MALNUTRITION AS HEALTH PROBLEMSM. NAZIR HZDEPARTEMENT OF CHILD HEALTHFACULTY OF MEDICINE, SRIWIJAYA UNIVERSITY

NUTRITION PROBLEMS IN INDONESIA (1)MACRONUTRIENT DEFICIENCY1.PROTEIN ENERGY MALNUTRION

2. MICRONUTRIENT DEFICIENCY2.1.VITAMIN A DEFICIENCY 2.2. NUTRITIONAL ANEMIA / IDA (IRON DEFICIENCY ANEMIA)2.3. JODIUM DEFICIENCY

3.OVER NUTRITION (OBESITY)

NUTRITION PROBLEMS IN INDONESIA (2)

a.STUNTED < 5 YEAR 36.8% CHRONIC MALNUTR.b.PREVALENCY OF ACUTE WASTED 13.6% ACUTE MALNUTRITIONc.PREVALENCY OF LBW 11.7% PREGNANT WOMEN MALNUTRITION HIGH PREVALENT OF MICRONUT DEF: NUTRITIONAL ANEMIA, JODIUM DEF AND DEFICIENCY OF VIT. AINCREASED INCIDENCE OF OBESITY RE-EMERGING OF INFECTION : TBC, HIV

PROTEIN ENERGY MALNUTRITION

*

NUTRITIONAL DEFICIENCYCAUSES OF PROBLEMS The State of the World Children , UNICEF, 1998

Health services andsanitation

NUT STATUS

INTAKE

INFECTION

behaviour/ care Mother and children

Available/Accesstabilityof food at home

POVERTY, LOW EDUCATED/ ILLITERATE,NO (AVAILABILITY/ ACCESTABILITY) OF FOOD AND OCCUP.

ECONOMIC CRISIS, POLITIC AND SOCIAL

directlycauses

undirectlycauses

Mainproblem

The root ofproblems

Ilustrasi 1

*

ADOLESC/

LBW

MEP < 5CHILDREN

SCHOOL &PUBERTY AGE

Adult nutritionaldeficiency

IMR, mental develop, Risk of chronic diseases in adult

Growth disorder, low of prestation & productions

MMR increased

Growth - developmdelayed

PREGN NUTR DEFICIENCY

NUTRITIONAL DEFICIENCY PROBLEMS IN LIFE CYCLE

Nutrition Throughout The Life Cycle. 1999

THE PREDISPOSSING FACTORSSOCIAL, ECONOMIC AND CULTURALCHRONIC INFECTIONMALABSORPTIONPERSISTENT/ CHRONIC DIARRHEACONGENITAL DISORDERMALIGNANCYIMMUNITY DISORDER

Infection Nutitional deficincy anorexia

intake

Atrophy of the intestinal epithelial cells

Disorders of digestion and absorbtion Fatty liverdisorders of liver function * synthesis* secretion* excretion* detoxification Intake

pneumoniaLung tuberculose

diarrhea

Helminthiasis

THE PATHOGENESIS AND THEIR HEALTH IMPACTPREDISPOSSINGFACTORSDECREASEDINTAKECATABOLISMORGAN ATROPHYORGAN DISFUNCTIONDECREASED IMMUNITYSYMPTOM S OF ORGAN DIFUNCTION/INFECTIONHOSPITALIZEDPNEUMONIADIARRHEASYMPTOMS OF DEF. MACRO/MICRO NUTR

COMPLEXSINFECTION

DECREASED OF IMMUNITY INFECTION >>SEVERE AND LONG DURATION OF ILLNESSALOS (AVERAGE LENGTH OF STAY) >>POST OPERATIVE RECOVERY >>POST OPERATIVE COMPLICATION >> COST OF CARE >>EFFECT OF MALNUTRITIONTHE MOST COMMON CAUSES MORBIDITY AND MORTALITYOF CHILDREN < 5 YEAR

HIV4%RTI 20%others28% Diarrhea12%Malaria8%22%measles5%Malnutrition as a main cause of child mortality (WHO, 2000)Measles11%Tetanus Neonatus6%Malaria7%Diarrhea28%others29%RTI 15%woughing cough4%19902000Protecting the Worlds Children, A Call for Action, 1990; Evidence and information for Policy/WHO, Child Adolescent Health and Development, 2001 WHO, Child and Adolescent Health and Development. On line www.who.int/child-adolescent-health/inegr.htm

Perinatalmalnutrition (underlying factor) 60%malnutrition (underlying factor) >50%*

*1.50% (10 million) of under 5 years suffered subclinical vitamin A deficiency (serum retinol < 20 g/L) 0,33% (66.000) of under 5 years with Xeroptalmia (bitots spot).

3.> 0,50% : Community health problem (WHO) Deficiency of Vitamin ASurvei Vitamin A (Suvita), 1992

Vitamin A deficiency - one third of children < 5 yr- to claim the lives of 70,000 children < 5 yr- 250,000-500,000 children in dev. countries ( blind each year)

highest prevalence in Southeast Asia and Africa.

Vitamin A deficiency

* Prevalency Age Group 1995 2001Adolscent girl (15-19 th) 57,1%26,5%Pregnant 50,9%40,1%< 5 years 40,5%47,0%School age 47,2% -

NUTRITIONAL ANEMIA - IDASurvei Kesehatan Rumah Tangga (SKRT)

Nutritional anemia/Iron deficiency anemia (IDA)

Iron deficiency anemia (IDA) caused by:

1. An iron-poor diet2. Body not being able to absorb iron very well3. Long-term, slow blood lossusually through menstrual periodsbleeding in the digestive tract (worm etc)Rapid growth (when more iron is needed):- in the first year of life - in adolescence

IDA can affect school performance.

Low iron levels:- decreased attention span, - reduced alertness, - learning difficulties, in young children and adolescents.

Iron supplementation- improves learning, - memory, - cognitive test performance - the performance of athletes with IDA

*45% Districts endemic:30% mild7 % moderate8 % severe 87 milion people lives in endemic area (prevalency 9.8%) (mapping GAKY, 1998)

Prevalency Iod deficiency 11.1 % (Survei GAKY, 2003)

JODIUM DEFICIENCY (GOITER)

Cretinism : severely stunted physical and mental growth due to untreated congenital def. of thyroid hormones (congenital hypothyroidism usually due to maternal hypothyroidism

Cretin

* OVER NUTRITION

ADULT IMT(> 27 kg/m) 11,1% (30 kg/m) 3,9% (Survei IMT tahun 1997) ADULT IMT(> 27 kg/m) 8,8% (30 kg/m) 10,3% (Riskesdas 2007) < 5 YEAR BW/A(>+2SD): 2,46% (2003)(Susenas) : 3,50% (2005) < 5 YEAR BW/BL(>+2SD) : 12,2% (2007)(Riskesdas)

1. Kiess W, Galler A, Reich A, et al. Clinical aspects of obesity in childhood and adolescence. Obes Rev. 2001;2(1):29 362. Clinton Smith J. The current epidemic of childhood obesity and its implications for future coronary heart disease. Pediatr ClinNorth Am. 2004;51(6):1679 16953. Snitker S, Le KY, Hager E, Caballero B, Black MM. Association of physical activity and body composition with insulin sensitivity in a community sample of adolescents. Arch Pediatr Adolesc Med. 2007;161(7):677 683Immediate and longterm health problems123Obstructive sleep disordersAsthmaElevated Blood Lipids/ insulin Hypertension, Heart diseaseType 2 diabeticMusculosceletal (Orthopedic) problemsMenstrual IrregularityDepression and social stigmatization.

TERIMA KASIH

GROWTH AND DEVELOPMENTMONITORING

*

GROWTH AND DEVELOPMENT CHARTSumber: materi pelatihan pemantauan pertumbuhan, Dit. Bina Gizi Masyarakat

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Age (month)

Fisical measurement

Healthy child will optimal growth and development

Growth

Development

Body weight: Increase (N1= Catch up growth)

age /month5678910111213

BW /kg6,06,57,27,88,28,79,29,59,9

InterpretationN1N1N1N1N1N1N1N1

Body weight: Increase (N2= normal growth)

Age /month5678910111213

BW/kg6,57,07,27,88,18,58,89,09,1

InterpretationN2N2N2N2N2N2N2N2

*Body weight: Not increase (T1=unappropriate growth)

Age/month5678910111213

BW/kg6,66,97,27,47,67,98,28,48,6

InterpretationT1T1T1T1T1T1T1T1

*Body weight: not increase (T2= not growing)

Age /month5678

BW /kg6,66,66,66,6

InterpretationT2T2T2

*Body weight not increase (T3=Negatif growth)

Age /month5678

BW /kg6,66,16,05,9

InterpretationT3T3T3

KMS WHO 2005, BW/A

Boy 0-24 monthsGirl 0-24 months

Boy 24-59 monthsGirl 59 months

NUTRITION ASSESSEMENT

Analysis of intake/day: food recall, food freq quantity and quality calori/ prot/ fat/ vit & mineral RDA2. Anthropometry: a. Measure: BW (kg) L/Ht (Cm) Age (y/m)b. Index: BW/A L-Ht/A BW/L-Htc. Standart: NCHS/ WHO, 50 %-ile =100%d. Local Stand: Lokakarya antropometri 19753. Clinical finding: a. Marasmus, Kwashiorkor, M-K b. Deficiency4. Biochemistry/ laboratorium:

Anthropometry:1. Age: BW/A, Ht-L/A, MUAC/A2. Usia (-): BW/L-Ht, MUAC/L-Ht3. Combine:Waterloo (2 index): BW/L-Ht, BW/AWHO (3 index) : BW/L-Ht, BW/A, L-Ht/A4. Anthropometric index, clinical finding, LabWellcome trustMc Laren5. BMI (Body Mass Index): BW (Kg) Ht (Cm)2

PEM Classification (lokakarya 1975, Puslitbang Gizi 1978)

CategoryBW/A L-Ht/A MUAC/A BW/L-Ht LLA/L-Ht

N100-80 100-95 100-85 100-90 100-85Mild

NUTRITION DISORDER BASED ON ANTHROPEMETRIC MEASUREMENTWASTED(ACUTE MALNUTRITION)BW/A

OK135S056WHO CDC 2000

Growth Chart WHO 2005Girl 11 monthsBW 9 kg, L 73 cmNormal nutritional status( 50th)Normal 3rd - 97th Girl 11 monthsBW 9 kg, L 73 cmNormal nutritional statusZ score MedianNormal + 2 SD

A: 2 th: BW/A: N Ht/A: N BW/Ht: N B: 4 th: BW/A: N Ht/A: N BW/Ht: N C: 5 th: BW/A: Mild Ht/A: Mild BW/Ht: N Stunted

ABC

***************

These graphs from WHO indicate that the result of Child Survival efforts and other factors has been a gradual shift in the role of major causes of infant and child mortality between 1990 and 2000. Diarrheal diseases have been reduced as a major cause. The burden of measles has been substantially reduced. HIV is beginning to become a measurable cause. ARI, where progress has been slow, becomes more prominent. So do peri- and neonatal causes, which in 1990 were lumped under other, and which are now the single largest category. In some countries, the other causes category now includes various kinds of injuries such as drowning, violence, accidents and injuries due to war.

Finally, undernutrition - estimated in 1990 to be the underlying cause of over half of under five deaths, is now estimated to be responsible for fully 60% of those deaths.

On the other hand, things havent changed that much: WHOs list of the ten leading causes of death for children in developing countries generally remain the same health conditions that are the focus of USAIDs child survival program. This includes malaria, which is the single largest direct cause of death among infants and young children in Africa.

One important thing has changed: since the 1980s, when the global Child Survival program began, the annual number of under five deaths has declined from an estimated 15 million/year to about 10.5 million, despite increasing numbers of children being born.********************************