NPI University of Bangladesh

Faculty of Engineering
Department of Food Engineering
Course Code: FE 3103
Course Title: Nutrition in Healthcare

Lecture – 3

What is malnutrition? Write the types of malnutrition.

Malnutrition:
Malnutrition refers to poor nutritional status. Malnutrition can be defined as a state of nutrition
in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes
measurable adverse effects on tissue/body form (body shape, size, composition), body function,
and clinical outcome. In broad terms, malnutrition includes not only protein-energy
malnutrition (both over and undernutrition) but also malnutrition of other nutrients, such as
micronutrients. Malnutrition of micronutrients can cause deficiency states or toxic symptoms.
Malnutrition can also occur because a person cannot properly digest or absorb nutrients from
the food they consume, as may occur with certain medical conditions. According to the World
Health Organization (WHO), malnutrition is the gravest single threat to global public health.
Globally, it contributes to 45 percent of deaths of children aged under 5 years.

Types of malnutrition:
The term malnutrition refers to both undernutrition and overnutrition. Malnutrition can be
categorized in mainly two types.
a) Undernutrition
b) Overnutrition
Undernutrition: Undernutrition includes being underweight for one's age, too short for one’s
age (stunted), dangerously thin (wasted), and deficient in vitamins and minerals (micronutrient
malnutrition) and can be categorized as
✓ Protein-energy malnutrition: marasmus, kwashiorkor, marasmic kwashiorkor.
✓ Micronutrient deficiencies.

Overnutrition: Overnutrition or hyperalimentation is a form of malnutrition in which the

intake of nutrients is oversupplied and overnutrition can be categorized as
 ✓ Overweight and obesity
✓ Health consequences (diabetes, cardiovascular diseases)

Other types of malnutrition

✓ Co-existence of under and overnutrition: “double burden of malnutrition”
• Obesity and PEM in the same family
• Obesity and micronutrient deficiencies in the same individual
✓ Chronic(stunting) and Acute (wasting) malnutrition: severe acute malnutrition (SAM),
moderate acute malnutrition (MAM).

Describe the causes of malnutrition.

Causes of malnutrition:
Immediate causes of malnutrition:
The immediate causes associated with malnutrition include poor diet and disease.
Poor diet: If a child doesn't get an adequate diet they will become malnourished. The poor
diet might be due to not enough food, or a lack of variety of foods in meals; low
concentrations of energy and nutrients in meals; infrequent meals; insufficient breastmilk;
and early weaning.
Disease: Diseases, especially infectious diseases, cause undernutrition because a sick child
may not eat or absorb enough nutrients, may lose nutrients from the body due to vomiting
or diarrhea, or have increased nutrient needs that are not met. The diseases most likely to
cause undernutrition are measles; diarrhea; AIDS; respiratory infections; malaria; and
intestinal worms.

The underlying cause of malnutrition:

Household food insecurity, or the lack of food, is a major factor in many humanitarian
emergencies. Displaced populations are often separated from their normal source of food.
Although some agencies, such as the World Food Program, have standardized
methodologies specifically to assess food insecurity, there are no consensus
recommendations regarding assessment methods. One simple way to crudely estimate the
contribution of household food insecurity in a malnourished population is to compare the
prevalence of acute protein-energy malnutrition in children less than 2 years of age to the
prevalence in children 2-4 years of age. Older children normally have a lower prevalence
rate of acute malnutrition, but if food insecurity is an important factor, they too will become
significantly malnourished.
Poor social and care environment often consists largely of poor infant feeding practices,
poor home care for ill children, and poor healthcare-seeking behavior. Nutrition surveys will
often ask questions about breastfeeding, general feeding practices, and home care and clinic
visits during the last episode of illness. However, this is not the only applicable method for
assessing the contribution of this group of underlying causes.
Poor access to health care and unhealthy environment can often be assessed using
disease surveillance data and program data. In nutrition assessments, surveillance data for
those diseases that are known to have substantial and rapid impact on nutritional status, such
as dysentery and pneumonia, should routinely be analyzed. Many such diseases can produce
rapid weight loss even in children and adults with normal pre-disease nutritional status. The
environment can be assessed with standard indicators of sanitation and water supply.

Basic causes of malnutrition:

The availability and control of resources (human, economic, and organizational) at the
various levels of society are a result of four major factors.
 These are
✓ political factors,
✓ cultural factors,
✓ environmental factors, and social factors.

Write down the names of three direct and two indirect nutrition interventions in a refugee
camp.
Nutrition interventions are done in a refugee camp to improve the nutritional well-being of
refugees mainly by tackling the immediate and underlying causes of malnutrition. It aims to
prevent malnutrition in the refugee population, especially among women, young children, and
other groups with specific needs; to identify, refer, and treat malnutrition individuals and to
monitor the nutrition situation in camps.
Direct Nutrition Interventions: Direct intervention targets the immediate cause of
undernutrition, dietary intake, and the prevention or cure of disease.
Three direct Nutrition Interventions are:
1) Behavior change interventions:
✓ Breastfeeding promotion
✓ Complimentary feeding

2) Micronutrients and deworming:

✓ Vitamin A supplements
✓ Therapeutic Zinc
✓ Point-of-use fortification
✓ Deworming
✓ Iron-folic acid supplements for pregnant women.
✓ Fortification of staples
✓ Iodine supplements
✓ Salt iodization

3) Complimentary and therapeutic Feeding:

✓ Prevention or treatment of moderate malnutrition in children 6-23 months.
✓ Treatment of severe acute malnutrition
Indirect Nutrition Interventions: Indirect nutrition interventions seek to have an effect on
the underlying cause of child undernutrition depicted in the UNICEF conceptual framework.
Two nutrition interventions are:
1) Improve water and sanitation.
✓ Adequate water supply for drinking and hand washing.,
✓ Promoting the establishment of safe storage of water, shallow wells, and rainwater
tanks.

2) Improving food security and agricultural production:

✓ Increasing the production of micronutrient-rich foods through biofortification and
diversification.
✓ Ensuring an adequate amount of food for the population of refugee camps.

What type of health and nutrition crisis may occur in a refugee camp and why? Explain
yourself.
A refugee camp is a temporary settlement built to receive refugees and people in refugee-
like situations. Refugee camps usually accommodate displaced persons who have fled their
home country, but there are also camps for internally displaced persons. Refugees may be
at a higher risk for contracting certain diseases and Nutritional problems due to factors such
as poor nutrition, poor sanitation, and lack of adequate medical care. The most common
health concerns are listed below.
Immunizations
Refugees arrive in their new countries with a variety of immunization needs. While refugees
may have had vaccinations in their country of origin, often they lack documentation because
they were forced to depart their home country in haste.
Tuberculosis
An estimated third of the world's population is infected with Mycobacterium tuberculosis.
This high incidence necessitates that those conducting the overseas exam (Panel Physicians)
screen all refugees for TB and further test anyone suspected of having active TB.
Sexually transmitted infections
Refugees can be at a higher risk for contracting sexually transmitted infections because of a
lack of access to protection and/or treatment, as well as the circumstances of war and flight,
making them subject to higher incidences of rape and sexual abuse. Refugees are regularly
screened for syphilis, gonorrhea, chlamydia, and HIV infection when they relocate.
Hepatitis B
Hepatitis B infection is endemic in Africa, Southeast Asia, East Asia, Northern Asia, and
most of the Pacific Islands. According to the CDC, the rate of chronic infection among
persons emigrating to the US from these areas is between 5% and 15%. Many states require
or recommend that all refugees be screened for hepatitis B, and proceed with immunizations
for all who are susceptible to this infection.
Parasitic infections
Intestinal parasites are a major health problem for many groups, including refugees, and the
presence of pathogenic parasites requires medical attention. "Over one billion persons
worldwide are estimated to be carriers of Ascaris. Consequences of parasitic infection can
include anemia due to blood loss and iron deficiency, malnutrition, growth retardation,
invasive disease, and death. Refugees are particularly at risk given the likelihood of poor or
contaminated water and poor hygienic conditions in camps.
Malaria
For refugees, asymptomatic malaria is not prevalent, the CDC recommends that any refugee
with signs or symptoms of malaria should receive diagnostic testing for Plasmodium, and
subsequent treatment for confirmed infections, but not presumptive treatment.
Anemia
Anemia is a common blood disorder worldwide. The WHO estimates the number of people
affected at close to 2 billion. Acquired causes of anemia in refugees and other immigrants
include iron deficiency, malaria, parasitic infection, tuberculosis, HIV, and anemia of
chronic diseases.
Mental health
Refugee mental health and integration into a new society are exquisitely interwoven.
Traumatic experiences that occurred in the home country or during the resulting flight from
that country are common. These experiences, in addition to the stresses of resettling in the
host country, increase the chances of a less successful adjustment to the society of the host
country. The influence of these traumatic and stressful events may be temporary and
manageable with straightforward solutions or maybe disabling and enduring. High rates of
mental health concerns have been documented in various refugee populations. Most studies
reveal high rates of post-traumatic stress disorder (PTSD), anxiety, depression, and
somatization among newly arrived refugees.
Malnutrition:
Due to severe energy and micro-nutrients deficiency, there are some Malnutrition problems
arise in refugee camps. Children and pregnant and lactating women are more prone to
malnutrition. The major nutritional problems of refugee camps are Severe Acute
Malnutrition and Moderate Acute Malnutrition, Vitamin-A Deficiency Disorder, Anemia,
Energy deficiency, and other vitamin and mineral deficiency disorders. The major cause of
malnutrition is lack of adequate food ration, intra-food ration distribution, and unhygienic
environment.
What are windows of opportunity? How can it prevent malnutrition?
Windows of opportunity:
A window of opportunity (also called margin of opportunity or critical window) is a period of
time during which some action can be taken that will achieve a desired outcome. Once this
period is over, or the “window has closed”, the specified outcome is no longer possible. It is a
favorable opportunity for doing something that must be seized immediately.
Windows of opportunity prevent malnutrition:
Concept of “1000 days”:
The 1000 days between pregnancy and a child’s 2nd birthday are the most critical time for a
positive impact on a child’s cognitive and physical development. The health and well-being of
a pregnant and lactating woman is directly connected with the growth and health of her infant.
The right nutrition for the mother and for the child during this time can have a profound impact
on the child’s growth and development and reduce disease risk, as well as protect the mother’s
health. Undernutrition during pregnancy, affecting fetal growth, is a major determinant of
stunting and can lead to consequences such as obesity and nutrition-related non-communicable
diseases in adulthood.
Focusing multi-sectoral nutrition efforts on evidence-informed interventions targeting this
critical window can have lasting implications across the lifecycle. The combination of good
health and reduced disease risk for both mothers and their children can also have a powerful,
lasting effect on a country’s prosperity.
It is widely recognized that the “windows of opportunity for reducing stunting are the 1000
days from pregnancy through 2 years of age. Although stunting reduction activities generally
target children under 5 years of age, a large proportion of the linear growth deficits that make
up the under -5 stunting burden are accumulated in the first 1,000 days. Similarly, acute
malnutrition peaks within this period before 24 months as a result of inadequate infant and
young child feeding practices and a high risk of exposure to infections.
Timely nutrition-specific interventions, at critical points in the lifecycle, can have a dramatic
impact on reducing malnutrition globally if taken to scale in high–burden countries. If scaled
to 90 percent coverage, it is estimated that 10 evidence-based, nutrition-specific interventions
could reduce stunting by 20% and severe wasting by 60%.
The economic argument for nutrition investments is very strong. Evidence shows that the right
nutrition during the 1,000-day window can:
✓ save more than 1 million lives each year.
✓ Significantly reduce the human and economic burden of diseases such as tuberculosis,
malaria HIV, and AIDS.
✓ Reduce the risk of developing various non-communicable diseases such as diabetes
and other chronic conditions later in life.
✓ Improve an individual’s educational achievement and earning potential.
✓ Increase a country’s gross domestic product by at least 2-3 percent annually
What kind of health and nutrition problems are faced in refugee camps? Explain it.
Health problems faced in refugee camps:
Inequitable access to services: Healthcare services are concentrated in the more accessible
areas of the camps. Some areas are over-served while in other areas refugees have no or
very limited access to health care.
Overburdened government health care facilities: Sadar Hospital (Cox’s Bazar) and
Teknaf and Ukhia upazila health complexes and primary health care (PHC) units are not
equipped to handle the huge influx of refugees, and are running substantially over capacity.
Rates of SAM are at 7.5% (well over the emergency threshold). Local healthcare facilities
and NGOs have limited capacity to treat children with SAM with complications.
Communicable disease outbreak risks: crowded living conditions, inadequate water and
sanitation facilities, and low vaccination coverage present significant risks of
communicable disease outbreaks.
Mental and psychosocial health: The needs are immense. Many refugees are reported to
have been physically and mentally traumatized by violence, including Sexual and Gender-
Based Violence (SGBV).
Sexual and Reproductive Health: Essential services, particularly obstetric services, are
inadequate in the hard-to-reach areas of the camps. Home deliveries are anecdotally
reported to be high.
Nutrition problems faced in refugee camps:
✓ Anemia
✓ Diarrhea
✓ Cholera
Anemia:
The three main types of anemia are due to blood loss, decreased red blood cell production,
and increased red blood cell breakdown. Causes of blood loss include trauma and
gastrointestinal bleeding, among others. Causes of decreased production include iron
deficiency, a lack of vitamin B12, thalassemia, and a number of neoplasms of the bone
marrow. Causes of increased breakdown include a number of genetic conditions such as
sickle cell anemia, infections like malaria, and certain autoimmune diseases.
Diarrhea:
A tin-roofed building at this Rohingya camp in Bangladesh is the new frontline in a battle
to curb outbreaks of diarrheal disease among half a million Rohingya refugees. Severe
diarrhea causes dehydration so quick and appropriate rehydration is vital to saving lives.
Cholera:
 To prevent an outbreak of cholera which is endemic in Bangladesh, a fixed site, mass oral
cholera vaccination (OCV) campaign targeting all persons aged > one year was conducted
among Rohingya refugees from October 10-18, with a follow-up campaign targeting
children aged 1-4 years November 4-9 years.
Protein-energy malnutrition:
There are a huge number of malnourished children who suffer from severe acute
malnutrition (SAM), moderate acute malnutrition (MAM), kwashiorkor, and marasmus.

Briefly describe the major malnutrition problems in Bangladesh.

The prevalence of malnutrition in Bangladesh is among the highest in the world. Millions of
children and women suffer from one or more forms of malnutrition including low birth weight,
wasting, stunting, underweight, Vitamin A deficiencies, iodine deficiency disorders, and
anemia. Globally, malnutrition is attributed to almost one-half of all child deaths.
Major Nutritional Problems:
✓ Protein-energy malnutrition
✓ Nutritional blindness
✓ Iron deficiency anemia

Protein-energy malnutrition:
Protein Energy Malnutrition (PEM) continues to be a major public health problem in many
developing countries. It affects mostly children under 5 years of age belonging to poor
underprivileged communities. The condition is particularly serious during the post-weaning
stage and is often associated with infection.
In clinical studies, patients with severe PEM are classified into 3 groups-
✓ kwashiorkor,
✓ marasmus and
✓ marasmic kwashiorkor.

Vitamin A deficiency:
In Bangladesh, vitamin A deficiency (VAD) has been identified as a major public health
problem in the last two decades. There has been a dramatic reduction in the prevalence of
night blindness among preschool children from the 1980s to 2004, which is attributed to
the successful program of vitamin A supplementation launched in 1973 (Keratomalacia,
the most severe form of VAD, is now seen occasionally among children hospitalized for
SAM. However, in a recent study in rural Bangladesh, sub-clinical VAD (serum retinol
<0.7 μg/dL) was found in 18.5% of 200 pregnant women. The vitamin A intake by nearly
half of pregnant women was less than the recommended dietary allowance.
Vitamin A deficiency Disorders VAD:
✓ Xerophthalmia: Mild to severe
✓ Corneal blindness and
✓ Stunted growth
✓ Impaired immune system

Iron deficiency:
Anemia is the most commonly used indicator to define iron deficiency in population-based
studies or in clinical settings. It is generally assumed that 50% of anemia cases are due to
iron deficiency; however, acute and chronic infections, including malaria, cancer,
tuberculosis, and HIV, can also lower blood hemoglobin levels. The presence of other
micronutrient deficiencies, including vitamins A and B, folate, riboflavin, and copper,
increases the risk of anemia. The main risk factors for iron-deficiency anemia include a low
intake of iron.
The criteria of SAM: