NUTRITIONA

L DISORDERS
Paulette Benjamin-Chin MD
Diplomate, Philippine Pediatric Society
 OBJECTIVE
1. Epidemiology of malnutrition in the
Philippines
2. Identify the common nutritional
problems in the Philippines
3. Discuss the pathophysiology, clinical
manifestations and appropriate
management of malnutrition.
 THE STATE OF
NUTRITION OF CHILDREN
IN THE PHILIPPINES
Double burden of Malnutrition
1.Undernutrition
2.Overnutrition
DIFFERENT FACES OF
MALNUTRITION
What government agency is
designated to conduct the
National Nutrition Survey:
A. DOH
B. DOST
C. FNRI
D. NSO
E. DECS
What government agency is designated
to conduct the National Nutrition
Survey:
 A. DOH
 B. DOST
 C. FNRI (Food & Nutrition Research
Institute)
 D. NSO
 E. DECS
45,047
172,323
DID YOU KNOW THAT…
ANTHROPOMETRIC MEASUREMENTS are a ready
measure of the nutritional status of an individual

“STUNTING” pertains to the presence of Chronic

malnutrition due to either energy deficient or repeated
infections
“WASTING” is a measure of Acute Malnutrition
“UNDERWEIGHT” maybe due to either acute or chronic
malnutrition
“OVERWEIGHT” is an indicator of overnutrition and a risk
factor of non-communicable diseases
8TH NATIONAL NUTRITION SURVEY
(FNRI ,2013)

Prevalence of wasted
children
(10-19 years)
2008 2013
12.4% 12.4%
 MALNUTRITION
Pathological state
 Relative or absolute deficiency or excess
of one or more essential nutrients
Clinically manifested
 Detected by biochemical, anthropometric
or physiological tests
 FETAL MALNUTRITION
 Maternal diet is the ultimate source of the
nutrients of the fetus
 Poor maternal diet increases the incidence of
developmental anomalies in the fetus
 Vitamin A and iron storage in the liver is less
 Calcium deposition in the skeleton is less
 Fat and protein storage is less
FIRST 1000 DAYS
- a child’s brain starts developing in
the womb
in the first 1000 days
- an infant’s brain forms 700-1000 new
neural connections per second
EASTMAN AND JACKSON

 Increaseincidence of Low birth

weight infants in mothers with
low weight before pregnancy and
low weight gain during pregnancy
Most likely to have low birth
weight infants:

 a. Teenage pregnant
 b. Vegetarian
 c. Alcoholic mother
 d. All
 e. None
Most likely to have low birth
weight infants:
a. Teenage pregnant
b. Vegetarian
c. Alcoholic mother
d. All
e. None
MOTHERS AT HIGH NUTRITIONAL RISK:

1. Adolescence- diet restriction (poor in

calcium, iron, vitamin A),psychological
stress.
2. High parity and frequency of
conception
3. Low pre-pregnant weight
4. Medical complications- diabetes,
malabsorption, anemia
MOTHERS AT HIGH
NUTRITIONAL RISK:
5. Obstetrical Record
6. Drug addiction, smoking, caffeine
ingestion
7. Inadequate Income
8. Psychological conditions
9. Vegetarians
 CRITICAL PERIODS OF
DEVELOPMENT

 Maternal exposure to Stress, Alcohol

and Drugs
 Undernutrition
 Lifestyle Factors
 Environmental factors
EPIGENETIC MODIFICATION

 changes in gene function that can

switch genes on and off leading to
alterations in physical and mental
health brought about by nutrition,
exposure to toxins and drugs
and environment
 FETAL IN UTERO
 DNA Methylation
 Histone Modification
 Noncoding RNAs
 Epigenetic modifications cause
altered gene expression and
susceptibility to adult-onset chronic
diseases
ADULT ONSET DISEASES

 Diabetes
 Hypertension
 Cardiovascular Disease
 Stroke
 Obesity
 MALNUTRITION
 Biggest single contributor to child
mortality from 1-3 y/o
 95 child deaths per day are associated
with malnutrition, in the Philippines
 1/1000 in the U.S.
 0.6 in Sweden
 0.8 in England
 26.9 in Guatemala
FORMS OF MALNUTRITION:

1.UNDERNUTRITION
2.SPECIFIC DEFICIENCY
3.OVERNUTRITION
4.IMBALANCE
 UNDERNUTRITION
 Pathological state resulting from
consumption of INADEQUATE QUANTITY of
food over an extended period of time.
 Synonymous to STARVATION
 SPECIFIC DEFICIENCY

Pathologic state resulting from a

relative or absolute lack of an
INDIVIDUAL NUTRIENT.
Vitamin deficiencies
OVERNUTRITION
Pathologic state resulting
from consumption of an
EXCESSIVE QUANTITY OF
FOOD, and hence calorie
excess over a period of time.
IMBALANCE
Pathologic state resulting
from a DISPROPORTION
among essential nutrients,
with or without the absolute
deficiency of any nutrients
 CAUSES OF
MALNUTRITION
I. Primary
II. Secondary
I. PRIMARY

• Due to DIETARY
INADEQUACY in amount
or in kind
FACTORS THAT MAY CONTRIBUTE
TO INADEQUATE DIET

1. Low income & low purchasing power of

families
2. Ignorance & erroneous food habits and beliefs
3. Scarcity of food supply
4. Overpopulation

 Common in developing countries

II. SECONDARY CAUSES:

• Due to some PATHOLOGIC OR

PHYSIOLOGIC CONDITIONS OF THE BODY,
preventing adequate ingestion of food, or
proper metabolism of nutrients
1. increased nutrient needs
2. decreased nutrient absorption
3. increased nutrient losses
SECONDARY
INFECTIOUS DISEASE
- gastroenteritis and respiratory
illness
FEBRILE DISEASES
- INCREASE nutritional demands and
diminish appetite
DIARRHEA
- interferes with absorption and may
cause loss of fluids and electrolytes
SECONDARY
 HEPATIC AND METABOLIC
DISEASES
- such as diabetes and thyroid
disease may hinder normal
metabolism.
 RENAL DISEASES invite abnormal
loss

Common in developed countries

 PATHOGENESIS OF
MALNUTRITION
 Inadequate supply of energy and nutrients 
Tissue depletion
 Biochemical Changes
 Functional Changes
 Classical Symptoms
 Anatomic Lesions
 NUTRITIONAL
ASSESSMENT
Weight Measurements
-Serves as an index of acute nutritional
status
- Accurate age,sex, and reference standard
is necessary for evaluation
Evaluated in 3 ways:
1. Weight for age
2. Weight for height
3. BMI
COMMON PRACTICES IN
WEIGHING PATIENTS
 HEIGHT/LENGTH
MEASUREMENTS
A better criterion of growth since this is
unaffected by excess fat or fluid
 AssessGrowth failure and chronic
undernutrition
BODY MASS INDEX (BMI)
Weight in Kg
Ht (m)²

 Betterreflect the amount of body fat

compared with the amount of muscle or
bone
BODY MASS INDEX (BMI)
WHO growth chart 0-19 y/o
Z Scores
+1 SD - overweight
+2 SD – obese
-1 SD - undernourished
Percentiles
>85% overweight
>97% obese
<15% undernourished
WATERLOW CLASSIFICATION - distinguish between
deficits in weight for height (WASTING) and deficit in height
for age (STUNTING)
NORMAL MILD MODERATE SEVERE
Ht for age % >95 90-95 80-90 <80
(Stunting)

Wt for Ht % >90 80-89 70-79 <70

(Wasting)
Wellcome Classification – provides a
standard criteria for the diagnosis of PROTEIN-
ENERGY MALNUTRITION

Wt for age EDEMA NO EDEMA

80-60 Kwashiorkor Undernutrition
(<-2 z scores)

<60 Marasmic- Marasmus

(< -3 z scores) Kwashiorkor
PROTEIN ENERGY
MALNUTRITION
I. MARASMUS
• derived from the Greek word
withering; used for severely wasted,
underweight, young child
- Infantile atrophy, Inanition, Athrepsia,
Cachexia, Decomposition
- due to a diet which is very low in both
protein and calories (“balanced
starvation”)
• COMMON AMONG 1-3 Y/O
CLINICAL
MANIFESTATIONS:
1. Failure to gain weight  wt loss 
emaciation
2. Loss of Subcutaneous tissue
3. Distended abdomen
4. Muscle wasting
5. Potbelly and winged scapulae (Muscle
weakness)
CLINICAL
MANIFESTATIONS:
6. Apathetic and quiet infant
7. Subnormal Temperature
8. Slow pulse rate with reduction of
BMR
9. Constipation or starvation type of
diarrhea
10. Growth retardation- 60% of
expected weight
KWASHIORKOR
II. Protein Malnutrition, Nutritional
Edema Syndrome, Malignant Mal,
Flour Malnutrition, Plurideficiency
Syndrome
- nutritional imbalance in early childhood
due to a diet that is VERY LOW IN
PROTEIN, but HIGH IN CALORIES in the
form of carbohydrates
- common in places where starchy foods
like rice, cassava, camote, banana and
corn are the staple food
CLINICAL MANIFESTATIONS:
I. DIAGNOSTICS SIGNS OF
KWASHIORKOR
1. Edema – cardinal sign,albumin
level< 1.5 g/dl
2. Protruding abdomen- hypotonia of
muscles
3. Muscle wasting- head lag
4. Psychomotor changes- apathetic
5. Delay in motor development
II. COMMON SIGNS OF
KWASHIORKOR

1. Hair changes- flag sign (alternating light and dark

bands in the hair)
2. Diffuse depigmentation of the skin- interference
with melanogenesis
3. Moonface
4. Anemia- iron and folic acid deficiencies
III. OCCASSIONAL SIGNS
OF KWASHIORKOR
1. Flaky paint rash or enamel
dermatoses
2. Hepatomegaly
3. Associated vitamin deficiency
4. Associated conditioning infections
PRINCIPAL FEATURES OF PROTEIN-
CALORIE DEFICIENCY
MARASMUS KWASHIORKOR

Age 0-2 years 1-3 years

Essential Features

Edema None Lower legs, face

Generalized
Wasting Gross loss of subcutaneous Hidden
fat
“skin and bone”

Muscle Wasting Obvious Sometimes hidden

Growth Retardation Obvious Sometimes hidden

Mental Changes Usually apathetic, Usually irritable, moaning,

quiet also apathetic
PRINCIPAL FEATURES OF
PROTEIN-CALORIE DEFICIENCY
Variable Features MARASMUS KWASHIORKOR
Appetite Usually good Poor
Diarrhea Often Often
Skin Changes Seldom Often- Diffuse
depigmentation
Occasional – Flaky paint
or enamel dermatosis

Hair Changes Seldom Often – Sparse,

straight, silky:
Dyspigmentation :
greyish or reddish
Moonface Seldom Often
Hepatic Enlargement Seldom Always

73
PRINCIPAL FEATURES OF PROTEIN-
CALORIE DEFICIENCY

Diagnostics MARASMUS KWASHIORKOR

Serum Albumin Normal to Low Low

Urinary urea/g Creatine Normal to Low Low

Urinary Hydroxyproline Low Low

Serum essential amino Low Low

acid index

Anemia Normal to Uncommon Common

(megaloblastic, IDA)

Liver Biopsy Normal or Atrophic Fatty Change

74
 PREVENTION
1.Adequate feedings for all ages
2. Early diagnosis and correction of
malnutrition
3. Prevention and control of infection
4. Good physical hygiene
5. Improvement of environmental
conditions
6. Health nutrition education
7. Prenatal care and family planning
 PHASES OF
TREATMENT:
PHASE 1
STABILIZATION PHASE (1-7 DAYS)
Identify co-morbidities as:
- Metabolic Imbalances
- Dehydration corrected- oral rehydration
- Treat Infection- antibiotic therapy
10 GENERAL PRINCIPLES
FOR ROUTINE CARE
1. Hypoglycemia
2. Hypothermia
3. Dehydration
4. Infection
5. Electrolytes (Potassium and Magnesium)
6. Micronutrients (Iron and Vit A)
7. Cautious feeding
8. Catch-up growth
9. Sensory Stimulation
10. Close follow up
REHABILITATION PHASE
2ND TO 6TH WEEK
 Intensive Feeding- determine route
 Goal: Catch-up Growth
 Mental Feeding
 OVERNUTRITION
Definition of Terms:
OVERWEIGHT- BMI 25-30 or 85th-95th
percentiles

OBESITY – BMI > 30 or >95th

generalized excessive accumulation of
fatty subcutaneous tissue due to
excessive intake of food compared to
utilization

MORBID OBESITY- BMI of 40 or above.

ETIOLOGY OF OBESITY

Gene-Environment Interaction
• Genetic predisposition
• Parental Obesity
• Environmental interaction
• Intrauterine environment
• Periods of critical growth
 CLINICAL
MANIFESTATIONS
1. Facial features
2. Adiposity in the mammary region
3. Abdomen is pendulous
4. External genitalia in boys appear small
because penis is buried in pubic fat
5. Obesity in upper extremities and thighs
greater
6. Acanthosis nigricans
ACANTHOSIS NIGRICANS
 TREATMENT
Two Principles:
1. Decreasing energy intake

2. Increasing energy output

 SAMPLE DIETARY
ADVICE
1. Avoiding all sweets, cakes, biscuits,
sweetened drinks, ice cream and chips
2. Avoiding or reducing intake of all fried
foods and added fats
3. Limiting milk intake to 2 glasses a
day.The use of low fat and skimmed milk
for children>5y/o
4. Increase physical activity such as
walking
 MEDICATION
Major classes of drugs:
1. Drugs that reduce food intake
- monoamine oxidasinhibitors,sympathomimetic drugs
2. Drugs that increase energy expenditure
- caffeine, ephedrine
3. Drugs that inhibit fat absorption
- Orlistat

*Anti obesity drugs not recommended for prolonged used

because of its cardiovascular effects.
 OTHER FORMS
OF TREATMENT
BARIATRIC SURGERY
reduction in the size or restriction of the stomach in
order to reduce the amount of food a person
consumes
The Roux-en-Y Gastric Bypass
Divided Gastric Bypass
Vertical Banded Gastroplasty (VBG)
Silastic Ring Gastroplasty (SRG
Adjustable Ring Gastroplasty (AGB)

- all work to achieve weight loss by restricting the volume of food int
From this…………to this
 LIPOSUCTION
Liposuction removing body fat using suction.
In traditional liposuction, small, thin blunt-
tipped tubes (cannula) are inserted
through tiny incisions in the skin. Fat is
suctioned out through these tubes as the
doctor moves the tubes around under the
skin to target specific fat deposits.
 PREVENTION
 Provide facilities to promote
increased physical activities
 Promote nutritional and physical
education in schools
 School meal programs should be
healthy choices
Thank You!