1. MALNUTRITION
Dr. Sunil Pal Singh.C

2. MALNUTRITION
1.Magnitude of malnutrition
2. Dimensions of malnutrition
3. Measurements of malnutrition
4. Prevention and control.

3. MALNUTRITION
Is defined as a pathological state resulting from an
absolute or relative deficiency or excess of one or
more essential nutrients.

4. MAGNITUDE OF PROBLEM
India – one fifth population (230 million people ) is
undernourished, (The State of Food Insecurity in the
World, FAO, 2008)
Global Hunger Index - India ranks 94th out of
119countries. (2/3rd of this score is attributable to its
high child malnutrition rate)
Change in the state of food and nutrition insecurity in
India was main cause of rise in number of hungry
persons in South Asia (FAO, 2004).

5. MAGNITUDE OF PROBLEM- CONTD.
NFHS-3 Survey :
56% women are Anemic
 30% are low birth weight (LBW) babies
47% children are underweight.

6. CAUSES OF DEATHS AMONG <5 YEAR CHILDREN
IN DEVELOPING COUNTRIES
Malaria *
8%
Measles *
Others 5%
29%
Diarrhoea
*
12%
Malnutrition* * Approximately
60% 70% of all
childhood deaths
are associated
Pneumonia * with one or more
20% of these five
Perinatal conditions
22% HIV/AIDS
4%
Source: WHO 2002; Lancet-2003

7. Female unwanted
Dies child Dies
Malnourished
mother
Poor Girl child
malnourished
Nutrition
Mother child
Dies
loss
Under developed
adolescents

9. Agro-climatic factors Demographic factors Socio-economic Disasters
factors
• Food production • Population Drought/Floods
• Religion Wars
• Land Ownership • Family Size • Community
• Type of land • Urbanisation • Occupation
• Income
• Rain fall
• Geographic conditions
Availability of &
• Agricultural techniques Physiological participation in
• Use of hybrid seeds factors
developmental
• Use of fertilizers • Pregnancy programmes
• Lactation • PDS
• Breast feeding • Rural Dev. Prog.
Socio-cultural practices • Employment
factors • Infant & child generation prog.
Feeding practices
• Illiteracy
• Ignorance
• Taboos Pathological Conditions
• Infections
• Diarrhoeas
Environmental factors • Resp. Infections
• Malaria
• Environmental sanitation • Others
• Personal hygiene • Infestations
• Safe drinking water • Hook worms
• Round worms
• Giardiasis etc.,

10. NUTRITIONAL PROBLEMS
1.Undernutrition:
Macro-nutr. : Low birth weight (LBW)
Protein energy malnutrition (PEM)
Chronic Energy Deficiency (CED)
Micro-nutr. : Vitamin A deficiency (VAD)
Iron deficiency anemia (IDA)
Iodine deficiency disorder (IDD) etc.
2.Overnutrition:
Overweight and Obesity
Diet related chronic diseases
Fluorosis etc.

13. 3. IMBALANCE
Imbalance can result if energy potential of fat in diet
exceed 30% of total input, that of saturated fatty acids
exceeds 10% or that of carbohydrates falls below 50%.

15. PATHOGENESIS
1. SATURATION
2. OVERSATURATION
3. UNSATURATION
4.POTENTIAL DEFICIENCY
5.LATENT DEFICIENCY
6.MANIFEST DEFICIENCY

16. INDICATORS OF NUTRITIONAL STATUS
1. Direct Indicators:
-- Nutritional Anthropometry
-- Clinical Assessment
-- Bio-chemical Estimations
-- Biophysical Tests
2.Indirect Indicators:
-- Dietary assessment
-- Prevalence of Morbidities
-- Vital statistics
3.In addition, Secondary Data:
-- Socio-economic
-- Demographic
-- Environmental

17. 1.NUTRITIONAL ANTHROPOMETRY
Height
Mid Upper Arm Circumferences
Head Circumferences,
Chest Circumferences,
Waist Circumferences and
Hip Circumference
Fat fold thickness at …Triceps, Biceps, Supra-Iliac,
Infra-scapular regions

18. NUTRITIONAL ANTHROPOMETRY
Weight : - Body mass
- Simple, widely used
- Sensitive to changes over short duration
Height : - Genetically Determined
- Environmentally influenced
- Reflects long duration undernutrition
MUAC : - Reflects muscle/fat
- Easy to measure
- Independent of age (<5 years)
FFT: - Measures body fat
- Correlates well with total body fat
- Equipment is expensive

19. FORMULA FOR AVERAGE WEIGHT.
WEIGHT KG
BIRTH 3
3-12 MONTHS AGE(MONTH) + 9
2
1-6 YEARS [AGE(YEAR) X 2] + 8
7-12 YEARS [AGE(YEARS) X 7] - 5
2

20. FORMULA FOR AVERAGE HEIGHT
HEIGHT CM
BIRTH 50
3 MONTHS 60
6 MONTHS 66
1 YEAR 75
2-12 YEARS [AGE(YEARS) X 6] +
77

21. WHO CLASSIFICATION OF MALNUTRITION
Acute and chronic malnutrition
W/A H/A W/H Interpretation
Decreased Normal Decreased Acute malnutrition
Decreased Decreased normal Chronic malnutrition
Decreased Decreased Decreased Acute-on-chronic malnutrition
Moderate and severe undernutrition:
Feature Moderate Severe
Oedema No Yes
Weight-for-height(wasting) <70%
70-79%
Height-for-age(stunting) 85-89% <85%

22. THE IAP CLASSIFICATION OF
MALNUTRITION
Nutritional status* Weight for age(% of expected)
NORMAL >80
Grade I PEM 71-80
Grade II PEM 61-70
Grade III PEM 51-60
Grade IV PEM <50

23. CLASSIFICATION ACCORDING TO HEIGHT FOR AGE
Height for age Waterlow’s Mclaren’s Vishweshwara rao’s
(% of expected) classification classification classification
Normal >95 >93 >90
First degree 90-95 80-93 80-90
Stunting/short*
Second degree 85-90 - -
Stunting
Third degree <85 <80 <80
Stunting/dwarf*
*Terminology used in Mc Laren’s classification

27. CLINICAL SIGNS OF MALNUTRITION
HAIR: Lack of lustre, thinness and sparseness,and
flag sign.
Face: diffuse depigmentation, nasolabial
dyssebacia.moon face.
Eyes: pale conjunctiva, bitots spots,corneal xerosis.,
conjunctival xerosis.

28. Lips: angular stomatitis, angular scars, cheilosis.
Tongue: scarlet and raw tongue, atrophic papillae.
Teeth: mottled enamel.

29. Gums: spongy bleeding gums.
Glands: thyroid enlargement, parotid enlargement.
Skin: follicular hyperkeratosis, petechiae, pellagrous
dermatosis, flaky- paint dermatosis.

30. Nails: koilonychia.
Subcutaneous tissue: oedema, amount of
subcutaneous fat reduced.
Muscular and skeletal system: muscle wasting,
knock knees, diffuse or local skeletal deformities.

31. GIT: hepatomegaly.
Nervous system: psychomotor changes, mental
confusion, motor weakness.
Cardiovascular system: cardiomegaly, tachycardia.

32. 2.DIET SURVEYS

33. TYPES OF DIET SURVEYS
 Food balance sheets
 Family diet survey
 Individual diet survey
 Food frequency
 Institutional diet surveys

34. WEIGHMENT DIET SURVEY (Households)
The method involves weighing of edible portion of
raw ingredients before cooking of food.
Duration of the survey could be for one, three or 7
consecutive days.

35. 24 HRS RECALL METHOD (OR) ORAL
QUESTIONNAIRE (OR) INDIVIDUAL DIET
SURVEY
The raw equivalents of different foods consumed by
an individual is computed as follows:
Raw quantity of a given
food stuff in the preparation
Volume of cooked
X
Total volume of food cooked Food consumed

36. INSTITUTIONAL LEVEL DIET SURVEY
(Hostels, Industrial Canteens, Jails and Orphanages)
The raw ingredients, total cooked foods and individual
plate servings are weighed. Individual intake of foods &
nutrients are computed.
Merits : Better accuracy
Limitation : Time consuming

37. Institutional level Diet Survey
(Hostels, Industrial Canteens, Jails and Orphanages)
Food stock registers are verified for a week.
The average intake/caput/day= (stocks at the beginning
of week - stocks at the end of week) / Total number of
inmates partaking x 7 days.

38. Biochemical Estimations
 Haemoglobin
 Serum Vitamin A
 Serum electrolytes and minerals
 Lipid profile
 Serum T3, T4, TSH
 Urinary Iodine Excretion

39. Biophysical Estimations
 Basal Metabolic Rate (BMR)
 Physical Work Capacity

40. 3.SECONDARY DATA

41. ENVIRONMENTAL FACTORS
• Environmental sanitation
- Solid & Liquid waste disposal
- Availability & Usage of sanitary Latrines
• Personal hygiene
- Preparation of food,
- Storage and handling of food
• Safe drinking water
- Access, distance of source from house
- Water handling practices at home

42. Socio-cultural factors
• Illiteracy : Total, Male, Female,
• Ignorance : Knowledge, Attitude
Practice
• Taboos : Beliefs, Customs
• Peer groups : Elders in the family

43. AGRO-CLIMATIC FACTORS
• Food production : Type, Yield
• Land Ownership : Extent of land owned
• Type of land : Wet, Dry, Semi arid
• Rain fall : Adequacy, scanty, delay
• Geographic conditions : Desert, Hilly, Coastal
• Agricultural techniques : Modern, primitive
• Use of hybrid seeds
• Use of fertilizers

44. PREVENTION AND CONTROL
AGRICULTURE MEASURES: Agrarian reforms, Food
production, Agricultural policy.
PUBLIC HEALTH MEASURES:Population
stablisation,Nutrition supplement,Health and
Nutrition education, primary health care.
SOCIO-ECONOMIC MEASURES:POVERTY
alleviation,Female emamcipation,socio-economic
development.

45. COMMUNITY NUTRITIONAL
PROGRAMMES.
Programmes Year Ministry
VITAMIN A PROPHYLAXIS PROGRAM 1970 Health and Family Welfare
PROPHYLAXIS AGAINST NUTRITOINAL 4th Five Health and Family Welfare
ANAEMIA year plan
CONTROL OF IODINE DEFICIENCY 1962 Health and Family Welfare
DISORDERS
CONTROL PROGRAMME
SPECIAL NUTRITIONAL PROGRAM 1970 Social Welfare
BALWADI NUTRITIONAL PROGRAM 1970 Social Welfare
ICDS PROGRAM 1975 Social Welfare
MID-DAY MEAL PROGRAM. 1961 Education
MID –DAY MEAL SCHEME 1995 Human Resources
Revised Development
2004

46. References
Park’s Textbook of Preventive and Social Medicine – 20th
Edition.
Foundations of community medicine-GM DHAAR,I
ROBBANI -2nd edition.
J.KISHORE’S National health programs of India -9th
edition.
GHAI Essential pediatrics-6th edition.
Nutrition and child development-KE ELIZABETH 4th
edition.
http://www.who.int/childgrowth/training/en/

47. THANK YOU