SEMINAR

ON
MALNUTRITION

SUBMITTED TO SUBMITTED BY
MRS. BINDU. K. SANKAR RIYA MARIYAT
ASST. PROFESSOR 1 ST YEAR MSc NURSING
GOVT. COLLEGE OF NURSING GOVT. COLLEGE OF NURSING
THRISSUR THRISSUR
INTRODUCTION
Malnutrition is a broad term commonly used as an alternative to under nutrition but technically
it also refers to over nutrition . People are malnourished if their diet doesn’t provide adequate
calories and protein for growth and maintenance or they are unable to fully utilize the food they
eat due to illness (under nutrition). They are also malnourished if they consume too many
calories (over nutrition). (UNICEF)

It can be due to deficiency, excess or imbalance of the nutrients

Malnutrition (literally "bad nutrition") is a disparity between the amount of food and other
nutrients that the body needs and the amount that it is receiving. This imbalance is most
frequently associated with undernutrition, but it may also be due to overnutrition.
Malnutrition can occur if you do not eat enough food. Starvation is a form of malnutrition. You
may develop malnutrition if you lack of a single vitamin in the diet. In some cases, malnutrition
is very mild and causes no symptoms. However, sometimes it can be so severe that the damage
done to the body is permanent, even though you survive.
Malnutrition continues to be a significant problem all over the world, especially among
children. Poverty, natural disasters, political problems, and war all contribute to conditions --
even epidemics -- of malnutrition and starvation, and not just in developing countries.
Children with severe malnutrition are at risk of several life-threatening problems like
hypoglycaemia, hypothermia, serious infection, and severe electrolyte disturbances. Because
of this vulnerability, they need careful assessment, special treatment and management, with
regular feeding and monitoring. Their treatment in hospital should be well organized and given
by specially trained staff.
WHO has estimated that 54% of child deaths are associated with malnutrition.
DEFINITION
WHO defines malnutrition as deficiencies, excesses or imbalances in a person's intake of
energy and/or nutrients. This is can be further divided into either "under nutrition" or obesity.
Identifying malnutrition at early stages can help reduce morbidity and mortality.
The World Health Organization (WHO) defines malnutrition as "the cellular imbalance
between the supply of nutrients and energy and the body's demand for them to ensure growth,
maintenance, and specific functions."

Severe malnutrition is defined as the presence of Severe wasting (<70% of the median weight-
for-height or <-3SD), and/or Oedema of both feet.
SEVERAL PRIMARY CAUSES:
Hunger, the most insidious, is mainly a deficiency of calories and protein. The main cause of
hunger is poverty. Hunger is most devastating when it attacks children, since it can affect their
mental and physical development for the rest of their lives, thus deepening the poverty cycle
since they have less access to education and opportunities for work later in life. However,
hunger also seriously affects adults, impeding their productivity and creating a host of
associated health problems, making their lives even more difficult. The W.H.O. estimates the
size of this group at roughly 1.2 billion people.
Micronutrient and/or protein deficiency is shown in a very large group of malnourished
people. They either do not receive adequate amounts of vitamins and minerals (micronutrients),
or the correct proportion of protein in their diets. This can also have very debilitating effects
on people and societies. The health symptoms may not be immediately visible to either the
individuals themselves or to health workers, or they can take years to manifest themselves. The
result is lost productivity. The worldwide size of the group is estimated at 2 billion people.
Over-consumption, taking in many more calories than required, is often accompanied by a
deficiency in vitamins and minerals. Many food companies sometimes exploit the human
inclination towards fatty and sugary foods by offering consumers cheap and often nutritionally
empty products. Compounded with their reduced physical activity and greater meat
consumption, these people, the overweight and obese, are a fast growing segment of the world's
population. They often live, as the middle and upper class, in those countries where hunger is
prevalent, such as in India and China. The health care costs, missed productivity and
environmental costs associated with this group are huge. The W.H.O. estimates this group to
be 1.2 billion people worldwide.
Poor diet if a person does not eat enough food, or if what they eat does not provide them with
the nutrients they require for good health, they suffer from malnutrition. Poor diet may be
caused by one of several different factors. If the patient develops dysphagia (swallowing
difficulties) because of an illness, or when recovering from an illness, they may not be able to
consume enough of the right nutrients.
Mental health problems - some patients with mental health conditions, such as depression,
may develop eating habits which lead to malnutrition. Patients with anorexia nervosa or
bulimia may develop malnutrition because they are ingesting too little food.
Mobility problems - people with mobility problems may suffer from malnutrition, simply
because they either cannot get out enough to buy foods, or find preparing them too arduous.
Digestive disorders and stomach conditions - some people may eat properly, but their bodies
cannot absorb the nutrients they need for good health. Examples include patients with Crohn's
disease or ulcerative colitis. Such patients may need to have part of the small intestine removed
(ileostomy). Individuals who suffer from Celiac disease have a genetic disorder that makes
them intolerant to gluten. Patients with Celiac disease have a higher risk of damage to the lining
of their intestines, resulting in poorer food absorption. Patients who experience serious bouts
of diarrhea and/or vomiting may Inca vital nutrients and are at higher risk of suffering from
malnutrition.
Alcoholism - an alcoholic is a person who suffers from alcoholism - the body is dependent on
alcohol. Alcoholism is a chronic (long-term) disease. Individuals who suffer from alcoholism
can develop gastritis, or pancreas damage. These problems also seriously undermine the body's
ability to digest food, absorb certain vitamins, and produce hormones which regulate
metabolism. Alcohol contains calories, reducing the patient's feeling of hunger, so he/she
consequently may not eat enough proper food to supply the body with essential nutrients.
Food shortages - in poorer developing nations food shortages are mainly caused by a lack of
technology needed for higher yields found in modern agriculture, such as nitrogen fertilizers,
pesticides and irrigation. Food shortages are a significant cause of malnutrition in many parts
of the world.
Food prices and food distribution - it is ironic that approximately 80% of malnourished
children live in developing nations that actually produce food surpluses (Food and Agriculture
Organization). Some leading economists say that famine is closely linked to high food prices
and problems with food distribution.
Lack of breastfeeding - experts say that lack of breastfeeding, especially in the developing
world, leads to malnutrition in infants and children. In some parts of the world mothers still
believe that bottle feeding is better for the child. Another reason for lack of breastfeeding,
mainly in the developing world, is that mothers abandon it because they do not know how to
get their baby to latch on properly, or suffer pain and discomfort.
PATHOPHYSIOLOGY

When a child's intake is insufficient to meet daily needs, physiologic and metabolic changes
take place in an orderly progression to conserve energy and prolong life. This process is called
reductive adaptation. Fat stores are mobilized to provide energy. Later, protein in muscle, skin,
and the gastrointestinal tract is mobilized. Energy is conserved by nergy reducing physical
activity and growth, reducing basal metabolism and the functional reserve of organs, and
reducing inflammatory and immune responses These changes s have important consequences:

✓ The liver makes glucose less readily, making the child more prone to hypoglycemia. It
produces less albumin, transferrin, and other transport proteins. It is less able to cope
with excess dietary protein and to excrete toxins.

✓ Heat production is less, making the child more vulnerable to hypothermia.

✓ The kidneys are less able to excrete excess fluid and sodium, and fluid easily
accumulates in the circulation, increasing the risk of fluid overload.

✓ The heart is smaller and weaker and has a reduced output, and fluid overload readily
leads to death from cardiac failure.

✓ Sodium builds up inside cells due to leaky cell membranes and reduced activity of the
sodium-potassium pump, leading t o excess body sodium, fluid retention, and edema.

✓ Potassium leaks out of cells and is excreted in urine, contributing to electrolyte

imbalance, fluid retention, edema, and anorexia.

✓ Loss of muscle protein is accompanied by loss of potassium, magnesium, zinc, and

copper.

✓ The gut produces less gastric acid and enzymes. Motility is reduced and bacteria may
colonize the stomach and small intestine, damaging the mucosa and deconjugating bile
salts. Digestion and absorption are impaired.
 ✓ Cell replication and repair are reduced, increasing the risk of bacterial translocation
through the gut mucosa.

✓ Immune function is impaired, especially cell-mediated immunity. The usual responses

to infection may be absent, even in severe illness increasing the risk of undiagnosed
infection.

✓ Red blood cell mass is reduced, releasing iron, which requires glucose and amino acids
to be converted to ferritin, increasing the risk of hypoglycemia and amino acid
imbalances. If conversion to ferritin is incomplete, unbound iron promotes pathogen
growth and formation of free radicals.

✓ Micronutrient deficiencies limit the body's ability to deactivate free radicals, which
cause cell damage. Edema and hair/skin changes are outward signs of cell damage.

When prescribing treatment, it is essential to take these changes in function into account.
Otherwise, organs and systems will be over whelmed, and death will rapidly ensue.

CLINICAL PRESENTATION
✓ Severe malnutrition may occur at any age but is most common between 6 and 30
months, except during famine.
✓ It often follows a severe illness such as measles or persistent diarrhoea, or repeated
infections - Severe wasting is due to loss of fat and skeletal muscle and is most visible
on the buttocks, thighs and upper arms, where the skin hangs loose in folds. The ribs
and shoulder blades are clearly visible.
✓ -The eyes may appear sunken due to wasting of the tissues behind the eye. The face
gives an 'old person' appearance. Weakened abdominal muscles and intestinal gas from
bacterial overgrowth in the small intestinal gas from bacterial overgrowth in the small
bowel can lead to a distended belly.
✓ -Wasted children are often anxious and irritable, and cry easily. Tears, however, may
be absent due to atrophy of the lacrimal glands.
✓ In oedematous malnutrition, the oedema usually appears first in the feet, and then the
lower legs. Gross oedema includes the arms and face and can develop quickly.
✓ Skin changes include abnormally dark, crackled, peeling patches (called 'flaky paint'
dermatosis) with pale skin underneath that is easily damaged and infected.
✓ Hair becomes brittle, is easily pulled out, becomes discoloured, and loses its color in
ethnic group.
✓ The liver may be enlarged with fat.
✓ Children with oedema are miserable, dislike being touched, and may have a
complaining cry.
✓ Children with oedematous malnutrition may appear chubby, but wasting becomes
evident when oedema fluid is lost during the first few days of treatment. In the presence
of oedema, muscle wasting can be best seen over the upper arms and shoulders.
In more severe cases:
• Skin may become thin, dry, inelastic, pale, and cold
 • Eventually, as fat in the face is lost, the cheeks look hollow and the eyes sunken
• Hair becomes dry and sparse, falling out easily Sometimes, severe malnutrition may
lead to unresponsiveness (stupor)
• If calorie deficiency continues for long enough, there may be heart, liver and respiratory
failure
• Total starvation is said to be fatal within 8 to 12 weeks (no calorie consumption at all)
Clinical signs of malnutrition

SITE SIGNS

• Face - Moon face (kwashiorkor), simian facies (marasmus)

• Eye - Dry eyes, pale conjunctiva, Bitot spots (vitamin A), periorbital edema

• Mouth - Angular stomatitis, cheilitis, glossitis, spongy, bleeding gums (vitamin

C), parotid enlargement

• Teeth - Enamel mottling, delayed eruption

• Hair - Dull, sparse, brittle hair, hypopigmentation; flag sign (alternating

bands of light and normal color); broomstick eyelashes; alopecia

• Skin - Loose and wrinkled (marasmus); shiny and edematous (kwashiorkor);

dry, follicular hyperkeratosis; patchy hyper- and hypopigmentation ("crazy paving" or
"flaky paint" dermatoses); erosions; poor wound healing

• Nails - Koilonychia; thin and soft nail plates, fissures, or ridges

• Musculature - Muscle wasting, particularly buttocks and thighs;

• Skeletal - Chvostek or Trousseau sign (hypocalcemia) Deformities, usually as

a result of calcium, vitamin D, or vitamin C deficiencies

• Abdomen - Distended: hepatomegaly with fatty liver; ascites may be present

• Cardiovascular - Bradycardia, hypotension, reduced cardiac output, small vessel

vasculopathy

• Neurologic - Global developmental delay, loss of knee and ankle reflexes, impaired
memory

• Hematologic - Pallor, petechiae, bleeding diathesis

• Behavior - Lethargic, apathetic, irritable on handling

TYPES OF MALNUTRITION

Malnutrition is divided into two main types

1. Under-nutrition
2. Over-nutrition

In under-nutrition nutrients are undersupplied, and in over-nutrition nutrients are over supplied
both causes nutritional disorders.

Under nutrition has many inter-related causes which need to be identified in order to
effectively design an emergency response. – The UNICEF conceptual framework for under
nutrition is a useful tool for understanding the causes of under nutrition.
✓ Inadequate food intake is the most common cause of malnutrition worldwide.
✓ In developing countries, inadequate food intake is secondary to insufficient or
inappropriate food supplies or early cessation of breastfeeding.
✓ In some areas, cultural and religious food customs may play a role.
✓ Inadequate sanitation further endangers children by increasing the risk of infectious
diseases that increase nutritional losses and alters metabolic demands
✓ In developed countries, inadequate food intake is a less common cause of malnutrition.
Instead, diseases and, in particular, chronic illnesses play an important role in the
etiology of malnutrition

It describes three levels of causality: immediate, underlying and basic.

1) The immediate cause of under nutrition is due to an imbalance between the amount of
nutrients absorbed by the body and the amount of nutrients required by the body as a
consequence of too little food intake or infection.

Immediate cause
• Reduced dietary intake
• Reduced absorption of macro- and/or micronutrients
• Increased losses or altered requirements
• Increased energy expenditure (in specific disease processes)

2) The underlying causes of under nutrition can be grouped under the three broad categories
of food insecurity, inadequate care and poor public health.

3) Basic causes - Political, legal and cultural factors may defeat the best efforts of households
to attain good nutrition and these are described as basic causes of under nutrition.

➢ Children with chronic illness are at risk for nutritional problems for several reasons,
including the following:

 Anorexia, which leads to inadequate food intake.  Increased inflammatory burden and
increased metabolic demands can increase caloric need.  Any chronic illness that involves
the liver or small bowel affects nutrition adversely by impairing digestive and absorptive
functions.

➢ Chronic illnesses that commonly are associated with nutritional deficiencies include the
following:
  Cystic fibrosis  Chronic renal failure  Childhood malignancies  Congenital heart
disease  Neuromuscular diseases  Chronic inflammatory bowel diseases

➢ In addition, the following conditions place children at significant risk for the
development of nutritional deficiencies:
 Prematurity  Developmental delay  In utero toxin exposure (ie, fetal alcohol exposure)
 Children with multiple food allergies present a special nutritional challenge because of
severe dietary restrictions.

Groups vulnerable to under nutrition typically include those with increased nutrient
requirements: children, pregnant and lactating women. - However, risk of under nutrition is
related to more than just physiological vulnerability. Groups within the population can be at
risk of under nutrition due to geographical vulnerability (displaced populations, inaccessible
populations) as well as political vulnerability (minority groups). - Older people, the disabled,
people with chronic illness and People living with HIV and AIDS

Overnutrition
Overnutrition is a condition where the intake of needed nutrients is oversupplied in a particular
form of diet. It is categorized as a type of malnutrition and causes health problems to the person
who is affected by it much like a lack of nutrients in a particular diet

DISORDERS DUE TO MALNUTRITION

✓ Protein-energy malnutrition
 Kwashiorkor
 Marasmus
 Marasmic-kwashiorkor
✓ Under nutrition of vitamins and minerals
✓ Obesity

There are 3 clinical forms of Protein-energy malnutrition or acute malnutrition.

1) Protein energy malnutrition

Marasmus – severe weight loss or wasting without oedema;

Kwashiorkor – bloated appearance due to water retention (bi-lateral oedema). Those with
kwashiorkor have oedema, Low weight-for age is not a criterion for hospital treatment by itself;
it could lead to stunted children being hospitalized, which would be inappropriate, as the short
stature is not going to be improved in the short term.
Marasmic-kwashiorkor – a combination of both wasting and bi-lateral oedema.

Marasmus
Marasmus is one component of protein-energy malnutrition (PEM). It is a severe form of
malnutrition caused by inadequate intake of protein and calories, and it usually occurs in the
first year of life, resulting in wasting and growth retardation. Marasmus accounts for a large
burden on global health. The World Health Organization (WHO) estimates that deaths
attributable to marasmus approach 50 percent of the more than ten million deaths of children
under age five with PEM.

A rapid deterioration in nutritional status in a short time can lead to marasmus, one form of
acute malnutrition. Marasmus is the most common form of acute malnutrition in nutritional
emergencies and, in its severe form, can very quickly lead to death if untreated. It is
characterized by severe wasting of fat and muscle which the body breaks down to make energy.
Wasting can affect both children and adults.

The child at risk for:

 Hypoglycemia  Hypothermia  Fluid overload/ heart failure  Infection

A wasted child can be classified as either moderately or severely acutely malnourished based
on body measurements.

Signs of Marasmus:
• Very thin body, bones prominent
• Wrinkled and dry skin, especially in the buttocks and arms Hair is thin and soft
• Face like an old man's
• Cries often
Kwashiorkor
The term kwashiorkor, meaning "the disease of the displaced child" in the language of Ga, was
first defined in the 1930s in Ghana. Kwashiorkor is one of the more severe forms of protein
malnutrition and is caused by inadequate protein intake. It is, therefore, a macronutrient
deficiency. Generally, kwashiorkor occurs when drought, famine, or societal unrest leads to an
inadequate food supply. Protein depleted diets in such areas are mostly based on starches and
vegetables, with little meat and animal products. A lack of maternal understanding regarding
balanced diets further contributes to the problem. Finally, infections and other disease states
negatively impact nutrient intake, digestion, and absorption.
Kwashiorkor is characterized by bilateral pitting oedema (affecting both sides of the body) in
the lower legs and feet which as it progresses becomes more generalised to the arms, hands and
face. Oedema is the excessive accumulation of fluid in body tissues which results from severe
nutritional deficiencies. All cases of kwashiorkor are classified as severe acute malnutrition.

Kwashiorkor is classified by the severity of the oedema, as follows:

+ Mild: both feet
++ Moderate: both feet, plus lower legs, hands or lower arms
+++ Severe: generalized oedema including both feet, legs, hands, arms and face.

Signs of Kwashiorkor:
• Legs and hands are swollen with water (edema)
• Skin has dark brown to black patches which can be peeled off
• Hair is thin and can easily be pulled out
• Face is flabby or moon-faced
 • Sad; does not smile
• Belly is enlarged
• Very slow learner
• Loss of appetite
• Apathy and irritability
• Changes in hair colour (yellow/orange)
• Dermatosis

Dermatosis is described based on the severity of signs as follows:

• + Mild: Discolouration or a few rough patches

• ++ Moderate: Multiple patches arms and/or legs
• +++ Severe: Flaking, raw skin, fissures

Difference between Marasmus and Kwashiorkor:

• Marasmus patients suffer from a peeling and alternately pigmented skin. Kwashiorkor
patients are characterized by a distended stomach, burns on the skin and diarrhea.
• Marasmus affects kids because of a lack of nutritional elements in the diet. Kwashiorkor
affects kids who do not receive enough protein in the diet.
• Marasmus affects infants and very young kids. Kwashiorkor affects kids who are a bit
older.
• Marasmus patients need to be treated with additional doses of vitamin B and a nutritious
diet. Kwashiorkor patients are treated by adding more protein in their diet.
2) Under nutrition of vitamins and minerals

Micronutrient deficiencies are another dimension of undernutrition.

Those of particular public health significance are vitamin A, vitamin B, iodine, iron, and zinc
deficiencies.

Under nutrition of minerals

• Calcium – Rickets
• Iodine deficiency – Goiter
• Iron deficiency – Anemia
• Zinc – Growth retardation

Under nutrition of vitamins

• Thiamine (Vitamin B1) – Beriberi

• Niacin (Vitamin B3) – Pellagra
• Vitamin C – Scurvy
• Vitamin D – Rickets
Vitamin A deficiency is caused by a low intake of retinol (in animal foods) or its carotenoid
precursors, mainly beta carotene (in orange colored fruits and vegetables and dark-green
leaves) (see Chapter 61). The prevalence of clinical deficiency is assessed from symptoms and
signs of xerophthalmia (principally night blindness and Bitot spots). Subclinical deficiency is
defined as serum retinol concentration 50.70 μmol/L. Vitamin A deficiency is the leading cause
of preventable blindness in children. It is also associated with a higher morbidity and mortality
among young children.

Thiamine (Vitamin B1) Deficiency Beriberi

Biochemically, there is accumulation of pyruvic and lactic acid in body fluids causing:

1. Cardiac dysfunction such as cardiac enlargement esp right side, edema of interstitial tissue.
2. Degeneration of myelin & of axon cylinders resulting in peripheral neuropathy and
3. weakness of eye movement, ataxia of gait and mental disturbance

Two forms:

1. Wet beriberi: generalized edema, acute cardiac symptoms and prompt response to thiamine
administration

2. Dry beriberi: edema not present and neurological

Riboflavin (Vitamin B2) Deficiency

Functions:

1. Acts as coenzyme of flavoprotein important in a. a., f. a. & CHO metabolism & cellular
respiration

2. Needed also by retinal eye pigments for light adaptation

Niacin (Vitamin B3) Deficiency Pellagra

Etiology:

1. Diets low in niacin &/or tryptophan

2. Amino acid imbalance or as a result of malabsorption
3. Excessive corn consumption
Symptoms

1. weakness, irritability & dizziness

2. dermatitis, diarrhea & dementia
3. Dermatitis may develop insidiously to sunlight or heat

a. First appears as symmetrical erythema

b. Followed by drying, scaling & pigmentation w/ vesicles & bullae at times

4. diarrhea, Mental changes include depression, irritability,

Iodine deficiency is the main cause of preventable intellectual. impairment (see Chapter 67).
An enlarged thyroid (goiter) is a sign of deficiency. Severe deficiency in pregnancy causes fetal
loss and permanent damage to the brain and central nervous system in surviving offspring
(cretinism). It can be prevented by iodine supplementation before conception or during the 1st
trimester of pregnancy. Postnatal iodine deficiency is associated with impaired mental function
and growth retardation. The median urinary iodine concentration in children age 6-12 yr is used
to assess the prevalence of deficiency in the general population, and a median of <100 µg/L
indicates insufficient iodine intake.

Iron-deficiency anemia is common in childhood either from low iron intakes or poor
absorption, or as a result of illness or parasite infestation (see Chapter 67). Women also have
relatively high rates of anemia as a result of menstrual blood loss, pregnancy, low iron intake,
poor absorption, and illness. Hemoglobin cutoffs to define anemia are 110 g/L for children 6-
59 mo, 115 g/L for children 5-11 yr, and 120 g/L for children 12-14 yr. Cutoffs to define anemia
for nonpreg nant women are 120 g/L, 110 g/L for pregnant women, and 130 g/L for men.

• Iron-deficiency anemia is a common anemia caused by insufficient dietary intake and

absorption of iron, and/or iron loss from bleeding which can originate from a range of sources
such as the intestinal, uterine or urinary tract.

• Iron deficiency causes approximately half of all anemia cases worldwide, and affects women
more often than men.

This can result if:

• The body does not make enough red blood cells
• Bleeding causes loss of red blood cells more quickly than they can be replaced

Zinc deficiency increases the risk of morbidity and mortality from diarrhea, pneumonia, and
possibly other infectious diseases (see Chapter 67). Zinc deficiency also has an adverse effect
on linear growth. Deficiency at the population level is assessed from dietary zinc intakes or
serum zinc concentrations.

Rickets

• Rickets is a softening of bones in immature mammals due to deficiency or impaired

metabolism of vitamin D, phosphorus or calcium.
• Rickets is among the most frequent childhood diseases in many developing countries.
• The predominant cause is a vitamin D deficiency, but lack of adequate calcium in the diet
may also lead to rickets (cases of severe diarrhea and vomiting may be the cause of the
deficiency).

3) Obesity

Obesity or increased adiposity is defined using the body mass index

(BMI), an excellent proxy for more direct measurement of body fat. BMI= weight in kg/(height
in meters). Adults with a BMI 230 meet the criterion for obesity, and those with a BMI 25-30
fall in the overweight range. During childhood, levels of body fat change beginning with high
adiposity during infancy. Body fat levels decrease for approximately 5.5 yr until the period
called adiposity rebound, when body fat is typically at the lowest level. Adiposity then
increases until early adulthood. Consequently, obesity and overweight are defined using BMI
percentiles for children 22 yr old and weight/length percentiles for infants <2 yr old. The
criterion for obesity is BMI 295th percentile and for overweight is BMI between 85th and 95th
percentiles.

ETIOLOGY

Humans have the capacity to store energy in adipose tissue, allowing improved survival in
times of famine. Simplistically, obesity results from an imbalance of caloric intake and energy
expenditure. Even incremental but sustained caloric excess results in excess adiposity.
Individual adiposity is the result of a complex interplay among genetically determined body
habitus, appetite, nutritional intake, physical activity (PA), and energy expenditure.
Environmental factors determine levels of available food, preferences for types of foods, levels
of PA, and preferences for types of activities. Food preferences play a role in consumption of
energy-dense foods. Humans innately prefer sweet and salty foods and tend initially to reject
bitter flavors, common to many vegetables. Repeated exposure to healthy foods promotes their
acceptance and liking, especially in early life. This human characteristic to adapt to novel foods
can be used to promote healthy food selection.

Environmental Changes Over the last 4 decades, the food environment has changed
dramatically related to urbanization and the food industry. As fewer families routinely prepare
meals, foods prepared by a food industry have higher levels of calories, simple carbohydrates,
and fat. The price of many foods has declined relative to the family budget. These changes, in
combination. with marketing pressure, have resulted in larger portion sizes and increased
snacking between meals. The increased consumption of high-carbohydrate beverages,
including sodas, sport drinks, fruit punch, and juice, adds to these factors.

Fast food is consumed by one third of U.S. children each day and by two thirds of children
every week. A typical fast food meal can contain 2000 kcal and 84 g of fat. Many children
consume 4 servings of high carbohydrate beverages per day, resulting in an additional kcal of
low nutritional value. Sweetened beverages have been linked to increased risk for obesity. The
dramatic increase in the use of high-fructose corn syrup to sweeten beverages and prepared
foods is another important environmental change, leading to availability of inexpensive
calories.

Sleep plays a role in risk for obesity. Over the last 4 decades, children and adults have
decreased the amount of time spent sleeping. Reasons for these changes may relate to increased
time at work, increased time watching television, and a generally faster pace of life. Chronic
partial sleep loss can increase risk for weight gain and obesity, with the impact possibly greater
in children than in adults. In studies of young, healthy, lean men, short sleep duration was
associated with decreased leptin levels and increased ghrelin levels, along with increased
hunger and appetite. Sleep debt also results in decreased glucose tolerance and insulin
sensitivity related to alterations in glucocorticoids and sympathetic activity. Some effects of
sleep debt might relate to orexins, peptides synthesized in the lateral hypothalamus that can
increase feeding, arousal, sympathetic activity, and neuropeptide Y activity.

Genetics determinants also have a role in individual susceptibility to obesity. Findings from
genome-wide association studies explain a very small portion of interindividual variability in
obesity. One important example, the FTO gene at 16912. is associated with adiposity in
childhood, probably explained by increased energy intake. Monogenic forms of obesity have
also been identified, including melanocortin-4 receptor (MCAR) deficiency, associated with
early-onset obesity and food-seeking behavior. Mutations in MC4R are a common cause of
monogenetic obesity but a rare cause of obesity in general. Deficient activation of MCAR is
seen in patients with proopiomelanocortin (POMC) deficiency, a prohormone precursor of
adrenocorticotropic hormone (ACTH) and melanocyte-stimulating hormone (MSH). resulting
in adrenal insufficiency, light skin, hyperphagia, and obesity. In addition, evidence suggests
that appetitive traits are moderately) heritable.

Microbiome - It is increasingly recognized the human gut microbiota play a role in regulating
metabolism. This novel area of research raises questions about the role of antibiotics in the
pathway to obesity and the possibility that probiotics could be therapeutic for certain
individuals.

Endocrine and Neural Physiology - Monitoring of "stored fuels and short-term control of
food intake (appetite and satiety) occurs through neuroendocrine feedback loops linking
adipose tissue, the gastrointestinal (GI) tract, and the central nervous system (CNS). GI
hormones, including cholecystokinin, glucagon-like peptide 1, peptide YY, and vagal neuronal
feedback promote satiety. Ghrelin stimulates appetite. Adipose tissue provides feedback
regarding energy storage levels to the brain through hormonal release of adiponectin and leptin.
These hormones act on the arcuate nucleus in the hypothalamus and on the solitary tract nucleus
in the brainstem and in turn activate distinct neuronal networks. Adipocytes secrete adiponectin
into the blood, with reduced levels in response to obesity and increased levels in response to
fasting. Reduced adiponectin levels are associated with lower insulin sensitivity and adverse
CV outcomes. Leptin is directly involved in satiety; low leptin levels stimulate food intake,
and high leptin levels inhibit hunger in animal models and in healthy human volunteers.
However, the negative feedback loop from leptin to appetite may be more adapted to preventing
starvation than excess intake.

✓ Children tend to be more aware of satiety than adults, so allow children to respond to
satiety, and stop eating.
✓ Do not force children to "clean their plate."

ASSESSMENT OF MALNUTRITION

Anthropometry

• It implies assessing the attainment of growth based on measures of physical characteristi cs

of the body (e.g., weight, height, etc.)
Biochemical tests
• Assessing specific components of blood and urine samples of an individual.

Clinical signs
• Assessing signs and symptoms of illness (e.g. oedema).

Dietary intake
• Assessing food intake of individuals over a specific period of time in order to determine
whether the quantity or quality of intake is adequate.

Nutritional index

Weight for height or length (WFH) an index used to measure wasting or acute malnutrition
MUAC for age, sex and height a specific indicator of wasting or acute malnutrition

Height for age (HFA) an index used to measure stunting or chronic malnutrition

Weight for age (WFA)an index used to measure underweight

MEASUREMENT OF UNDERNUTRITION

The term malnutrition encompasses both ends of the nutrition spectrum, from undernutrition
to overweight. Many poor nutritional outcomes begin in utero and are manifest as low
birthweight (LBW, <2,500 g). Preterm delivery and fetal growth restriction are the 2 main
causes of LBW, with prematurity relatively more common in richer countries and fetal growth
restriction relatively more common in poorer countries.

One status is often assessed in terms of anthropometry. International standards of normal child
growth under optimum conditions from birth to 5 yr have been established by the World Health
Organization (WHO). To compile the standards, longitudinal data from birth to 24 month of
healthy, breastfed, term infants were combined with cross-sectional measurements of children
ages 18-71 month. The standards allow normalization of anthropometric measures in terms of
z scores (standard deviation [SD] scores).

A z-score is the child's height (weight) minus the median height (weight) for the child's age
and sex divided by the relevant SD. The standards are applicable to all children every where,
having been derived from a large, multicountry study reflecting diverse ethnic backgrounds
and cultural settings.

Height-for-age
Height-for-age (or length-for-age for children <2 yr) is a measure of linear growth, and a deficit
represents the cumulative impact of adverse events, usually in the first 1000 days from
conception, that result in stunting, or chronic malnutrition. A low height-for-age typically
reflects socioeconomic disadvantage.

Weight-for-height
A low weight-for-height, or wasting, usually indicates acute malnutrition. Conversely, a high
weight-for-height indicates overweight. Weight-for-age is the most commonly used index of
nutritional status, although a low value has limited clinical significance because it does not
differentiate between wasting and stunting.

Weight-for-age
Weight-for-age has the advantage of being somewhat easier to measure than indices that
require height measurements.

Mid-upper arm circumference

In humanitarian emergencies and some community or outpatient settings, mid-upper arm
circumference is used for screening wasted children.

Body mass index (BMI)

Body mass index (BMI) is calculated by dividing weight in kilograms by the square of height
in meters. For children, BMI is age and gender specific. BMI-for-age can be used from birth to
20 yr and is a screening tool for thinness (less than -2 SD), overweight (between +1 SD and +2
SD), and obesity (greater than +2 SD). To diagnose obesity, additional measures of adiposity
are desirable because a high BMI can result from high muscularity, and not only from excess
subcutaneous fat.

TREATMENT:
Principles of Treatment

Treatment are separated into 2 phases, stabilization and rehabilitation. These steps apply to all
clinical forms and all geographic locations, including North America and Europe. The aim of
the stabilization phase is to repair cellular function, correct fluid and electrolyte imbalance,
restore homeostasis, and prevent death from the interlinked triad of hypoglycemia,
hypothermia, and infection.

The aim of the rehabilitation phase is to restore wasted tissues (te, catch-up growth). It is
essential that treatment proceeds in an ordered progression and that the metabolic machinery
is repaired before any attempt is made to promote weight gain. Pushing ahead too quickly risks
inducing the potentially fatal "refeeding syndrome".

Caregivers bring children to health facilities because of illness, rarely because of their
malnutrition. A common mistake among healthcare providers is to focus on the illness and treat
as for a well-nourished child. This approach ignores the deranged metabolism in malnourished
children and can be fatal. Such children should be considered as severely malnourished with a
complication, and treatment should follow the 10 steps. Two other potentially fatal mistakes
are to treat edema with a diuretic and to give a high-protein diet in the early phase of treatment.
Emergency Treatment

It mainly include the therapeutic directives for malnourished children with shock and other
emergency conditions. Note that treatment of shock in these children is different (less rapid,
smaller volume, different fluid) from treatment of shock in well-nourished children, because
shock from dehydration and shock from sepsis often coexist and are difficult to differentiate
on clinical grounds. Thus the physician must be guided by the response to treatment: children
with dehydration respond to intravenous (IV) fluid, whereas those with septic shock will not
respond. Since severely malnourished children can quickly succumb to fluid overload, they
must be monitored closely.

Stabilization

It include the therapeutic directives for stabilization steps 1-7. Giving broad-spectrum
antibiotics and feeding frequent small amounts of F75 (a specially formulated low-lactose milk
with 75 kcal and 0.9 g protein per 100 mL to which potassium, magnesium, and micronutrients
are added), will re- establish metabolic control, treat edema, and restore appetite. The parenteral
route should be avoided; children who lack appetite should be fed by nasogastric tube, because
nutrients delivered within the gut lumen help in its repair. Table 57.10 provides recipes for
preparing the special feeds and their nutrient composition. Of the 2 recipes for F75, one requires
no cooking, and the other is cereal based and has a lower osmolality, which may benefit
children with persistent diarrhea. F75 is also available commercially; maltodextrins replace
some of the sugar, and potassium, magnesium, minerals, and vitamins are already added.

Dehydration status is easily misdiagnosed in severely wasted children. because the usual signs
(e.g., slow skin pinch, sunken eyes) may be present even without dehydration. Rehydration
must therefore be closely monitored for signs of fluid overload. Serum electrolyte levels can
be misleading because of sodium leaking from the blood into cells and potassium leaking out
of cells. Keeping the intake of electrolytes and nutrients constant allows systems to stabilize
more quickly than adjusting intake in response to laboratory results.

Therapeutic Combined Mineral Vitamin mix (CMV) contains electrolytes, minerals, and
vitamins and is added to ReSoMal and feeds. If unavailable, potassium, magnesium, zinc, and
copper can be added as an electrolyte/mineral stock solution, and a multivitamin supplement
can be given separately.

Rehabilitation

The signals for entry to the rehabilitation phase are reduced or minimal edema and return of
appetite.

A controlled transition over 3 days is recommended to prevent refeeding syndrome. After the
transition, unlimited amounts should be given of a high-energy, high-protein milk formula such
as F100 (100 kcal and 3 g protein per 100 mL), or a ready-to-use therapeutic food (RUTF), or
family foods modified to have comparable energy and protein contents. To make the transition,
for 2 days replace F75 with an equal volume of F100, then increase each successive feed by 10
ml. until some feed remains uneaten (usually at about 200 ml/kg/day). After this transition,
give 150-220 kcal/kg/day and 4-6 g protein/kg/day, and continue to give potassium,
magnesium, and micronutrients. Add iron (3 mg/kg/ day). If breastfed, encourage continued
breastfeeding. Children with severe malnutrition have developmental delays, so loving care,
structured play, and sensory stimulation during and after treatment are essential to aid recovery
of brain function.

Community-Based Treatment

Many children with severe acute malnutrition can be identified in their communities before
medical complications arise. If these children have a good appetite and are clinically well, they
can be rehabilitated at home through community-based therapeutic care, which has the added
benefit of reducing their exposure to nosocomial infections and providing continuity of care
after recovery. It also reduces the time caregivers spend away from home and their opportunity
costs and can be cost effective for health services.

To maximize coverage and compliance, community-based therapeutic care has 4 main

elements:
• community mobilization and sensitization
• active case finding
• therapeutic care
• follow-up after discharge.

Community-based therapeutic care comprises steps 8-10, plus a broad-spectrum antibiotic

(step 5). RUTF is usually provided, especially in times of food shortage. RUTF is specially
designed for rehabilitating children with severe acute malnutrition at home. It is high in energy
and protein and has electrolytes and micronutrients. added. The most widely used RUTF is a
thick paste that contains milk powder, peanuts, vegetable oil, and sugar. Pathogens cannot grow
in it because of its low moisture content. Hospitalized children who have completed steps 1-7
and the transition can be transferred to community. based care for completion of their
rehabilitation, thereby reducing their hospital stay to about 7-10 days.

General treatment measures

✓ Breast-feed the baby 1 to 2 hours after delivery. Continue breastfeeding as long as the
mother has milk. Start supplementary feeding when the baby is 4 months.
 ✓ Do not use condensed milk as breast milk substitute.
✓ For severe cases, bring the child to the nearest health center, hospital, or clinic. Consider
this as an emergency. The child usually has diarrhea or lung infection. Avoid delay of
treatment. Affer emergency condition is controlled, treatment and nutrition
rehabilitation must be continued at home.
✓ Treat the existing infection or illness and prevent its recurrence.
✓ Prepare nutritious and appetizing food.
✓ If a child has no appetite, encourage small but frequent feedings. Do not force him or
her to eat.
✓ Minimize giving junk foods, soft drinks, and artificially colored or flavored snack food
with "empty calories."
✓ Encourage the child to have regular meals. Snacks should be given 2 hours before
meals.
✓ Provide stimulating materials to hear, see, touch, taste, and smell.
✓ Provide a warm, loving environment.
✓ Seek help and support of community leaders.
MANAGEMENT
Many children hospitalized with a common illness as the primary diagnosis (e.g. diarrhoea or
pneumonia) are severely malnourished. A common and often fatal mistake is to try to treat the
illness first and the malnutrition afterwards. This ignores the profound metabolic and
physiological changes that exist in severe malnutrition and greatly increases the risk of death.
The correct approach is to regard such children as having severe malnutrition with a coexisting
infection and to treat both conditions simultaneously.
Severe malnutrition is managed in two phases: a stabilization phase, during which
homoeostasis is restored and acute life threatening conditions are prevented or treated, and a
longer rehabilitation phase of rapid catch-up growth.
Treatment procedures are based on a 10-step approach and are similar for both wasted and
oedematous children.
Severely malnourished children die in hospital from four main causes: hypoglycaemia,
hypothermia, heart failure, and infection.
Centres with a record of low mortality take immediate steps to prevent death from these causes.
Centers where the mortality is high have practices that contribute to these causes of death.
Severely malnourished children die in hospital from
1-Hypoglycemia: Severely malnourished children are at increased risk of hypoglycaemia due
to increased demands for, and a limited supply of, glucose.
This is because:
• Their liver makes glucose less easily;
• They have less glycogen in reserve because their muscles have wasted;
• They usually have multiple infections and the immune response requires relatively large
amounts of glucose;
- Treat: They need a specially prepared diet, such as F 75, which contains sugar or another
readily available source of glucose. If this is not immediately available, give a solution of 10%
glucose or sucrose.
2. Hypothermia. Severely malnourished children have an increased risk of developing
hypothermia due to:
• reduced heat production from lowered basal metabolism and diminished physical
activity;
• increased heat loss from their relatively larger surface area/kg and loss of the insulation
normally provided by subcutaneous fat; and
• infections, which increase the demand for glucose via the immune system 3.
Dehydration. Severely malnourished children often have diarrhoea.
It is difficult to diagnose dehydration in a severely malnourished child because the common
signs (slow skin pinch, sunken eyes, dry mouth, absent tears) are similar to the signs of
malnutrition itself. All severely malnourished children with watery diarrhoea should be
assumed to have some dehydration.
3. Dehydration.
Severely malnourished children die from fluid overload during rehydration. There are three
main reasons:
The degree of dehydration is overestimated, because of confusion between signs of
malnutrition and signs of dehydration;
• fluids are given intravenously, which increases the risk of overload; and
• children are not monitored carefully during rehydration, so fluid overload is not
diagnosed until it is too late.
Severely malnourished children with diarrhoea should not be given IV fluids, except when
there is shock. Instead they should be rehydrated orally with a special rehydration solution for
malnutrition (ReSoMal)
This is low in sodium (45 mmol/l) and has added potassium, magnesium, and sugar.
Rehydration (5 ml/ kg every 30 min for 2 h and then 5-10 ml/kg/h for up to 10 h) is slower than
for well-nourished children. Pulse and respiration rates should be monitored every 30 min for
the first 2 h and then hourly for signs of Overhydration.
4. Electrolytes.
All severely malnourished children have excess body sodium (even though plasma sodium may
be low) and deficiencies of potassium and magnesium. Oedema is partly due to these
imbalances. All malnourished children should be given extra potassium (4 mmol/kg/d as
potassium chloride) and extra magnesium (0.6 mmol/kg/d as magnesium chloride) for at least
2 weeks. A combined solution (e.g. a vitamin mineral mix) can be added to feeds and to
ReSoMal.
Sodium should be restricted. Diuretics make potassium deficiency worse and should never be
given to treat oedema.
5. Infection.
Infections are easily missed in severely malnourished children as the normal signs are often
absent.
All children should, therefore, be presumed to be infected, even if there are no clinical signs.
A broad spectrum oral antibiotic such as cotrimoxazole should be given straightaway on the
first day of admission. Children who are hypoglycaemic, hypothermic or who appear seriously
ill should be given IM or IV ampicillin and gentamicin.
Malnourished children are very vulnerable to nosocomial infection. Good ward hygiene and
handwashing by doctors, nurses and other carers are therefore important.
Overcrowding and sharing of cots should be avoided. Measles vaccination should be given to
non immunized children aged 9 months
6. Micronutrients deficiencies. All severely malnourished children have vitamin and mineral
deficiencies which must be corrected. A large dose of vitamin A should be given on Day 1 to
boost immune function and prevent blindness. If there is any sign of xerophthalmia, the dose
should be repeated on Day 2 and Day 14.
Other deficiencies are treated by giving multivitamins, folic acid, zinc and copper. Provision
of iron should be delayed until the child is gaining weight in the rehabilitation phase.
7. Initial feeding.
During the stabilization phase, the aim is to provide just enough energy and protein to meet
basic needs (100 kcal/kg/d and ~1g protein/kg/d) and 130 ml fluid/kg/d (or 100 ml/kg/d if the
child has gross Oedema).
Giving too much food initially stresses the liver, kidneys, heart and gut. Initial feeding should
consist of small, frequent feeds of a low osmolar and low lactose diet that contains 75 kcal and
0.9 g protein per 100 ml. Milk based feeds (such as starter formula F-75) are best for most
children and should be started immediately after admission. Breastfeeding should be continued.
8. Catch-up growth.
Readiness to enter the rehabilitation phase and start catch-up growth is signalled by a return of
appetite, usually about one week after admission.
Feeding should then be increased. A controlled transition over 3 days is recommended to
prevent a child suddenly consuming huge amounts, which can lead to heart failure. Thereafter,
unlimited amounts should be given.
The aim of the rehabilitation phase is to achieve intakes of 150-220 kcal/kg/d and 4-6 g
protein/kg/d.
The recommended catch-up formula (F-100) contains 100 kcal and 2.9 g protein/100ml.
Modified porridges or modified family foods can be used, provided they have comparable
energy and protein concentrations. Mothers should be encouraged to continue breastfeeding.
Rates of weight gain are considered poor if <5 g/kg/d, moderate if 5-10 g/kg/d, and good if >10
g/kg/d.
9. Prepare for follow-up.
Continuing care after discharge and back referral letters should be organized before children
leave hospital. The parent or caregiver needs to be given knowledge and skills to feed the child
at home in ways that will promote good health and continued catch-up growth. Parents should
be advised to take their child for regular follow-up checks and ensure that booster
immunizations are given, and also 6-monthly vitamin A doses in areas where vitamin A
deficiency and xerophthalmia are common.
INTERVENTION FOR OBESITY

Evidence shows that some interventions result in modest but significant and sustained
improvement in body mass. Based on behavior change theories, treatment includes specifying
target behaviors, self-monitoring, goal setting, stimulus control, and promotion of self-efficacy
and self-management skills.

Behavior changes associated with improving BMI include drinking lower quantities of sugar-
sweetened beverages, consuming higher-quality diets, increasing exercise, decreasing screen
time, and self-weighing. Most successful interventions have been family based and consider
the child's developmental age. "Parent-only" treatment can be as effective as "parent-child"
treatment. Because obesity is multifactorial, not all children and adolescents will respond to
the same approach. For example, loss-of-control eating, associated with weight gain and
obesity, predicts poor outcome in response to family-based treatment. Furthermore, clinical
treatment à programs are expensive and not widely available. Therefore, interest has grown in
novel approaches such as internet-based treatments and guided self-help.

It is important to begin with clear recommendations about appropriate caloric intake for the
obese child. Working with a dietitian is essential. Meals should be based on fruits, vegetables,
whole grains, lean meat, fish, and poultry. Prepared foods should be chosen for their nutritional
value, with attention to calories and fat. Foods that provide excessive calories and low
nutritional value should be reserved for infrequent treats. Weight reduction diets in adults
generally do not lead to sustained weight loss. Therefore the focus should be on changes that
can be maintained for life. Attention to eating patterns is helpful. Families should be
encouraged to plan family meals, including breakfast. It is almost impossible for a child to
make changes in nutritional intake and eating patterns if other family members do not make
the same changes. Dietary needs also change developmentally; adolescents require greatly
increased calories during their growth spurts, and adults who lead inactive lives need fewer
calories than active, growing children.

Psychologic strategies are helpful. The "traffic light" diet groups foods into those that can be
consumed without any limitations (green), in moderation (yellow), or reserved for infrequent
treats (red) (Table 60.6). The concrete categories are very helpful to children and families. This
approach can be adapted to any ethnic group or regional cuisine.

Motivational interviewing begins with assessing how ready the patient is to make important
behavioral changes. The professional then engages the patient in developing a strategy to take
the next step toward the ultimate goal of healthy nutritional intake. This method allows the
professional to take the role of a coach, helping the child and family reach their goals. Other
behavioral approaches include family rules about where food may be consumed (e.g., "not in
the bedroom").
Increasing Physical Activity without decreasing caloric intake is unlikely to result in weight
loss. However, aerobic exercise training has been shown to improve metabolic profiles in obese
children and adolescents. Further more, it can increase aerobic fitness and decrease percent
body fat even without weight loss. Therefore, increasing PA can decrease risk for CV disease,
improve well-being, and contribute to weight loss. Increased PA can be accomplished by
walking to school, engaging in PA during leisure time with family and friends, or enrolling in
organized sports. Children are more likely to be active if their parents are active. As with family
meals, family PA is recommended. When adults lose significant weight, they may regain that
weight despite eating fewer calories. The body may adapt to weight loss by reducing the basal
metabolic rate (BMR), thus requiring fewer calories. One approach to this phenomenon is to
increase PA.

Active pursuits can replace more sedentary activities. The American Academy of Pediatrics
recommends that screen time be restricted to no more than 2 hr/day for children >2 yr old and
that children <2 yr old not watch television. TV watching is often associated with eating, and
many highly caloric food products are marketed directly to children during child-oriented
television programs.

Pediatric healthcare providers should assist families to develop goals to change nutritional
intake and PA. They can also provide the child and family with needed information. The family
should not expect immediate lowering of BMI percentile related to behavioral changes, but can
instead count on a gradual decrease in the rate of BMI percentile increase until it stabilizes,
followed by a gradual decrease. Referral to multidisciplinary, comprehensive pediatric weight
management programs is ideal for obese children whenever possible.

Pharmacotherapy for weight loss in the pediatric population is understudied. Randomized

controlled trials (RCTs) have evaluated many medications, including metformin, orlistat,
sibutramine, and exanatide . Available medications result in modest weight loss or BMI
improvement, even when combined with behavioral interventions. Various classes of drugs are
of interest, including those that decrease energy intake or act centrally as anorexiants, those
that affect the availability of nutrients through intestinal or renal tubular reabsorption, and those
that affect metabolism. The only U.S. Food and Drug Administration (FDA)-approved
medication for obesity in children <16 yr old is orlistat, which decreases absorption of fat,
resulting in modest weight loss. Complications include flatulence, oily stools, and spotting.
This agent offers little benefit to severely obese adolescents. Because multiple redundant neural
mechanisms act to protect body weight, promoting weight loss is extremely difficult. Thus
there is considerable interest in combining therapies that simultaneously target multiple weight-
regulating pathways. One example, approved for adults, combines phentermine, a
noradrenergic agent, with topiramate, a y-aminobutyric acid (GABA)-ergic medication. This
combination resulted in a mean 10.2-kg weight loss vs 1.4 kg in the placebo group. Side effects
are common and include dry mouth, constipation, paresthesias, insomnia, and cognitive
dysfunction. Another promising example is the combination of amylin (decreases food intake
and slows gastric emptying) with leptin., which has no anorexigenic effects when given alone.
This combination requires injection and is in clinical trials in adults. Another FDA-approved
drug for adults is lorcaserin, a selective serotonin 2C receptor agonist. Establishing long-term
safety and tolerability in children is a challenge because medications of interest have CNS
effects or interfere with absorption of nutrients. Teratologic effects must be considered for use
in adolescent girls.
Hormone replacement therapy is available for patients with leptin deficiency and may
become available for patients with POMC deficiency. Setmelanotide binds to and activates
MC4R and may be useful for patients with POMC deficiency-associated obesity,

In some cases it is reasonable to refer adolescents for bariatric surgery evaluation. The
American Pediatric Surgical Association guidelines recommends that surgery be considered
only in children with complete or near-complete skeletal maturity, a BMI >= 40 and a medical
complica tion resulting from obesity, after they have failed 6 mo of a multidis ciplinary weight
management program. Surgical approaches include the Roux-en-Y and the adjustable gastric
band (Fig. 60.6). In obese adults, bariatric surgery reduces the risk of developing type 2
diabetes mellitus. In obese adult patients with existing type 2 diabetes, bariatric surgery
improves diabetic control. Nutritional complications of bariatric surgery include malabsorption
and vitamin (A, B₁, B₂, B, B, D, E, K). and mineral (copper, iron) deficiencies that require
supplementation..

FOOD RESPONSE INTERVENTION

General food ration distribution - Free distribution of a group of several food items, ideally
including fortified and blended foods, to households.

Emergency school feeding - Provision of food for school age children either in school or as a
take-home ration.

Food for work - Provision of a general food ration rather than wages to households for building
vital new infrastructure.

Supplementary feeding - Provision of supplementary food rations, either to prevent moderate

acute malnutrition (through blanket Supplementary Feeding Programmes- SFPs) or to treat
moderate acute malnutrition (through targeted SFPs)

Therapeutic care - Treatment of individuals with severe acute malnutrition either through in-
patient care or community based care.

Livelihood support - Provision of cash for work, cash grants, micro-finance, commodity
vouchers, and cash vouchers in order to stimulate livelihoods.

Infant and young child feeding support - Provision of programing to protect, promote and
support optimal infant and young child feeding. This can include breast feeding counselling
and development of safe, secluded areas for breastfeeding (commonly referred to as baby
friendly areas).

Health, water and sanitation support - Provision of essential health services, vitamin A
supplementation, provision of safe water supplies and sanitation, immunization and de-
worming.

PREVENTION OF MALNUTRITION

• Use of modern agricultural techniques to increase the agricultural production

• Proper education to peoples regarding importance of food
• Enrichment of food
• Fortification of food
• Genetic engineering for the development of new varieties eg- golden rice
• Government projects to provide healthy food to infants and pregnant woman
• Staple food should available at very cheap rate
• Common people should adopt rotation in food
• Use of probiotic microorganism in food
• Global public health and disease control measures.

Preventive guidelines of obesity in children

✓ Do not punish a child during mealtimes with regard to eating. The emotional
atmosphere of a meal is very important.
✓ Interactions during meals should be pleasant and happy.
✓ Do not use foods as rewards.
✓ Parents, siblings, and peers should model healthy eating, tasting new foods, and eating
a well-balanced meal.
✓ Children should be exposed to a wide range of foods, tastes, and textures. New foods
should be offered multiple times. Repeated exposure leads to acceptance and liking.
✓ Forcing a child to eat a certain food will decrease the child's preference for that food.
✓ Children's wariness of new foods is normal and should be expected. Offering a variety
foods with
✓ low-energy density helps children balance energy intake
✓ Parents should control what foods are in the home.
✓ Restricting access to foods in the home will increase rather than decrease a child's desire
for that food.

CONCLUSION

Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or

nutrients. The term malnutrition covers 2 broad groups of conditions. One is ‘undernutrition’—
which includes stunting (low height for age), wasting (low weight for height), underweight
(low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important
vitamins and minerals). The other is overweight, obesity and diet-related noncommunicable
diseases (such as heart disease, stroke, diabetes, and cancer).

RELATED RESEARCH STUDY

Prevalence and determinants of undernutrition among under-five children residing in

urban slums and rural area, Maharashtra, India: a community-based cross-sectional
study

Abstract

Background: Undernutrition among under five children in India is a major public health
problem. Despite India’s growth in the economy, the child mortality rate due to undernutrition
is still high in both urban and rural areas. Studies that focus on urban slums are scarce. Hence
the present study was carried out to assess the prevalence and determinants of undernutrition
in children under five in Maharashtra, India.
Methods: A community-based cross-sectional study was conducted in 16 randomly selected
clusters in two districts of Maharashtra state, India. Data were collected through house to house
survey by interviewing mothers of under five children. Total 2929 mothers and their 3671
under five children were covered. Multivariate logistic regression analysis was carried out to
identify the determinants of child nutritional status seperately in urban and rural areas.

Results: The mean age of the children was 2.38 years (±SD 1.36) and mean age of mothers was
24.25 years (± SD 6.37). Overall prevalence of stunting among children under five was 45.9%,
wasting was 17.1 and 35.4% children were underweight. Prevalence of wasting, stunting and
underweight were more seen in an urban slum than a rural area. In the rural areas exclusive
breast feeding (p < 0.001) and acute diarrhea (p = 0.001) were associated with wasting, children
with birth order 2 or less than 2 were associated with stunting and exclusive breast feeding (p
< 0.05) and low maternal education were associated with underweight. Whereas in the urban
slums exclusive breast feeding (p < 0.05) was associated with wasting, sex of the child (p <
0.05) and type of family (p < 0.05) were associated with stunting,and low income of the family
(p < 0.05) was associated with underweight

An Epidemiological Study of Malnutrition Among Under Five Children of Rural and

Urban Haryana

Abstract

Introduction
A child is future of nation. Malnutrition is a big public health problem in India as it can be
attributed for more than half (54 percent) of all under five mortality in India.

Aim
To assess prevalence of malnutrition among urban and rural population of Haryana using newly
developed WHO growth standards.

Settings and Design

A community based cross-sectional survey was conducted in children of 3-60 months age
living in the urban and rural field practice areas of Department of Community Medicine
MMIMSR, Mullana, Ambala during January 2012 to December 2012.

Materials and Methods

Seven hundred and fifty children, aged 3-60 months, were studied for nutritional status, socio-
demographic measures were obtained from structured questionnaire and followed by
anthropometric assessment using standards methods. Z score for Anthropometric data was
calculated by WHO Anthro 2010 software (beta version).

Statistical Analysis
Descriptive statistics as well as simple proportion were calculated with SPSS 20.

Results
We found that 41.3% children were underweight and 14% were severe underweight. Female
children were more nutritionally deprived than males. Among sociodemographic factors
maternal educational and working status as well as SES class and rural background of family
had greater impact on nutritional status of child.

Conclusion
We found that almost half of our under five children are underweight, girl child being affected
more. For attainment of best possible nutrition and growth in children, targeted short-term
strategies addressing underlying risk factors and more long-term poverty alleviation strategies
may be needed.
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