MALNUTRITION

AS HEALTH PROBLEMS

M. NAZIR HZ
DEPARTEMENT OF CHILD HEALTH
FACULTY OF MEDICINE, SRIWIJAYA UNIVERSITY
NUTRITION PROBLEMS IN INDONESIA (1)

1. MACRONUTRIENT DEFICIENCY
1. PROTEIN ENERGY MALNUTRION

2. MICRONUTRIENT DEFICIENCY
2.1.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
MALNUTRITION
c. PREVALENCY OF LBW 11.7% PREGNANT WOMEN
MALNUTRITION
d. HIGH PREVALENT OF MICRONUT DEF: NUTRITIONAL
ANEMIA, JODIUM DEF AND DEFICIENCY OF VIT. A
e. PREVALENCY OF OBESITY INCREASE
f. RE-EMERGING OF INFECTION : TBC, HIV
 NUTRITIONAL ANEMIA - IDA

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

Survei Kesehatan Rumah Tangga (SKRT)

4
 Deficiency of Vitamin A

1. 50% (10 million) of under 5 years suffered subclinical

vitamin A deficiency (serum retinol < 20 g/L)

2. 0,33% (66.000) of under 5 years with Xeroptalmia

(bitot’s spot).

3. > 0,50% : Community health problem (WHO)

Survei Vitamin A (Suvita), 1992

5
 JODIUM DEFICIENCY (GOITER)

 45% Districts endemic:

30% mild
7 % moderate
8 % severe
 87 milion people lives in endemic area
(prevalency 9.8%)
(mapping GAKY, 1998)

 Prevalency Jod deficiency 11.1 %

(Survei GAKY, 2003)

6
 OVER NUTRITION

o ADULT IMT (> 27 kg/m²)  11,1%

(≥30 kg/m²)  3,9% (Survei IMT tahun 1997)
o ADULT IMT (> 27 kg/m²)  8,8%
(≥30 kg/m²) 10,3% (Riskesdas 2007)
o < 5 YEAR BW/A (>+2SD) : 2,46% (2003) (Susenas)
: 3,50% (2005)
o < 5 YEAR BW/BL (>+2SD) : 12,2% (2007) (Riskesdas)

7
EFFECT OF MALNUTRITION

DECREASED OF IMMUNITY

INFECTION >>
SEVERE AND LONG DURATION OF ILLNESS
ALOS (AVERAGE LENGTH OF STAY) >>
POST OPERATIVE RECOVERY >>
POST OPERATIVE COMPLICATION >>
COST OF CARE >>

THE MOST COMMON CAUSES MORBIDITY AND MORTALITY

OF < 5 YEAR
 Malnutrition as a main cause of child mortality
(WHO, 2000)
HIV
4% Diarrhea
12%
others
Diarrhea others
29% 28%
malnutrition 28% malnutrition Malaria
8%
(underlying factor) (underlying factor)
>50% 60%
Malaria Perinatal
7% 22%
woughing
RTI cough RTI
15% 4% Tetanus
Neonatus 20%
Measles 6% measles
5%
11%
1990 2000
Protecting the World’s 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 9
 THE PREDISPOSSING FACTORS

1. SOCIAL, ECONOMIC AND CULTURAL

2. CHRONIC INFECTION
3. MALABSORPTION
4. PERSISTENT/ CHRONIC DIARRHEA
5. CONGENITAL DISORDER
6. MALIGNANCY
7. IMMUNITY DISORDER
THE PATHOGENESIS AND THEIR HEALTH IMPACT
CATABOLISM

ORGAN ATROPHY
DECREASED
ORGAN DISFUNCTION
INTAKE HOSPITALIZED
DECREASED IMMUNITY

PNEUMONIA
PREDISPOSSING SYMPTOM S OF DIARRHEA
FACTORS
ORGAN DIFUNCTION/ SYMPTOMS
INFECTION OF DEF. MACRO/
MICRO NUTR

COMPLEXS
 Epithelial cell intestine atrophy

Absorption and digestion disorder

Fatty liver liver function disorder

* synthesis
* secretion
* excretion
* detoxification
Infection PEM
anorexia

intake <<

immunity Macro/Micronut. def

PEM

Reccurent infection
Helminthiasis
diarrhea
Vitamin A deficiency

Nutritional anemia/
Iron deficiency anemia (IDA)
pneumonia

Lung tuberculose
 NUTRITIONAL DEFECIENCY
CAUSES OF PROBLEMS

NUT STATUS

INTAKE INFECTION directly

causes

Available/
behaviour/ careHealth services undirectly
Accesstability and
Mother and children causes
of food at home sanitation

POVERTY, LOW EDUCATED/ ILLITERATE, Main

NO (AVAILABILITY/ ACCESTABILITY) OF FOOD AND OCCUP. problem

ECONOMIC CRISIS, POLITIC AND The root of

SOCIAL problems
18
The State of the World Children , UNICEF, 1998
 NUTRITIONAL DEFICIENCY PROBLEMS IN
LIFE CYCLE
IMR, mental develop,
Risk of chronic
diseases in adult
Growth -
Adult nutritional developm
deficiency delayed

LBW
MEP < 5
CHILDREN

SCHOOL &
PUBERTY AGE

Nutrition Throughout The Growth disorder, low of

Life Cycle. 1999 MMR increased prestation & productions
GROWTH AND DEVELOPMENT
MONITORING
 GROWTH AND DEVELOPMENT CHART
Fisical measurement

Healthy child will optimal

growth and development

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

Age (month)
21
Sumber: materi pelatihan pemantauan pertumbuhan, Dit. Bina Gizi Masyarakat
Body weight: Increase (N1= Catch up growth)

age /month 5 6 7 8 9 10 11 12 13

BW /kg 6,0 6,5 7,2 7,8 8,2 8,7 9,2 9,5 9,9

Interpretation N1 N1 N1 N1 N1 N1 N1 N1
Body weight: Increase (N2= normal growth)

Age /month 5 6 7 8 9 10 11 12 13

BW/kg 6,5 7,0 7,2 7,8 8,1 8,5 8,8 9,0 9,1

Interpretation N2 N2 N2 N2 N2 N2 N2 N2
 Body weight: Not increase
(T1=unappropriate growth)

Age/month 5 6 7 8 9 10 11 12 13

BW/kg 6,6 6,9 7,2 7,4 7,6 7,9 8,2 8,4 8,6

Interpretation T1 T1 T1 T1 T1 T1 T1 T1

24
Body weight: not increase
(T2= not growing)

Age /month 5 6 7 8
BW /kg 6,6 6,6 6,6 6,6

Interpretation T2 T2 T2

25
Body weight not increase
(T3=Negatif growth)

Age /month 5 6 7 8
BW /kg 6,6 6,1 6,0 5,9

Interpretation T3 T3 T3

26
KMS WHO 2005, BW/A
Boy 0-24 months Girl 0-24 months
Boy 24-59 months Girl 59 months
NUTRITION ASSESSEMENT
1. Analysis of intake/day:
food recall, food freq quantity and quality
calori/ prot/ fat/ vit & mineral RDA
2. Anthropometry:
a. Measure : BW (kg) L/Ht (Cm) Age (y/m)
b. Index : BW/A L-Ht/A BW/L-Ht
c. Standart : NCHS/ WHO, 50 %-ile =100%
d. Local Stand: Lokakarya antropometri 1975
3. Clinical finding : a. Marasmus, Kwashiorkor, M-K
b. Deficiency
4. Biochemistry/ laboratorium:
Anthropometry:
1. Age : BW/A, Ht-L/A, MUAC/A
2. Usia (-) : BW/L-Ht, MUAC/L-Ht
3. Combine:
Waterloo (2 index): BW/L-Ht, BW/A
WHO (3 index) : BW/L-Ht, BW/A,
L-Ht/A
4. Anthropometric index, clinical finding, Lab
Wellcome trust
Mc Laren
5. BMI (Body Mass Index): BW (Kg)
Ht (Cm)2
PEM Classification (lokakarya 1975, Puslitbang Gizi 1978)

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

N 100-80 100-95 100-85 100-90 100-85

Mild <80-60 <95-85 <85-70 <90-70 <85-70
Severe <60 <85 <70 <70 <70

Classification (BW/BL-Ht):
>150% : Severe Obesity 90-110% : Normal
135-150%: Moderate Obesity 70-90% : Mild
120-135%: Mild Obesity <70% : Severe
>120% : Obesity
110-120%: Over nutrition
 NUTRITION DISORDER BASED ON
ANTHROPEMETRIC MEASUREMENT

WASTED NORMAL
(ACUTE MALNUTRITION)
BW/A <<< BW/A N
BL/A N BL/A N
L BW/BL N
BW/BL <<<

STUNTED
WASTED STUNTED
(CHRONIC AND ACUTE (CHRONIC MALNUTRITION)
MALNUTRITION) BW/A N/>
BW/A <<< BL/A <<<
BL/A <<< BW/BL N/>>
BW/BL <<<

BW
WHO CDC 2000

OK135S056
Growth Chart WHO 2005

Girl 11 months
BW 9 kg, L 73 cm
Normal nutritional status
( 50th)
Normal 3rd - 97th

Girl 11 months
BW 9 kg, L 73 cm
Normal nutritional status
Z – score Median
Normal + 2 SD
 A: 2 th: BW/A : N
Ht/A : N
BW/Ht : N
B B: 4 th: BW/A : N
C Ht/A : N
A
BW/Ht : N
C: 5 th: BW/A : Mild
Ht/A : Mild
BW/Ht : N
Stunted