Night blindness

Bilateral edema
 ረሃብና ያልጠመጣጠነ ምግብ ችግር የሚያስከትለው ጉዳት..

what is the
deficiency?

Folic acid / Folate deficiency

KWARSHIORKOR
MARASMUS
SCURVY
PELLAGRA
Bitot’s Spots
02/17/2022 10
 Measurement of fat free mass: Mid upper arm circumference (MUAC)

 Is used for screening purposes especially in emergency

situations where there is shortage of human resource,
time and other resources as it is less sensitive as
compared to the other indices.

 It is measured half way between the olecranon process

and acromion process using non-stretchable tape.

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 Skin fold thickness is a double fold of skin and
subcutaneous tissue done at the following anatomical
sights:
 Biceps skin fold
 Triceps skin fold_TSF
 Subscapular skin fold
 Suprailliac skin fold
 Mid axillary skin fold
 Thigh skin fold
 Calf skin fold

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1.3. Weight
 Weighing sling (spring balance) also called salter scale
is used for measurement of weight in children < 2 years.

 In children the measurement is performed to the nearest

10g.
 In adults and children ≥2 years, beam balance is used
and the measurement is performed to the nearest 0.1 kg.
 For both digital (electronic) scales
can be used and are very accurate.

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1. Anthropometric Measurements of Growth

1.1. Length
 A wooden measuring board (also called sliding board) is
used for measuring length.
 It is measured in recumbent position in children ≤2 yrs
old to the nearest 1mm.
 It is always greater than height by 1-2cm.
 One assistant is needed in taking the measurement.

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 Cont’d…

Dental Fluorosis

02/17/2022 16
 cont’d…
In Ethiopia,
Fluoride concentrations above 1.5 mg/l have been
reported from all parts of Ethiopia, but the highest levels
were found in the Rift Valley, the lowland area with the
most recent volcanic activity in the country.
In the early 1970s, 124 analyses of Rift Valley lake water
showed that 67 (54%) had fluoride concentrations above 2
mg/l and 38 (31%) had levels above 8 mg/l; 35% of the
152 community water sources tested in the Rift Valley
had concentrations of 5 mg/l and higher

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Clinical Manifestations
 Foetus and Infants
Depressed growth
Delayed sexual development
Mental retardation and learning disability
Deafness and a kinetic mutism
Abortion and still birth
 Adult deficiencies:
Goiter
Symptoms of low-thyroid-hormone level (children and adults):
Listlessness
Sluggish behavior
 Beasts of burden
Poor reproduction (abortion, still birth)
Weakness

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 Calcium Deficiency

Genu valgum Genu varum Bowing of long bones in legs

Rachitic Deformities

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 Complications of Rickets

Rib beading (rachitic Rosary)

Chest deformity Scoliosis

02/17/2022 20
 Cont’d…
Deficiency
Xeropthamlmia (dryness of the eyes)- due to
Lack of mucus secretion (due to destruction of goblet cell)
Night blindness (Nyctalopia)
Changes in eyes with eventual blindness if deficiency is
severe and untreated N

Susceptibility to infection and mortality

Dry, rough skin
 Bitot’s spots
Changes in mucous membranes
Bitot’s Spots
Poor bone growth & weak tooth enamel
Diarrhea
Bitot’s Spots
Slow growth
Infertility
21
Functions of Folic Acid
• Maintains nervous system, intestinal tract, sex organs,
white blood cells, normal patterns of growth.
• Regulates embryonic and foetal development of nerve cells.
• Treats anemia due to folic acid deficiency occurring from
alcoholism, liver disease, hemolytic anemia, sprue,
pregnancy, breast-feeding, oral contraceptive use.
• Acts as co-enzyme for normal DNA synthesis
• Deficiency: Megaloblastic anemia,
and neural tube defect

22
 Cont’d…
Deficiency (a disease of 4 Ds: Diarrhoea,
Dermatitis, Dementia & Death)
Early Symptoms:
• Muscle weakness
• General fatigue
• Loss of appetite
• Skin lesions, including rashes, dry scaly skin,
wrinkles,
coarse skin texture
• Nausea and vomiting
• Dermatitis (affecting the sun exposed areas) Cassal’s Necklace
• Diarrhea
Late consequences of severe deficiency
called pellagra.

23
 Cont’d…
• Riboflavin deficiency

Angular stomatitis
Glossitis
24
Cont’d…
Deficiency:
Cracks and sores in corners of mouth (angular
Stomatitis/ Cheilitis)
Inflammation of tongue and lips
Eyes too sensitive to light and easily tired
Itching, burning and reddening ( Drunkard’s eye)
Itching and scaling of skin around nose, mouth,
scrotum, forehead, ears, scalp
Trembling
Dizziness
Insomnia
Slow learning

25
 Treatment of Dehydration

– Never use the standard protocol for well nourished child

& not ORS but resomal

– Whenever possible hydrate only orally. IV fluids are

dangerous, use only if severe shock with loss of
consciousness from confirmed dehydration

– Give a total of 50ml per kg in 12hrs

– Start 5ml/kg Q30 min for 1st 2hrs then 5-10ml/kg per
hour for the rest 10 hrs
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Essential Nutrition Actions (ENAs)

 It is an integrated long term nutritional intervention

• An action oriented approach to nutrition

• If we use ENA approach to nutrition, estimated decrease
of child mortality is 25%
• There are seven action areas:

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1. Promotion of Breastfeeding

Key messages
• Timely initiation of breastfeeding (1 hour of birth)
• Exclusive breastfeeding until six months
• Breastfeed day and night at least 10 times

• Correct positioning & attachment

• Empty one breast before switching to the other

• Estimated decrease of child mortality is 13% if the child is

optimally breastfed

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Observe for signs of milk transfer
• Sustained suck/swallow pattern with occasional pauses
• Audible swallowing
• Relaxed arms and hands
• Moist mouth
• Satisfied after feeding

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2. Appropriate complementary feeding

Key messages:
• Introduce e complementary foods at 6 months
• Continue breastfeeding until 24 months & more
• Increase the number of feeding with age
• Increase density, quantity and variety with age
• Responsive feeding
• Ensure good hygiene (use clean water, food and utensils)

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3. Feeding of the sick child

 Key messages:
• Increase breastfeeding and complementary feeding
during and after illness
• Appropriate Therapeutic Feeding.

 
 

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4. Women's nutrition

Key messages: during pregnancy and lactation

 Increase feeding
 Iron/folic Acid Supplementations
 Treatment and prevention of malaria
 De-worming during pregnancy
 Vitamin-A capsule after delivery 

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5. Control of vitamin-A deficiency
Key messages:
 Promote breastfeeding: source of vitamin A
 Vitamin A rich foods
 Maternal supplementation
 Child supplementation
 Food fortification 

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6. Control of anemia
Key messages:
 Supplementation of women and children

 De-worming for pregnant women and children (twice/year)

 Malaria control
 Iron rich foods

 Fortifications

7. Controls of iodine deficiency disorders

Key message: access and consumption by all families of iodized salt

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Contact points for application of the ENAs
• There are six critical contact points in the lifecycle

1. During Antenatal Care

 Antenatal visit, Iron/Folic Acid

 De-worming
 Maternal diet
 EBF

 Safe delivery, iodized salt  

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2. Delivery

 Safe delivery
 EBF
 Vitamin A, Iron/Folic Acid
 Diet, FP and STI

3. Postnatal and family planning

 EBF, Diet, Iron/Folic Acid
 FP, STI prevention
 Child's vaccination
02/17/2022 36
4. Immunizations
 Vaccination, Vitamin-A supplementation

 De-worming
 Assess and treat infant's anemia

5. Well child and GMP

 Monitor growth

 Assess and counsel on feeding

 Iodized salt

 Check and complete vaccination

 Vitamin A/de-worming
02/17/2022 37
6. Sick child
 Monitor Growth
 Assess and treat
 Counsel on feeding
 Assess and treat for anemia, vitamin-A deficiency
 Immunization/de-worming

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Chapter X: Nutritional Anthropology

• Is a general overview of human food selection, and the

factors influencing food selection.
• Humans accept food items as "edible" or reject as
"inedible“ and establish preferences among the edible
items based on a number of cultural and sensory
characteristics.

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• The term "cultural" includes: symbolic, social, and
economic factors
• The term "sensory" used here incorporates:
psychophysical, cognitive, and affective factors (usually
analyzed separately by psychologists)
• Selection of food depends on the translation of biological
information about foods (safe versus dangerous;
nutritious versus empty calories) and cultural likes and
dislikes
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• Cultural cuisine: a term used to describe, "the culturally
elaborated body of food-related practices of any given
culture," which include:
– The selection of a set of basic (staple or secondary) foods.
– The frequent use of a characteristic set of flavorings;
– The characteristic processing (e.g. chopping and cooking)
– The adoption of a variety of rules dealing with acceptable
foods, festival foods……

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Cultural or religious practices, such as avoiding meat, may
limit the range of foods people eat.
– For example, a strict vegan will not consume any
meat products and, therefore, they should choose non-
meat food sources which are high in protein, iron and
vitamin B12.

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Economic and ecological factors affecting food choice
• Economic and cultural studies have shown how income
and food costs determine food selections, and often
dominate considerations of healthfulness, social
desirability, taste, and availability of foods in the
environment
• Even with adequate nutrition knowledge, people may not
have the economic means to feed themselves at optimal or
even adequate levels.
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Ritual and economic status as factors in food choice
• Members of a particular society mark symbolic, social groups,
and religious group connections by sharing
– food avoidances, festival foods, and ordinary food
preparations and consumption in common.
• Status factors also affect food choices and concepts of what is
culturally "appropriate”
• In Latin America, people miss ''wild" greens in favor of
cultivated vegetables because consumption of wild foods is
considered to be a sign of poverty
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• The problem of making low-cost foods, designed or
aimed toward the poor, acceptable to them is also well-
known.
• On the opposite end of the budgetary spectrum,
relatively expensive foods may be consumed out of
proportion with expenses for other food items because
they are of high cultural value, as in the case of
carbonated beverages in developing countries.

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Food availability
• Most foods are grown in a particular season of the year,
e.g. strawberries are harvested in summer. These are
called ‘seasonal foods’.
• Buying foods when they are in season will often ensure
the food price is lower.
• Technology and the importation of food, however, has
allowed food to be available all year round.

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 Sensory characteristics affecting food selection

• These includes: taste, smell, texture, color (and other

visual characteristics), even sound (e.g. crunchiness) and
physiologically perceived characteristics, like “filling"
• The exact dimensions of these characteristics, as well as
degrees of acceptance or preference for them, differ
among and within the same culture.

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Perception of physiological effects and food classification

• Individual foods or methods of food preparation are

also classified and ranked according to their perceived
physiological effects.
• The physiological sensation of satiety is a first factor.
 E.g. the Bemba of Zambia classify different grains
according to "fillingness.“
• Hunting and gathering cultures put a high value on
"meat"
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• The psychological and cultural components of food desires
are not well understood.
• The factors permitting or encouraging consumption of
"dangerous" foods (tainted, toxic, or carcinogenic) are an
additional area for investigation.
• Cultural descriptions, such as the "tingling" sensation that
follows ingestion of the Japanese fugu fish, toxic if not
prepared correctly, makes it highly desirable as a cultural
weakness even though people know a small error in
preparation will be lethal.
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Illness as a factor in food selection and restriction
• Unwillingness to eat and lack of appetite or occasional
overindulgence are signs of illness and restoration of "normal"
appetite is the sign of a renewed health state.
• Diets which exclude many foods due to a person’s health
concerns or for medical reasons need to be planned carefully.
• For example, people who are lactose intolerant cannot eat some
dairy products and so must make sure that they eat other foods
which are good sources of calcium (e.g. Tinned salmon and
sardine, hard cheese and yogurt)

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Gender as a factor in food classification
• Symbolism in division of foods may follow closely the
– More general male-female divisions of labor
– Dominant-subordinate relationships in a society

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Dietary structure
• People structure consumption in terms of dietary patterns. These
include
– Ordinary daily rounds of meals and snacks,

– As well as annual cycles of feasts and fast days,

– Which in combination with classifications of individual foods

comprise the group's “food habits”.
• How often one eats, the times of day or night that one eats, the
kinds of food one eats in general and on each eating occasion, and
with whom one eats are ways of communicating information about
one's own social and cultural identity and relationships with others.
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• Foods may be classified as meal items including staples such as cereal
grains, tubers, plantains, & relishes or condiments such as salt, mineral
earths, and chili peppers
• Or may be classified as categories appropriate to particular meals,
such as “bread” for breakfast and meat & potatoes for dinner foods .
• Alternatively, they may be classified snack foods for those that are
"uncooked" and consumed without the major cooked staple or eaten
outside of the regular meal settings.
• Or, certain dishes may be considered as special foods eaten only at feasts
or as famine food if other more preferred foods are unavailable.

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