Nutritional problems of

Public Health Importance

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 NUTRITIONAL DEFICIENCY DISEASES

• On global scale the five principal nutritional deficiency diseases are:

1. PEM and CMAM

2. Xerophthalmia/VAD/

3. Nutritional anemia/IDA/

4. Endemic goiter/IDDs/

5. Zinc deficiency

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 PROTEIN-ENERGY MALNUTRITION(PEM)
• Malnutrition essentially means “bad nourishment”. It
concerns not enough as well as too much food, the
wrong types of food, or the inability to use nutrients
properly to maintain health.
• Malnutrition in all its forms is a considerable public health
concern
• Undernutrition
• Overnutrition
• Overweight and
• Obesity

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Nutrition situation
• 768 million people were affected by hunger in 2021,

• 3.1 billion in 2020 unable to afford a healthy diet.

• 2.3 billion people, were moderately or severely food insecure in 2021, up

from 25.4% before the covid-19 pandemic.

• Around 40% of all adults and 20% of all children are now overweight or
obese.

• 149 million-stunted

• 45 million –wasted
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Cont…
• In Ethiopia Case fatality of severe malnutrition in many
hospital is high
• 44% (37%), 29%(21%) and 7% are stunted, underweight and
wasted (2011 and 2019 est.)

• If it is not recognized it is not treated properly and

deaths are not prevented

• Malnutrition long term year round problem in Ethiopia

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Problem of Low income countries
Africa = 35.5%

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 PROTEIN ENERGY MALNUTRITION

• Is a multi-deficiency state which arises from inadequate

energy, protein and micronutrient supply to cells in body

to satisfy physiological requirements.

▪ Other synonymous terms are:

• Multi-deficiency syndrome

• Failure to thrive
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 Acute Malnutrition classification
1. Severe acute malnutrition (SAM)
• W/H < 70% NCHS median or a MUAC<11.5cm) or there is edema

• WFHZ less than -3 or edema

• Mortality is over 20%.

2. Moderate Acute malnutrition (MAM)

• (W/H between 70% and 80% NCHS median);

• WFH Z score b/n -2 and -3

• No edema

3. Global acute malnutrition (GAM)

=SAM+MAM
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 PEM…

▪ Have two clinical forms

• Marasmus- retarded growth with wasting of subcutaneous fat

• Kwashiorkor- growth failure with wasting of muscles and

preservation of subcutaneous fat and pitting type of edema

• Mixed: Marasmic Kwashiorkor (MK)- Edema of kwashiorkor

with wasting of marasmus

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 Cont.

Milder forms

• Wasting: Thinness using weight for height (W/H)

• Stunting: Linear growth retardation using height for age (H/A)

• Underweight

• Using weight for age (W/A)

• A result of wasting and/or stunting

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 Nutritional marasmus

• Progressive wasting of the body and is

associated with insufficient intake or
malabsorption of nutrients

• The result of cumulative, usually slow,

inadequate energy and protein intake.

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 Characteristics of marasmus
• Occurs in children < 2 yrs of age

• Severe deprivation

• Develops slowly

• Severe weight loss

• Severe muscle wasting

• Low growth (<60%), Low WAZ

• No edema, no fatty liver

• Anxiety, apathy

• Possible good appetite

• Hair thin, dry; skin dry

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• “Old Man“ face 12
 Kwashiorkor
•Caused by lack of nutrients
including protein in the diet

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 Characteristics of Kwashiorkor
• 1st to 3rd yrs of life

• Edema; enlarged fatty liver

• Low protein, infections

• Some muscle wasting

• Apathy, misery, irritable

• Loss of appetite

• Hair dry

• Dermatosis (skin lesions)

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 Management of PEM= CMAM

• Focus on:
• Correction of specific nutrient deficiencies

• Treatment of complications and

• Rx of superimposed infections

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 Management…..
• The treatment approach is classified into three phases

1) Acute stabilization phase:

• focuses on treatment of infections and other complications

2) Transition phase

3) Rehabilitation phase:
• focuses on the restoration of the lost tissue and promotion of
catch up growth

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 Phase-1 (Stabilization phase)

• Management of Medical Complications

• Routine drugs are given to correct specific deficiencies

• Feeding with F-75 milk (low caloric and sodium) is

begun

• The children should be together in a separate room or

section of the ward and not mixed with other patients

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 Pathophysiology
Reductive adaptation

is the physiological response of the body to under

nutrition and the body conserves energy by:

▪ reducing physical activity and growth

▪ reducing basal metabolism by:

▪ slowing protein turnover
▪ slowing and reducing Na+/K+ pumps
▪ reducing inflammatory and immune responses
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 Transition phase
• Started when the child appetite recovers and the main medical

complications are under control and edema start to reduce

• F-100 or RUTF (Ready-to-Use Therapeutic Food) is introduced.

• Important for slow transition

• the introduction of large amounts of RUTF or F100 could lead to imbalance

of body fluids and severe medical complications.

• In this phase:

✓ Routine drugs are continued

9/2/2023 ✓ Feeding with RUTF or F100 is started 22

 Phase-2 (Rehabilitation Phase)
• For children that progress through phase 1 and transition phase

• when they have good appetite and no major medical

complication.

• During this phase :

• Routine drugs, deworming tablets and iron, are started

• Feeding with RUTF or F100 is increased in amount

• Child starts gaining weight

• Whenever possible, implemented as OTP with RUTF.

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 Magt of SAM….
▪ Follow-up:

• after discharge
• the child and the child’s family are followed to prevent
relapse
• assure the continued physical, mental and emotional
development of the child.

• All children will be monitored in each phase to assess their

progress.

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 The Components of CMAM

1. Stabilization Center (SC)

• For 15% of SAM cases with poor/no appetite, clinically
complicated, +++ edema and Marasmic Kwash cases

2. Outpatient Therapeutic program (OTP)

• For 85% SAM with good appetite and no medical complication

3. Supplementary Feeding Program (SFP)

For MAM children and PLW

4. Plus the community mobilization/outreach component

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9/2/2023 26
 Transformation!
After Rx
Before Rx

VS

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 Prevention of PEM
• Improving access to high-quality foods and to health care;

• Improving nutrition and health knowledge & practices;

• Effectively promoting exclusive breastfeeding for the first six

months of a child’s life where appropriate;

• Promoting improved complementary feeding practices for all

children aged 6–24 months; and

• Improving water and sanitation systems and hygiene practices.

• Addressing the Immediate, Underlying and Basic causes

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 Vitamin A deficiency
Disorders (VADD)

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Vitamin A deficiency
• Vitamin A deficiency is a lack of vitamin A in humans. It is common in
developing countries but rarely seen in developed countries

• Night blindness is one of the first signs of vitamin A deficiency .

• Night blindness is the difficulty for the eyes to adjust to dim light. Affected
individuals are unable to distinguish images in low levels of illumination.

• People with night blindness have poor vision in the darkness, but see
normally when adequate light is present.

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Causes of vitamin A deficiency

• Poor dietary intake of pre-formed vitamin A .

• Maternal low dietary Vit A intake

• Iron deficiency can affect vitamin A uptake.

• Excess alcohol consumption can deplete vitamin A

• A stressed liver may be more susceptible to vitamin A toxicity.

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 Vitamin A deficiency

•Deficiency of vitamin A leads to:

➢Night blindness & xerophthalmia
➢Growth retardation
➢Acquired immune deficiency
➢Keritinization of epithelia in RT, GIT & UT
with increased risk of RTI, malabsorption &
UTI.
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Symptoms

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Target populations

• vitamin A deficiency remains a widespread public health

problem, especially in countries of South Asia and Africa.

• Globally,
• preschool-age children and
• women of reproductive age are the two population groups most commonly
recognized

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Assessments

• serum retinol, with hyporetinolemia defined as concentrations

<0.70 µmol/l,
• Most widely used approach for population based studies

• clinical parameters determined via eye exam, and/or

• functional indicators like night blindness.

• Prevalence of Bitots spot

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Public health importance
• significant public health problem, when
• population prevalence of low serum retinol (<0.70mmol/l) ≥10%,
• night blindness (XN) >1%,
• Bitot’s spots (X1B) >0.5%,
• corneal xerosis and/or ulceration (X2, X3A, X3B) >0.01%, or
• xerophthalmia related corneal scars (XS) >0.05%
(WHO 1995)

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 Prevention and control of Vitamin A
deficiency
1. High Dose vitamin A Supplementation
a) Universal Supplementation Schedule
• Children 6-11 moths = 100,000 IU every 6 months
• Children 12-59 months 200,000 IU every 6 month
• Lactating women within 6 week after delivery = 200,000IU A
single dose

b) Diseases Targeted Supplementation Schedule

• Measles, diarrhea and xeropthalmia

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 2. Breast feeding = Colostrum has high concentration of
vitamin A, it is called the first immunization of the baby
3. Dietary Modification: Fortification of oil, floor ,
sugar
4. Dietary Diversification – Behavior change
communication on the consumption of vitamin A
friendly foods eg. Growing and consuming Orange
fleshy sweet potatoes
5.Nutrition education and counseling

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Iodine deficiency Severe form of IDD

• Causes
• Low dietary intake of iodine
• Increased intake of goitrogens
• Living in mountain (highlands)
• Low intake of sea foods

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Health impact

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Spectrum of IDDs

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 Public health importance
Endemic Goiter
An area is said to be endemic if 10% or more of child population has goiter.
Classification of Endemia of Iodine deficiency disorders by Severity

Grades of severity of iodine deficiency disorders

Mild IDD Moderate IDD Severe IDD

1. Prevalence of goiter (total) 5-19% 20-29% >=30%

2. Cretinism 0 0 0-5

3. Median Urine iodine ug/d 3.5-5 2-3.4 0-1.9

4. Prevalence of neonatal TSH > 50 ug/d <1% 1-5% >5%

Intervention
1. Supply iodized salt for the whole family

•The Quality and Standards Authority of Ethiopia, has set the iodine
level to be 60-80 PPM as potassium iodate, after making allowance
for losses of iodine during storage and distribution.

In Ethiopia, an iodine content of 80 – 100 PPM is required as KIO3 at

the port of entry or at the packaging factory to satisfy the
recommended daily requirement of 150µg of iodine per a person to
prevent IDD
Cost: cost of iodizing it is extremely low – only about US$ 0.05 per
person per year (WHO)
Assessment(MUIC)

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Adequate salt iodization
▪ Universal salt iodization (USI) is the most widely practiced
intervention in eliminating iodine deficiency disorders (IDDs).

• adequately iodized salt specifies a minimum of 15 parts per

million (ppm) of iodine (15 to 40 ppm –normal) at the
household level,

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Intervention
Table2. Possible interventions

Choice of intervention methods

Severity of
IDD

Iodized salt at the concentration of 10-25 mg/kg. It may

Mild IDD
disappear with socioeconomic development
Can be controlled with iodinated salt at the concentration of 25
to 40mg/kg if the salt can be produced and effectively distributed.
Moderate IDD Otherwise iodized oil ether orally or by injection should be used
through the primary health care system contacts
Iodized oil either by injection or orally for the prevention and
Severe IDD control of central nervous system defects
Source: Shils OS, Modern nutrition in Health and Diseases Vol II: 261.
 Iron deficiency Anemia
IDA

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Deficiencies

Deficiency
❑Global problem affecting more than two billion people

❑In almost all developing countries, between one third and one half of the female and child
population are anemic.

❑Among pregnant women and children 1-5 five years of age in developing countries,
anemia prevalence is estimated to be 50-60%.

❑In sub-Saharan Africa the prevalence rate for pregnant women is 50%
❑Ethiopia -41% of pregnants were anemic

❑ while that for non-pregnant women is 40%.

❑In Ethiopia, 44% of children and 17 percent of women are anemic (DHS,2011)
 c/F

Signs and symptoms

❑Slowness/listlessness
❑Light headedness
❑Heart palpitations upon exertion
❑Fatigue
❑Irritability
❑Paleness of skin
❑Cracking of lips and tongue
❑General feeling of poor health
 Consequences
Consequences
In adults, anemia with a hemoglobin concentration of less than 11g/dl leads to
❑Reduced physical work capacity

❑Reduced mental (cognitive) performance-Poor attention span and learning ability in children
❑Low tolerance to infections
❑Poor physical growth.

❑Premature birth, inter-uterine retardation, and low birth weight

❑When the hemoglobin concentration level falls below 4 g/dl it may result in death from anemic

heart failure.
 Population at Risk

❑Low birth weight infants

❑Children aged 6-59 months

❑Adolescent girls and boys(10-19 years)

❑Pregnant and lactating women

❑ People living with HIV and AIDS

 Intervention

❑Supplementation of iron and folic acid

❑Treatment of severe anemia
❑Deworming
❑Bed net distribution

❑ Dietary diversification – increased production and consumption of locally available

iron rich foods
❑Dietary modification -Fortification of foods with iron Supplementation of iron and
folic acid
Cont…

Universal Supplementation for Pregnant and Lactating Women

 Zinc deficiency

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Introduction

• An estimated 17.3% of the world’s population is at risk of inadequate

zinc intake.

• phytate: zinc molar ratio of the diet is very important

• The estimated prevalence of inadequate zinc intake was correlated

with the prevalence of stunting under five years of age
• (r = 0.48, P,0.001)

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Cont…

• The efficiency of zinc absorption from the diet usually ranges from
about 15% to 35% in adults,

• But it depends on the amount consumed and the presence of

other dietary factors, such as phytate

• Several zinc transporters are involved in zinc secretion. (ZnT-4)

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Causes of Zinc deficiency

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Causes

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Stages of deficiency

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Indicators for Zinc deficiency
• the percentage of the population with plasma
(serum) zinc concentrations below an appropriate cut-off
• The prevalence of usual dietary zinc intakes below the Estimated
Average Requirement (EAR)
• the percentage of children less than five years of age with height-for-age Z
scores less than -2 SD
• prevalence of stunting is greater than 20%

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Indicators
• the estimated prevalence of inadequate zinc intake is
>25% and the prevalence of stunting is >20%,
• the estimated prevalence of inadequate zinc intake is >25% and the
prevalence of stunting is <20%,
• the estimated prevalence of inadequate zinc intake is <25% and
prevalence of stunting is >20%, or
• estimated prevalence of inadequate zinc intake is <25% and
prevalence of stunting is <20%.

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Effects among children

• zinc deficiency in children aged <5 years increases

• the risk of inci-dence for diarrheal disease by 1.28 (95% CI 1.10–
1.50),
• pneumonia by1.52 (95% CI 1.20–1.89) and
• malaria by 1.56 (95% CI 1.29–1.89).

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Impacts
• Following the IZiNCG tech-nique,
• the global prevalence of zinc deficiency = 31%,(4–73%)
• Zinc deficiency was estimated to cause
• 176 000 diarrhoea deaths,
• 406 000pneumonia deaths and
• 207 000 malaria deaths.
• The associated loss of disability-adjusted life years (DALYs) more than
28 million.

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Zinc supplementation
• In populations at risk of zinc deficiency, preventive zinc
supplementation reduces the
• incidence of premature delivery,
• decreases morbidity from childhood diarrhea and
• acute lower respiratory infections,
• Lowers all-cause mortality, and
• increases linear growth and weight gain among infants and young
children
• In addition, therapeutic zinc supplementation during diarrheal
episodes reduces the duration and severity of the illness

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Prevention strategies
• Zinc supplementation:
• For shortening severity and duration of diarrhea among children
• Reduced Respiratory infection?
• Adjuvant therapy for pneumonia??

• Dietary diversification
• Eating high variety of zinc rich foods
• Dietary fortification

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