MALNUTRITION IN THEPHILIPPINES
Edgar M. Gerodias, R.N.,ECF,PCM, Hep. B Prec. CAP I, FMD
Joanna Ruth Palermo, R.N., ICF,PBL, AIDS Prec., TB Stage V, FMD
Common Malnutrition Problems
in the Philippines
•Protein -Energy Malnutrition (PEM) - A lack of energy and protein which results in growth redardation.
•Iron Deficiency Anemia (IDA) - A deficiency in iron wherein hemoglobin concentration is below the normal level which results in short attention span, reduced ability to learn and irritability.
Common Malnutrition Problems in the Philippines
Vitamin A Deficiency (VAD) - Lack of vitamin A that may result to xeropthalmia (dryness of the eye), nightblindness (inability to see in dim light) eyes sensitive to bright light, rough dry skin and membranes of nose and throat , low body resistance to disease, poor growth, and blindness in severe cases.
Iodine deficiency Disorders (IDD) - Lack of iodine in the body which results in goiter, mental retardation, deaf-mutism, difficulty in standing or walking normally, and stunting of the limbs.
Common Malnutrition Problems in the Philippines
Vitamin A Deficiency (VAD) - Lack of vitamin A that may result to xeropthalmia (dryness of the eye), nightblindness (inability to see in dim light) eyes sensitive to bright light, rough dry skin and membranes of nose and throat , low body resistance to disease, poor growth, and blindness in severe cases.
Iodine deficiency Disorders (IDD) - Lack of iodine in the body which results in goiter, mental retardation, deaf-mutism, difficulty in standing or walking normally, and stunting of the limbs.
– This condition is characterized by an enlargement of the entire gland, or of one of its two lobes, caused by a deficiency of iodine in the diet.
Simple Goiter
The Food Fortification Program RA 8976
Republic Act 8976 or the Food Fortification Act of 2000 was signed into law on November 7, 2000 for full implementation on November 7, 2004, to address the problem of micronutrient malnutrition
This law is complimentary to RA 8172 or the ASIN Law (An Act Promoting Salt Iodization Nationwide), passed in December 1995, mandating the iodization of all salt sold in the country.
Key Provisions of the Law:
Rule IV: The Philippine Food Fortification Program
Sec. 1 – The Philippine Food Fortification Program shall cover all imported or locally processed foods or food products for sale or distribution, for human consumption in the Philippines.
Key Provisions of the Law:
Sec. 2 – The Philippine Food Fortification Program shall consist of two systems:
• Voluntary food fortification
• Mandatory food fortification for specific food products enumerated in Sec. 6 of RA 8976 and those that may be required by the National Nutrition Council.
Key Provisions of the Law:
Sec. 3 – The Implementing Rules and Regulations shall apply to all manufacturers, or producers, importers, traders, tollees, retailers, repackers of food products covered by Sec. 2 of Rule IV of the IRR, as well as restaurants and food service establishments where such food products are encouraged to be served.
Sangkap Pinoy a term used by the DOH for micronutrients added to
food to enhance its nutritional quality These micronutrients are vitamin A, iron and iodine,
which cannot be synthesized by the human body, and therefore must be provided through the diet.
The intake of these micronutrients through the Filipino diet is often inadequate and is responsible for the micronutrient malnutrition afflicting a majority of the population.
SANGKAP PINOY SEAL
Sangkap Pinoy Seal (SPS) is a mark of DOH recognition of a food product that is properly fortified with either vitamin A, iodine or iron or a combination of these micronutrients and that complies with regulations of the Bureau of Food & Drug (BFAD) of the DOH for quality, labeling and addition of fortificants.
SANGKAP PINOY SEAL Approved Products
NOODLES
No. PRODUCT FORTIFICANT 1 Dolphin Plus Vermicelli Bihon Iron, Iodine 2 Excellent Insant Mami Chicken, Beef Vitamin A, Iron 3 Goodah Instant Noodles Beef, Chicken Vitamin A, Iron 4 Lucky Me Instant Mami Chicken, Beef Vitamin A, Iron
Pancit Canton, Chicken and egg, Pancit Canton with Kalamansi Vitamin A
5 MAGGI Rich Mami Noodles Beef, Chicken, Chicken Asado Vitamin A
NOODLES
6 Maggi Noodle Buddies
Buttered Corn, Cheezy Bacon Vitamin A
7 Saucy-Mi (Original, Toyomansi, Hot & Spicy, Beef & Onion, and Instant Pancit Palabok Vitamin A
8 Ho-Mi Canton (Classic, Toyomansi, Chili Anghang, and Pinoy Beefsteak) Vitamin A
9 Ho-Mi Instant Mami (Chicken & Garlic, Beef Wanton and Beef Brisket) Vitamin A
10 Nooda Crunch Ready to Eat Noodle (Cheese, Barbeque, and Pizza) Vitamin A
11 Payless Instant Mami
Chicken, Beef, Pancit Canton with Chilimansi, Beef Bulalo Vitamin A
SNACK FOODS
12 Granny Goose Tortillas
Barbecue, Cheese, Chili, Cheese Party flavored, Corn Snack
Vitamin A, Iron & Iodine
13 Granny Goose Nibbles
Cheese, Ham and Cheese, Sizzling Hot Cheese, Corn Snack
Vitamin A, Iron & Iodine
14 Granny Goose Kornets
Natural, Barbecue, Cheese Vitamin A, Iron & Iodine
15 Clover Chips Cheese flavor Vitamin A 16 Oishi Prawn Crackers Vitamin A 17 Oishi Kirei Yummy Flakes Vitamin A
SNACK FOODS
18 Oishi Boogyman Vegetable Crunch Vitamin A 19 Oishi Cheese Barrel Vitamin A 20 Oishi Rinbee Cheese Sticks Vitamin A
21 PeeWee Crunchy BBQ and Pizza flavored snack Vitamin A, Iron
22 Cheez-it Tasty Snack Cracker Vitamin A, Iron 23 Moby Caramel Puff Vitamin A 24 Moby Chocolate flavored Snack Vitamin A, Iron 25 Ri-Chee Crunchy Snacks Milk flavored Vitamin A 26 Kenken Puffcorn Iron
Honey Caramel, Chocolate
27 Regent Golden Sweet Corn Iron
SNACK FOODS
28 Regent Snack Rice Cracker- Vegetable Flavor Iron
29 Regent Cheese Ball - Cheese flavored snack Iron 30 Regent Cheese Ring - Cheese flavored snack Iron 31 Regent Ebisen Prawn Crackers Iron 32 Tomi Corn Chips
Chicken, Sweet Corn, Keso Vitamin A, Iron
33 Humpy Dumpy Corn Chips Buttered Corn Vitamin A, Iron
on a cob, Chili & Garlic Mexican Barbecue Royal Cheese
SNACK FOODS
34 Fastsnax Corn Snacks
Barbecue Fries Vitamin A Cheeseburger
35 Jack 'n Jill Mr. Chips Vitamin A, Iron
Nacho Cheese, Sweet Corn
36 Jack 'n Jill Chiz Curls Vitamin A, Iron
37 Roller Coaster Potato Rings Cheese flavor Vitamin A, Iron
38 Maggi No Cook Rice Porridge
Guinataang Monggo, Champorado, Goto, Arroz Caldo
Vitamin A
SUPPLEMENTARY FOODS FOR INFANTS
39 Cerelac infant Cereals Vitamin A, Iron & Iodine
Rice-soya, Wheat, Wheat-Banana, Rice, Squash & Spinach, Choco-Cereal
40 Gerber Infant Cereals Vitamin A, Iron
Brown Rice, Brown Rice with Soya, Mix fruit with soya, Chicken Stew with vegetable and milk, Cream of Chicken with rice & milk, Cream of brown rice with milk, Green mongo
41 Nutri-Pak Champorado, Monggo, Beef, Chicken, Raisin-Nuts, Guinataan Vitamin A
BISCUITS
42 Goya Knick Knacks Coated Biscuit
Chocolate, Milk Vitamin A, Iron
43
Magic Flakes Crackers Sandwich Butter Cream, Chocolate, Orange, Peanut Butter, Artificial Coconut Flavor
Vitamin A
BREADS
44 Arlee's Power Bread Loaf, Bun Vitamin A, Iron
45 Sandwich Bread Egg and
Milk, Wheat, Raisin, Sandwich White
Vitamin A
46
Goldilocks Fresh Bake buns and rolls, pandesal, dinner rolls, buns
Vitamin A
SANDWICH SPREAD
47 Miracle Whip Spread
Sandwich Spread, Salad & Sandwich Spread, Ham and Bacon Spread Vitamin A
48 Miracle Whip All-Purpose Dressing Vitamin A Regular all-purpose Reduced Fat all-purpose dressing 49 Star Margarine
Classic, Mantekeso, Sweet Blend & Garlic Vitamin A, Iodine
50 Dari Crème Margarine Classic, Buttermilk Vitamin A 51 Minola Margarine Vitamin A
CHEESE PRODUCTS
52 Eden Pasteurized Filled Cheese Spread
Vitamin A, Iodine
53 Kraft Cheddar-Cheese Spread Vitamin A, Iodine
54 Kraft Chiz Whiz Processed Cheese Spread
Vitamin A, iodine
55 Cheezee Pasteurized Processed
Filled Cheese (in block form and jar)
Vitamin A
MILK
56 Alacta Grow Milk for older kids Vitamin A, Iron
57 Lactum Powder Regular, Chocolate
Vitamin A, Iron & Iodine
CHOCOLATE DRINKS
58 Ovaltine Chocolate Beverage Powder
Vitamin A, Iron, Iodine
FRUIT DRINKS
59 Eight O'Clock Orange Instant Drink Mix Vitamin A
60
Tang Juice Drink Mangga (instant drink mix full sugar & instant drink mix hybrid) Orange, Mandarin-Orange, Pineapple, Grape, Pomelo, Soursop
Vitamin A
61 Magnolia Fruit Drinks Mango, Orange, Pineapple Vitamin A
62 Magnolia Ice Tea Drinks lemon Vitamin A
63 Fruit C Orange Juice Drink Vitamin A
MEAT AND FISH PRODUCTS
64 555 Sardines Regular, Hot Vitamin A
65 Toyo Canned Sardines Vitamin A
66 Señorita Canned Sardines Vitamin A
67 Mekeni Picnic Premium Hotdog Vitamin A
68 Swift Mighty Meaty Hotdog Vitamin A
69 Boomboom Hotdog Regular, Jumbo Vitamin A
70 Purefoods Beefies Hotdog Vitamin A
CONDIMENTS
71 Papa Banana Catsup Vitamin A
DIAMOND SANGKAP PINOY SEAL
In 2004, the Diamond Sangkap Pinoy Seal was introduced to be used solely for staple products mandated for fortification, namely cooking oil, wheat flour, rice, refined sugar and salt.
Currently there are 71 products under the Diamond SPS
RICE
Iron-Fortified Rice Iron
SALTFirst Choice Iodized Salt Iodine Fidel Iodized Salt Iodine
SUGAR
Azukal Pure Cane Sugar Vitamin A
DIAMOND SANGKAP PINOY SEAL
a campaign to support various health programs to reduce childhood illnesses and deaths by promoting positive child care behaviors
A program of the Department of Health in partnership with the Local Government Units and other government and non-government organizations
GARANTISADONG PAMBATA
GARANTISADONG PAMBATA
GP is done twice a year one week in April and one week in October.
Second week of October was designated as "Garantisadong Pambata" week.
GARANTISADONG PAMBATA SERVICES
Giving VIT A capsules (VAC) supplement to all 12-59 months old children.
Catch up immmunizations (children who missed the routine immunizations like BCG, OPV, DPT, Measles)
Distribution of iron supplements to infants and pregnant women
GARANTISADONG PAMBATA SERVICES
Promotion of child positive caregiving behaviors like
exclusive breastfeeding of infants from 0-6months old, feeding infant micronutrient rich complementary foods
starting 6 months old, use of iodized salt daily, Buying and eating fortified foods, brushing of teeth properly and regularly, letting children play safe toys no smoking in front of preschooler
Marasmus speaks:
I am derived from a word meaning withering or wasting… Hence, my physical manifestations
are related to my meaning…
Kwashiorkor reacts:
I come from the African language meaning “the sickness of the older child when the next
baby is born. This corresponds to the “weaning time of the older child.” Therefore, I am the result of the misfortune in the family…
Etiology:
Marasmus-due to a diet very low in calories (CHO, fats
and protein)-BALANCED STARVATIONKwashiorkor-a deficiency of PROTEIN with adequate or
even excess of calories.
Age Incidence:
Marasmus-often the result of unsuccessful BF or
insufficient BM supply with little or no other food given.
BF may be given on:a. Scheduledb. Per Demand
Marasmus-failure to gain weight leads to loss of weight
which leads to emaciation-the face becomes shrunken (old man’s face),
muscle wasting best seen and felt at the buttocks, thighs , upper arms and scapular region (winged scapula)
Kwashiorkor-usually occurs in a breastfed child until he is
weaned gradually into starchy diet, without high protein foods
-it is highly probable that deficiencies of other nutrients such as Vit. A, B complex, other minerals and etc. are frequent contributing factors
Clinical Features
1. DiagnosticEdema-is a cardinal sign (meaning syndrome
should not be diagnosed in its absence) -1st detected at the anklegeneralized but more marked on the subcutaneous tissues of the dependent parts such as legs, forearms, penis, scrotum, the lower back, and the lower face (moonface)
-protruding abdomen is due to hypotonia of the abdominal muscles and the intestine and edema of the abdominal wall
-muscle wasting can be demonstrated functionally by testing the infants ability to hold his head when gently pulled from a lying to a sitting position
Psychomotor changes-looks miserable and does not smile-motor development is retarded
Irritability-psychological trauma d/t maternal withdrawal assoc. with weaning from the breast plays an impt. role
Mental changes-1st 3 years of life is very critical in brain
development
2. Common Signs-certain signs though not necessary for
diagnosis are common and are usually present singly or in combination
a. Hair changes-occasionally serve to indicate the duration of the deficiency: long scanty, pale,pluckability records a prolonged period of deprivation
FLAG SIGN-alternate light and dark bands in the hair indicates alternating periods of protein adequacy and deprivation
b. Depigmentation of the skin-there is general lightening of the color of the pigment of the skin due to interference in melanogenesis
c. Anemia-nutritional anemia-the hemoglobin content of the blood is lower than the
prescribed value for a given age group as a result of deficiency of folic acid or B12 like hookworm infestation
3. Occasional Signs of Kwashiorkora. Flaky Paint Rash or Enamel Dermatoses -seen in advanced cases; if present it is
pathognomonic of the disease -these are patches of skin turn reddish, then
purplish with macules and vesicleslater they become dry, peel off, leaving a raw, weeping areas like burns
-seen mostly in the hidden parts of the body like buttocks, groins and trunk.
Grave Prognosis:Hepatomegaly-there is usually enlargement of
the liver which has a smooth surface and edge
Marasmus and Kwashiorkor are assoc. with Vit. A deficiency
Difference Between Marasmus and Kwashiorkor
Marasmus KwashiorkorMuscle Wasting Poor appetiteGrowth Retardation DiarrheaApathetic, Quiet Diffuse depigmentationGood Appetite Flaky-paint/enamel orDiarrhea dermatosis
MoonfaceHepatic Enlargement
Kwashiorkor Ching!
Kwashiorkor Triple Treat!
Mr. Marasmus 2007! Bongga!
Pathophysiology of Diarrhea in Malnutrition
Types of Diarrhea:1. Infectious Diarrhea2. Non- Infectious Diarrhea
Infectious Diarrhea- PCM inflicts profound damage on the GIT particularly the stomach and duodenum.
Infectious Diarrhea-damage further the intestinal pits which has already been weakened by malnutrition
Vicious Cyclemalnutrition
malabsorptiondiarrhea
2. Non-Infectious DiarrheaMalnutritionatrophy of the intestinal villi which
contains the brush borderdissacharide: Lactose) enzyme lactase is secreted in the outermost layer of the brush borderin severe casessucrase and maltase TOTAL DISSACHARIDE INTOLERANCE or malabsorption
Lactose Intolerance-80% of the malnourished child. The intake of
regular milk which contains lactose promote and perpetuate diarrhea
Intake-1 hour after ingestion, vomiting, abdominal cramps.
How to confirm the dx. Of lactose intolerance:Aspirate watery-portion of the feces and test for -ph, reducing substancepH=<6 acidicReducing substance= trace to +1
TREATMENT OF PCM
1. Evaluate the Clinical Condition- determine the presence of any
medical emergency, make a clinical diagnosis and treat accordingly.
Ex. Severe dehydration secondary to Infectious Diarrhea
Dehydration:
REPLACEMENTMild – 5% weight loss 50 ml/kg BWModerate – 10% weight loss 100ml/kg BWSevere – 15% weight loss 150ml/kg BW
Treat with antibiotics
TREATMENT OF PCM
2. Assess the Nutritional Status- make Nutritional diagnosis
3. Rehabilitate the malnourished childa.) refer to malward if warranted
- institute medical and nutritional managementb.) home basis
- enroll in teaching programs if necessary
TREATMENT OF PCM
4. Institute follow-up measures such as:Weighing Medical and nutritional advice Immunization, deworming , sanitation advice,
family planning advice food production information Income- generating activities
HOW TO RE-INTRODUCE MILK FEEDINGS
Since early introduction of full-strength milk which contain lactose will provoke and perpetuate diarrhea, milk feedings should be resumed with extreme caution.
After 2-3 days without milk, a very dilute mixture of milk preparation is given :
S26 or Bona 1:2 dilution
1 part milk : 2 parts water1:7 1:6 1:2 (1 – 2 days)By starting gradually, exacerbation of
diarrhea due to lactose intolerance is AVOIDED
HOW TO RE-INTRODUCE MILK FEEDINGS
HOW TO RE-INTRODUCE MILK FEEDINGS
To increase the caloric content of the dilute milk, one may add sugar (sucrose or pure glucose) provided there is no intolerance to them.
For patients who are not tolerant to milk Re-feeding - Give NON LACTOSE FORMULA:
Al 110 – glucose Isomil and Nutratigen – sucroseSobee - DextrimaltoseNursoy – soya
DIETARY MANAGEMENT OF MALNOURISHED CHILD
- the essence of dietary management is to give the child HIGH CALORIC, HIGH PROTEIN DIET aiming at 100 – 200 cal/kg BW/ day 4-8 gm protein/kg BW/ day mode: feed frequently
DIETARY MANAGEMENT OF MALNOURISHED CHILD
NPO for 24 – 48 hours – IVF
50 – 75 cal/kg/day2 gm/kg/day of protein
No bouts of diarrhea
- Starting them on a full diet will definitely cause a relapse of their diarrhea:
DIETARY MANAGEMENT OF MALNOURISHED CHILD
Increase 200 mg/day of caloriesIncrease protein 8gm/day
Until weight gain is OPTIMAL (2-4 weeks)
Maintain CHO = 110 – 120 cal/kg/dayPROTEIN = 4 – 8 gm/BW/day
DIETARY MANAGEMENT OF MALNOURISHED CHILD
PROGNOSIS: most of the clinical features and pathologic changes are REVERSIBLE but if SEVERE malnutrition occurs early in life, specially before 6 months of age, when psychomotor and brain development is critical the changes noted maybe IRREVERSIBLE.
“A child should never be the result of chance, but should always be the product of a responsible gift of love of its parents to each other
and to the Creator Himself”