3 Protein Energy Malnutrition, (PEM).pptx

Protein Energy Malnutrition

1. Protein Energy Malnutrition ( PEM ) Nutrition related health problems Developing countries Macronutrients : Protein-Energy (Calorie) Malnutrition ( PEM / PCM ) Micronutrients: Iron , iodine and vitamin A (and of course Zn) are the nutrients most lacking and cause several disorders Developed countries and countries in transition None Communicable Chronic Diseases/NCD/ : Hypertension, CVDs, Stroke, Diabetes (None insulin dependent), Obesity, Dental carries, Carcinomas, Osteoporosis, etc Factors - Changes in life style (sedentary, stress) and - feeding pattern ↑ fat intake, ↑ sugar intake, ↑ energy intake, ↓fibers

2. PEM …… Other terms of PEM are Multi-deficiency syndrome Failure to thrive The term PEM/PCM/PED has been used to describe A range of disorders primarily characterized by growth failure or retardation in children

3. PEM …… Growth deficit is catalogued based on Clinical forms as Marasmus Retarded growth with wasting of subcutaneous fat Chronic onset Kwashiorkor Growth failure with wasting of muscles and preservation of subcutaneous fat and pitting type edema Acute onset Mixed: Marasmus -Kwashiorkor (MK) Edema of kwashiorkor with wasting of marasmus

4. Differences Between the two Forms PEMs

5. Dermatosis

6. Milder to moderate forms of PEM Wasting :thinness, assessed by using weight for height (W/H)measurement. Stunting : linear growth retardation, assessed by using height for age (H/A)measurement Underweight : A result of wasting and/or stunting , assess using (W/A) measurement.

7. Classification of moderate and severe malnutrition Malnutrition Classification of PEM Moderate Severe Symmetric edema (bilateral pitting edema) No Yes (edematous malnutrition or kwashiorkor) Weight for Height SD Score % Median –2 to – 3 70 to 79 < -3 severe wasting < 70 or marasmus Length (Height) for age SD Score % Median –2 to – 3 85 to 89 < -3 severe stunting < 85

8. 1. All nutritional health children have weight of 16 kg and height of 107 Cm with 1.5kg standard difference in wide population. Tamru is young child visits pediatrics clinic. He has height of the population and weight 11 kg). A. What is your anthropometric assessment tool for Tamru ? B. Determine Tamru’s nutritional status with Z-SD and percentile median

9. Assessment of PEM Nutritional Assessment A measurement is the extent to which the individual’s physiologic need for nutrients is being met Is an interpretation of commonly used methods (anthropometric, biochemical, clinical, dietary and ecological ) data to tell the nutritional status of a person or group of people - It defines nutritional status by using various assessment methods (ABCDEFGHs)

10. A-Anthropometric Assesses nutritional status of all population group by determining the prevalence of under weight and height, thinness, over wt B-Biochemical assesses micronutrient deficiency e.g. Iron , vit -A .. C- Clinical Assesses manifestation of disorder D- Dietary survey determined adequacy of food and nutrient intakes of households and all population E-Ecology determined socioeconomic and demographic characteristic of household and individual

11. 1. Anthropometry Measurement of physical dimension and gross composition of human body Anthropometric assessment is done for two purposes For measurements of growth For measurements of body composition 1.1 Anthropometric measurements of growth Head circumference, Length, Height, Weight

12. Measurement of head circumference (HC) Need a flexible, non stretchable tape - Subject stand with left side facing; arms relaxed - Tape should rest at occipital protuberance and supraorbital ridge at same level on each side of head;

13. Weight measurement Weight can be measured with a : - Hanging spring scale (< 2 years children) - Beam balance (> 2 years) -Portable electronic scale - Calibration needed after every measurement - Remove or make allowance for clothing -Wait until the subject calm or remove the cause of anxiety

14. Measurement of recumbent length Note: Toes are pointing upwards Knees must be straight. If subject restless, then only left leg used to measure the Ht Measured in children: Younger than 24 months Less than 85cm long if age is not known Who are too ill to stand Correct measurement of length requires that: Child is relaxed with no shoes on Child lies parallel to the long axis of the board Crown of the head is against the fixed board Movable board is brought up against the heels

15. Standing height Measured in children over 24 months of age(85-110 cm tall) -The child stands barefoot wearing little clothing - Child faces forward with legs straight -Head, shoulder blades ,buttocks and heels contact the vertical board - Movable headboard is gently lowered;

16. Anthropometric indices are derived from combination of two or more raw measurements Conditioning factors: Age , birth weight, birth length, gestational age, sex, parental stature, and feeding mode during infancy, maturation in adolescence, pre pregnancy weight , maternal height, parity and pregnancy.

17. 1.2 - Anthropometric assessment of body composition It is based on a model in which the body consists of two chemically distinct compartments Fat and Fat free mass ( skeletal muscle, non-skeletal muscle, and soft lean tissue and the skeleton) Assessment of body fat It is the most variable component of the body which varies with age ,sex and weight Measured By: A. Skin fold thickness B. Waist-to-hip circumference ratio

18. A-Skin fold thickness Provides an estimate of the size of subcutaneous fat depot Assumptions: Thickness to the subcutaneous adipose tissue reflects a constant proportion of the total body fat The selected skin fold sites are representative Biceps and Triceps (mid point of the arm), Sub-scapular ( left arm and shoulder relaxed ) Supra-iliac (above iliac crest at mid axillary line and Mid- axillary (on the mid axillary line at the level of xyphoid process) * measured by precision skin fold thickness calipers

19. Biceps skin fold measurement skin fold thickness calipers B- Waist to hip circumference ratio Used to distinguish lower trunk ( hip and buttocks) and fatness in upper trunk (waist and abdomen)

20. Waist to hip circumference ratio It is the circumference of the waist measured mid-way between the lowest rib cage and anterior superior illiac spine and divided by the circumference of the hip measured at the level of the greater trocanter of the fumer . If the ratio is > 1 in male, and > 0.87 in female there is high risk of coronary heart disease.

21. 1.3-Index Combination of two measurements -Height for age Low HA is stunting (Chronic malnutrition) -Weight for age Low WA is underweight -Weight height ratios (Benn’s Index) Low WH is wasting ( acute malnutrition) -Body Mass Index (BMI) = Weight (kg)/(Height in meters) 2 Best for measuring adult nutritional status 18.5 – 24.9 kg/m2: Normal

22. Calculation of indices 1. Percentiles / %/ Weight for age (W/A) = Child Weight X 100 Wt of the reference child of the same age Weight for height (W/H) = Child weight X100 wt of the reference child of the same height Height for age (H/A) = Child Height X 100 Ht of the reference child of the same age

23. Expressing anthropometric measurements in Z-score - Z scores (SDs)= -1 to -2 mild, < -2 to -3 moderate, = < -3 sever Z-scores = Individual’s value – median value of reference population Standard deviation value of reference population < -2 Z Height for Age = > Stunted < -2 Z Weight for Height = >Wasted < -2 Z Weight for Age = >Underweight  

24. Ht for age Z- score = Observed height – Median reference* height Reference SD in height Wt for age Z- score = Observed weight – Median reference* wt Reference SD in weight Wt for Ht Z- score = Observed weight – Median reference* wt Reference SD in weight *Median value of reference children of same age & sex **Median weight of reference children of same height & sex  

25. Identifying PEM in children and adults Under five children I-Gomez classification (weight-for-age) II-Well come classification (weight-for-age) III-Water low classification (height-for-age) Adults In adults, PEM is called Chronic Energy Deficiency (CED) It is characterized by weight loss and lack of energy  NCHS = National center for health statistics, USA.

26. I. Gomez classification : Employs weight for age Disadvantage of Gomez Classification Edema is ignored and yet it contributes to weight Age is difficult to know accurately in developing countries (where illiteracy is common) % of NCHS reference Level of malnutrition >= 90 Normal 75 - 89 Mild (Grade I) 60 – 74 Moderate (Grade II) < 60 Severe (Grade III)

27. II. Welcome classification : Employs weight-for-age In clinical setups in order to clearly distinguish the different clinical forms ( Marasmus , Kwashiorkor or mixed) Disadvantage Doesn’t differentiate acute from chronic malnutrition %NCHS Level of malnutrition Edema No Edema 60 - 79 Kwashiorkor Undernourished < 60 Mixed Marasmus

28. III. Water low classification Weight-for-height and height-for-age are used together in a two by two table In field (community) set ups, the water low setup is used to distinguish the acute and chronic forms of malnutrition Water low classification Weight for height >= 80% < 80% Height for age >= 90% Normal Wasted < 90% Stunted Wasted and stunted

29. 1.4 –MUAC/ maid upper arm circumference / Useful in the diagnosis of PEM MUAC for age can differentiate normal children from those with PEM as reliably as weight for age Has been used for screening for PEM in emergencies such as famines and refugee crises In emergency situations, the measurement of weight or height may not be feasible and ages of children are often uncertain A single cutoff of 12.5 cm (12 in Ethiopia) has sometimes been used in the past for children <5 year as a proxy for low weight for height (wasting) . > 13.5cm = normal ; . 12.5 -13.5cm = at risk; . < 12.5 cm = marasmic

30. 1.5- BMI Identify chronic energy deficiency ( CED ) in adults the three degrees of CED are parallel to the Gomez classification of PEM in children Grades of CED BMI 0 (Normal) 18.5 – 25 kg/m 2 I (Mild underweight) 18.4 – 17.0 kg/m 2 II (Moderate underweight) 16.9 – 16.0 kg/m 2 III (severe underweight) < 16.0 kg/m 2 A pregnant women with BMI less than 16 kg/m 2 will have Low birth weight in 50% of the cases Decreased work capacity Poor resistance of infection

31. 2-Biomarkers Measurement of either total amount of the nutrient in the body or the concentration in a particular storage site (organ) in the body or in the body fluids Advantages Objective and not subject to the biases of self report Disadvantage Depend upon issues like practicality and cost Considerations include Ability to access easily the body compartments for measurement (e.g. blood, urine, adipose tissue) Procedures to collect, process and store samples Resources and technology needed for laboratory analysis Example -Serum Iron, Leukocyte ascorbic acid, Hair zinc

32. 3-Clinical methods Used to detect deviations from the normal state of nutrition just by observing and interpreting clinical signs and symptoms of deficiency or excess Signs : o bservations made by qualified examiner Symptoms : Manifestations reported by the patient Diagnosis of a nutritional deficiency should not exclusively on clinical methods Because the signs and symptoms are often nonspecific and only develop during the advanced stages of nutritional depletion (poor specific and sensitive)

33. 4- Dietary methods The method used for measuring food intake at National Household Individual level Of two types Methods to assess current intake Weighed food record : Gold standard Methods to assess past intake 24 hours dietary recall Repeated 24 hours recall Estimated food records Dietary history Food frequency questionnaire

34. Types of food intake measurement Indirect measurement of food intake: make use of information on the availability of food at national, regional, or household levels to estimate food intakes, rather than using information obtained directly from individuals who consume the food. Direct measures of food intake: Information on food intake can be obtained directly from consumers in a number of different ways.

35. Why studying food people eat? /propose / Public Health: to evaluate the adequacy and safety of the food that people eat at national or community level and to identify the need for or to evaluate nutrition-based intervention programs. Clinical: to assist with the prevention, diagnosis, and treatment of diet-related conditions. Research: to study the interrelationships between food intake and physiological function or disease conditions under controlled conditions or in field conditions.

36. 5-Ecological methods Collection of information on a variety of other factors known to influence the nutritional status Socioeconomic and demographic data Household composition Education Literacy Ethnicity Religion income, Employment Material resources Water supply and household sanitation Access to health and agricultural services Land ownership and other information

37. Management of PEM Therapeutic Feeding Program (TFP) for the management of SAM Integrates the management of Severe Acute Malnutrition (SAM) into hospitals, health facilities and medical universities SAM management includes two approaches I-Acute stabilization phase Therapeutic Feeding unit (In patient care) for children with SAM and complications The main focus is treatment of infections and other complications such as dehydration, hypothermia, hypoglycemia& other electrolyte imbalances (see protocol from the MOH)

38. Uncomplicated OTP – First Contact, Appetite test

39. Phase 1. Patients without an adequate appetite and/or a major medical complication are initially admitted to an in-patient facility for Phase 1 treatment. The formula used during this phase (F75) promotes recovery of normal metabolic function and nutrition-electrolytic balance. Rapid weight gain at this stage is dangerous, that is why F75 is formulated so that patients do not gain weight during this stage.

40. - Transition Phase. A transition phase has been introduced for in-patients because a sudden change to large amounts of diet, before physiological function is restored, can be dangerous and lead to electrolyte disequilibrium. During this phase the patients start to gain weight as F100 or RUTF is introduced. The quantity of F100 given is equal to the quantity of F75 given in Phase 1 or an equivalent amount of RUTF. As this is resulting in a 30% increase in energy intake the weight gain should be around 6 g/kg/day; this is less than the quantity given, and rate of weight gain expected, in Phase 2.

41. II-Rehabilitation phase Required for On the restoration of the lost tissue and promotion of catch up growth Whenever patients have good appetite and no major medical complication they go through Out-patient therapeutic program (OTP) indicated for children with uncomplicated SAM and with good appetite In Phase 2 RUTF or F100 used in both in-patient and out-patient settings) according to look-up tables.

42. Phase I Stabilization Phase II Rehabilitation Treatment Antibiotic, Anti-malarial, Vitamin A, etc. Care Attend to complications (e.g. shock, hypoglycemia) Feed F-75 Therapeutic Milk F-100 Therapeutic Milk (RUTF) Quantity 135ml/kg/day 200ml/kg/day Time 1-7 Days, 3 to 4 Weeks Inpatient Care Outpatient Care

43. Rehabilitation phase……. How much to give? The synthesis of new tissues requires protein and other nutrients. Synthesis also requires a considerable amount of energy. Aim is to provide all necessary nutrients so that none limits the rate of recovery Normal rate of growth of children is such that they gain weight of 1g/kg/day by -taking 105 kcal/kg/day and -0.78 g of protein/kg/day *: Stick to the current guidelines from the MOH

44. Assess progress Patients should be weighed at least weekly, preferably daily and the weights plotted Failure to maintain rapid catch-up may signal an undiagnosed infection and/or inadequate intake Keeping a record of the child’s food intake helps to elucidate the cause of poor weight gain Management of PEM see on table teaching aid of MOH

45. Prevention of PEM (options for intervention) 1. Dietary diversification Production of food stuffs at the back yard garden and intensification of horticultural activities 2. Nutrition education Focuses on educating mothers/care givers and fathers on the importance of having a balanced diet through diversification of food On job training to DAs Inclusion of nutrition courses in curriculum 3. Economic approach Aims at improving the incomes of the target community as a solution to their nutritional problems Different methods in this approach Food for work, food subsidy, income generating projects

46. 4. Dietary modification Focuses on modifying the energy, protein and micronutrient content of the complementary foods. In order to reduce dilution of the energy and protein contents of the complementary foods and their level of contamination, These need to educate mothers and demonstrate to them the benefits of sprouting (germination) and fermentation. Fermentation Renders the food less contaminated probably because of the formation of acid Germination Using sprouted (germinated) flour otherwise known as “power flour” or amylase rich flour ( ARF ) makes the complementary food more liquid but less dilute 5. Supplementation Could also be considered based on the local needs

47. Public Health Consequences Undernutrition has a series of public health consequences that diminish the individual quality of life and the prospects for social progress Susceptibility to mortality (death) Undernutrition is associated with greater mortality rates from most childhood diseases. Undernutrition accounts for 33-60% child deaths world wide Susceptibility to acute morbidity (disease) - more likely to contract diarrheal, malarial and respiratory infections and more likely to suffer from these illnesses for longer duration Decreased cognitive development Specific nutrient deficiencies also impaired cognitive development (e.g. iodine)

48. Decreased economic productivity People of larger stature and musculature are more efficient and accomplish more physical labor Prompt and complete recovery from infectious diseases that is promoted by adequate nutritional status increases economic productivity Susceptibility to chronic diseases in later life There is early appearance and greater prevalence and severity of obesity, hypertension, stroke and cardiac ischemia and diabetes in people with low birth weight and nutritional problems in early life