Chapter Six

Nutritional deficiency states

Prepared by Addisalem G

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 Learning objectives
• At the end of this lesson:
• Students will be able to describe nutritional
problems of public health importance at the end of
this chapter
• Students could identify the commonest macro and
micronutrient deficiencies; and explain how to
prevent them accordingly

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 overview
• When imbalance between the dietary intake and nutrient
requirements occurs, various clinical/physical signs and symptoms
manifest
• Health problems arising from the inadequate or excess nutrient in
the body compared to the requirement is termed as malnutrition

• Health problems as a result of inadequate nutrients is termed as

under-nutrition, while the health problems associated with excess
nutrients is termed as over-nutrition

• This chapter will be presented by concerning undernutrition

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 Cont…
• Undernutrition can be manifested as protein energy
malnutrition and micronutrient deficiencies
• It is the commonest problem in developing countries
• Most of the time over nutrition is manifested with
obesity
• Major nutritional problem in developed countries
• Today developing countries are facing the double
burden of malnutrition
 Causes of malnutrition
• Immediate causes:-at personal level
 Inadequate dietary intake
 Disease

• Underlying causes:-at household level

 Household food insecurity
 Inadequate maternal and child care
 Insufficient health services and unhealthy environment

• Basic causes:-at society level

 Concern with economic, political and ideological structures
 lack of potential resources

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UNICEF causes of malnutrition framework

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 Protein-energy malnutrition
• Protein and energy nutrients are required in bulk, protein
energy malnutrition implies deficiency (starvation) or excess in
total food consumption
• most serious nutritional problem in developing countries
• Two conditions(clinical forms) manifest when extreme food
deprivation occurs
1. Marasmus
– Extreme wasting of tissues
– This is more due to lack of energy nutrients as well as the inevitable
lack of protein
– By closely inspecting the skin (thin, loose, detached, folded) marasmus
can easily be confirmed
– Marasmus occurs between six months and first year of life
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 Marasmus cont…

Signs and symptoms of Marasmus

• failure to thrive
• Irritability
• fretfulness
• diarrhea
• Many infants are hungry
• little or no subcutaneous fats
• Weak and atrophic muscle
• The weight is much below the standard for age
• Temperature may be subnormal
• The abdomen may be shrunken or distended with gas
• Visible peristalsis
• old man’s appearance

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Marasmus

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 Normal
hair Alert and
irritable

Severe wasting
Thin, -prominent ribs,
flaccid skin spine, scapulae
hanging in -Old man face
folds
(baggy
pants)
Source: NutritionWorks
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 Kwashiorkor

• Kwashiorkor in children is manifested when inadequate food,

particularly inadequate food devoid of protein is consumed
Signs and symptoms of kwashiorkor
• Growth failure occurs always
• Bilateral edema-the most important manifestation
• Wasting of muscle is also typical but may not be evident
because of edema
• Skin color change (Peeling of the skin)
• Discoloration of hair- flaggy hair
• Moon face
• Diarrhea and vomiting
• Hepatomegaly 11
 Kwashiorkor cont…
• Behavioral changes such as apathy, lethargy,
irritability, and reluctance to eat
• Serum protein is reduced
• Serum amylase is reduced
• Examination of duodenal juice reveals reduction in
pancreatic enzymes
• Electrolyte imbalance

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 Hair -
thinner
and lighter
Apathetic
Moon face and
No appetite miserable

Oedema
(symmetrical
oedema
involving at
Skin least the
lesions feet)
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Source: NutritionWorks
 Kwashiorkor cont…
• Edema/ kwashiorkor must be carefully assessed
because edema is fatal if untreated early
• To determine whether edema is present,
– grasp the child's foot so that your thumb is on top
of the foot.
– Press the thumb down gently for a few seconds and
release your hands.
– The child has edema if a pit (dent) remains in the
foot after lifting your thumb.

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How to examine bilateral pitting leg edema

How to hold the feet (for a few seconds) observation

 Marasmic kwashiorkor
• The child’s upper body is wasted, but the
lower limbs are swollen with edema

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 Comparison of the features of kwashiorkor and marasmus
Feature Kwashiorkor Marasmus
Growth failure Present Present
Wasting Present Present, marked

Oedema Present (sometimes mild) Absent

Hair changes Common Less common
Mental changes Very common Uncommon

Dermatosis, flaky-paint Common Does not occur

Appetite Poor Good

Anaemia Severe Present less severe

Subcutaneous fat Reduced but present Absent

Face May be oedematous Drawn in, monkey-like

Fatty infiltration of liver Present Absent

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 Malnutrition Classification
Systems
• The most widely used system is WHO
classification (Z-scores)
• The Road-to-Health (RTH) system
• The Gomez system was widely used in the
1960s and 1970s

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The Gomez classification of malnutrition based
on weight-for-age standards
Classification Percentage of standard weight for age
Normal ≥90
Grade I (mild malnutrition) 75-89.9
Grade II (moderate malnutrition) 60-74.9
Grade III(severe malnutrition) <60

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 Road to health
Classification Percentage of standard weight for age
Normal ≥80% median
Mild to moderate 60% - < 80% of median
Severe < 60% of median

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 Wellcome classification of severe forms of
protein-energy malnutrition
Percentage of standard Oedema present Oedema absent
weight for age
60-80% Kwashiorkor Undernourishment
<60% Marasmic kwashiorkor Nutritional marasmus

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The Waterlow classification of malnutrition

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 Treatment of Severe Acute Malnutrition
(SAM)
• This part is a group assignment

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 Micronutrient deficiencies of public health
importance
At the end of this section the students will be able
to:
• Identify micronutrient deficiencies of public health
importance in Ethiopia
• Describe clinical manifestations of each
micronutrient deficiencies
• Identify consequences of micronutrient deficiencies
• Describe prevention modalities of micronutrient
deficiencies of public health importance

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 Vitamin A deficiency(VAD)
• Vitamin A deficiency is a major public health
problem in Ethiopia
• The most common cause is inadequate
consumption of vitamin A – rich foods
• Repeated infections of diseases such as
measles or diarrhea causes Vit A deficiency

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 Consequences of Vitamin A deficiency
• Night blindness
• conjuctival xerosis
• bitot’s spots
• Corneal ulcerations/keratomalacia
• Corneal scar
• Increased morbidity and mortality among young
children
• cessation of growth
• deterioration of epithelium
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 Identifications of vitamin A deficiency at
the community level
Vitamin A deficiency sign/symptoms Who cut - off level for
identifying a public
health problem

Night blindness >1%

Bitot’s Spot(s) >0.5%
Conjuctival >0.01%
Xerosis/ulceration/kratomalacia

Corneal scar >0.05%

Serum retinol <0.70 mol/L 10%

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 PREVENTION OF VITAMIN A DEFICIENCY

• A diet containing plenty of vitamin A is the

best method.
• Breast-feed infants for at least one year. Do
not discard the 1st breast milk
• At 6 months start to feed infants with dark
green vegetables, yellow and orange fruits and
if possible, some finely chopped and well
cooked liver.
• Include some fats in the child’s diet

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 PREVENTION OF VAD cont…
• Children with diarrhea, measles, respiratory and other
serious infections need extra vitamin A.
• Pregnant and lactating mothers should eat foods rich in
vitamin A every day.
• Tell families that night blindness is an early warning sign
of xerophthalmia.
• Teach school children to look for night blindness in young
children.
• Learn which vitamin A rich food is available in the locality
• Supplementation of Vitamin A (biannual for children of
6mths to 59mths)

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 FOOD FORTIFICATION

• This strategy could have been beneficial to the

whole people of Ethiopia if many types of
foods for human consumption were to be
processed and fortified in the factory

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 Iron deficiency anemia(IDA)
• Daily requirements -for men 8 to 10mg
-for women 10 to 18 mg
• For pregnant and lactating mother the requirement
increases to 20mg
• Presence of vitamin C enhances the absorption of iron
• the most prevalent micronutrient deficiency in the
world
• Among pregnant women and children 1-5 years in
developing countries, the prevalence of IDA is high

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 Causes of IDA
• Insufficient iron in diet
• Blood loss during menstruation
• Hook worm infestation
• Heavy load of other intestinal parasites such
as Schitomiasis, Tricuriasis and Ascariasis
• Blood loss and others

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 Consequences of Iron deficiency
• delay the psychomotor development
• Low cognitive performance
• Anemia
• Preterm birth
• Underweight birth
• Increased maternal and under five mortality

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 PREVENTION AND TREATMENT OF IRON DEFICIENCY

The main strategies are:

• Supplementation of iron tablets
• Dietary improvement of iron rich foods
• Changing of dietary habits and food preparation
practices through nutrition education
• Fortification of foods with iron
• Control of malaria infection
• Deworming of intestinal parasites
• Control of febrile and chronic diseases
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 Iodine deficiency disorder
• highly essential for regulation of physical growth and
neural developments
• essential component of the thyroid hormones, thyroxin
and triiodothyroxine
SOURCE OF IODINE
• Milk, sea foods
• Drinking water
• Plant source depends on whether or not iodine present
in the soil
• Iodized Salt
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 The major consequences of iodine
deficiency include:
• Mental retardation
• Defects in the development of nervous system
• Goiter
• Physical sluggishness
• Reduced work capacity
• Impaired work performance
• Decreased average intelligence by 10-15 IQ points
• Loss of memory
• Inability to produce enough milk for offspring
• Lower birth weight
• Growth retardation
• Dwarfism
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 consequences of IDD cont…
• Deaf-mutism
• Cretinism
• Reproductive failures (abortion, prematurity,
stillbirth)
• Increased childhood morbidity and mortality
• Economic stagnation and
• Impotency

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 IDD cont…
• WHO considers that if a goiter rate is over 5% in
the population it is a public health problem
• Simplified classification of goiter

– Grade 0 = No palpable or visible goiter

– Grade 1 = A goiter that is palpable but not visible

– Grade 2 = A swelling in the neck that is clearly

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 IDD cont…
HOW DO WE PREVENT IDD
• IDD can be eliminated by the daily
consumption of iodized salt
• Universal salt iodization strategy is best way to
alleviate iodine deficiency out of the whole
community in Ethiopia
• Iodine supplementation should be considered
in endemic areas of deficiency
 Zinc deficiency
• Zinc is a component of many enzyme systems,
including those involved in protein synthesis,
carbon dioxide transport and use of vitamin A
• Zinc also occurs in insulin
SOURCE OF ZINC
• Meats and sea foods
• Liver and milk
• Fish
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 Zinc deficiency con…
• Deficiency occurs as a result of disease that
either hinders absorption of zinc or cause
excessive excretion of zinc in the urine
• Zinc plus ORS for treatment of diarrhea is a
good strategy to prevent zinc deficiency and
reduce mortality from diarrhea

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 Consequences of zinc deficiency
• impaired growth
• dwarfism
• impaired wound healing
• weakened immune system
• impaired sense of smell and taste
• Delayed sexual development

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Thank You !

Let us together to break the cycle of undernutrition!! 43