaneous deficiency of protein and calories and commonly associated with infection.
Occurs in both adults and children
More common in children
Two main types
Kwashiorkor
Marasmus
Under nutrition is defined based on Anthropometric Indicators, Clinical Sign and Clinical tests
All of the above 4 forms often overlap in one child or in a population

22. Clinical Manifestations of Acute Malnutrition
Kwashiorkor
Bilateral Pitting Edema
Moon face
Dermatosis
Apathy (absence of emotion)
Loss of appetite
hair changes
Irritability (agitation)

23. Clinical Manifestations of Acute Malnutrition
2. Marasmus (Severe wasting)
Old man face
Thin appearance
Skin under upper arm loose
Ribs and shoulder bones easily seen
Skin of buttocks has baggy pants
No bilateral pitting oedema

24. Prevention of Malnutrition
Primary Prevention
Health Education to mothers about good nutrition and food hygiene through Lady Health Workers
Immunization of children.
Growth monitoring on Growth Charts specially of all children under 5 years of age
Secondary Prevention
Mass Screening of high risk populations, using simple tools like Weight for age or MUAC.
Tertiary Prevention
Good Nutritional Care, supplementary feedings and rehabilitation, counseling of mothers.
All mothers of malnourished children must be counselled, about proper nutritional care of the child, importance of breast feeding, proper and healthy weaning practices, benefits of immunization, and growth monitoring. 24

25. Chronic malnutrition
It is the impair development of body function due to long term deficiency/excess in nutrient/energy intake. e.g., stunting.

26. Acute Malnutrition Types 1. Moderate 2. Severe (without Complication)
3. Severe (with Complication)

27. Severe Malnutrition : Criteria
Middle Upper Arm Circumference (MUAC) is less than 11.5cm in children between 6 – 59 months of age
And/or
Presence of Bilateral Pitting Oedema

28. Moderate Malnutrition : Criteria
Middle Upper Arm Circumference (MUAC) between 11.5 cm – 12.5 cm in children between 6 – 59 months of age and <21cm in PLWs
Edema not present

29. Acute Malnutrition, Indices and cutoffs
Bilateral Pitting Oedema
MUAC
WFH z-score (WHO)
SAM
Present (+, ++, +++)
< 11.5 cm
< -3
MAM
Not Present
11.5 <12.5 cm
≥ -3 and < -2

30. NUTRTITINAL PROGRAMMES IN PAKISTAN
TAWANA PAKISTAN
NATIONAL PROGRAMM FOR FP AND PHC/ LHV PROGRAMME
BAIT UL MAL FOOD SUPPORT PROGRAMME
CMAM (UNICEF & WFP)

31. Goal and Objectives of CMAM Program
To reduce malnutrition related morbidity and mortality within communities.
Objectives
To prevent deterioration in nutritional status of the population (treat moderate acute malnutrition).
To prevent mortalities (treat severe acute malnutrition)
To prevent and treat silent hunger.
To promote proper breastfeeding and care practices (IYCF)
To promote personal hygiene and healthy practices.
To integrate management of acute malnutrition into the existing health facilities through capacity building of the health workers.

32. Recent History in the Management of Severe Acute Malnutrition (SAM)
Traditionally, children with SAM are treated in centre-based care: paediatric ward, therapeutic feeding centre (TFC), nutrition rehabilitation unit (NRU), other inpatient care sites. (This approach greatly limits coverage and impact)
The centre-based care model follows the World Health Organization (WHO) Guidelines for Management of Severe Malnutrition.
In 2001 CTC (Community Based Therapeutic Care) approach was introduced in emergency situations. (Resulted in dramatic increase of program coverage and number of children successfully treated.
Community Based Management of Acute Malnutrition (CMAM) evolved from CTC. 32

33. CMAM ? Community based management of acute malnutrition.
Community based public health approach to treating malnutrition
Benefits at individual & population level
Improves access to care
Close liaison with community improves case coverage (proportion of diseased subjects receiving care)
Reduces opportunity costs to family
Supports family coping mechanisms and /or family unit

34. CMAM A community-based approach to treating SAM
CMAM helps identify SAM in the community before the onset of complications (Screening in Community through LHWs/CHWs/ Volunteers)
Most children with SAM without medical complications (80%) can be treated as outpatients at accessible, decentralised sites with RUTF.
Children with SAM and medical complications are treated as inpatients in SC.
Community outreach for community involvement and early detection and referral of cases
Also known as community-based therapeutic care (CTC), ambulatory care, home-based care (HBC) for the management of SAM 34

35. Classification for the Community Treatment of Acute Malnutrition
Severe Acute Malnutrition With Medical Complications*
Inpatient Care
Severe Acute Malnutrition Without Medical Complications
Outpatient care
Moderate Acute Malnutrition Without Medical Complications**
Supplementary Feeding
*Complications anorexia or no appetite, intractable vomiting, convulsions, lethargy or not alert, unconsciousness, lower respiratory tract infection (LRTI), high fever, severe dehydration, severe anaemia, hypoglycaemia, or hypothermia
**Children with MAM with medical complications are admitted to supplementary feeding but are referred for treatment of the medical complication as appropriate 35

36. 4 Principles of CMAM Maximum access and coverage Timeliness
Appropriate medical and nutrition care
Care for as long as needed
(Following these steps ensure maximum public health impact) 36

37. 37 37

38. Timeliness (continued)
Find children before SAM becomes serious and medical complications arise
Good community outreach is essential
Screening and referral by outreach workers (e.g., community health workers [CHWs], volunteers) 38

39. THANK YOU