Nutrition

Malnutrition
By
Dr FARHANA JABEEN
SHAH
Pediatrics nutrition
Daily caloric requirement
Upto 10 kg: 100 kcl/kg/day
11-20 kg: 1000 kcl + 50 kcl/kg for each kg above
10 kgs
Above 20 kg: 1500 kcl + 20 kcl/kg for each kg above
20 kgs
Daily water requirement
Upto 10 kg: 100 ml/kg/day
11- 20 kg: 1000 ml/kg + 50 ml/kg for each kg above
10 kgs
Above 20 kg: 1500 ml + 20 ml/kg for each kg above 20
kgs
Pediatric nutrition and nutritional
disorders
Macronutrients
Carbohydrates: 50-70% of total calories
Fats: 30-35%
proteins: 10-15%
Micronutrients
Vitamin A: 1500-5000 IU/ day Folic acid: 0.2 1
mg/day
Vitamin B1: 0.5- 1.5 mg/day Vitamin C: 30-35
mg/day
Vitamin B2: 0.6- 1.5 mg/day Vitamin D: 400 IU/day
Vitamin B6: 0.4-1.4 mg/day Vitamin E: 5-15 IU/day
Vitamin B12: 1-2.5ug/day
Nicotinic acid: 5-20mg/day
Pediatric nutrition and nutritional
disorders
Minerals
Calcium: 0.5 - 1.5 g/day
Phosphorus: 0.5 -1.5g/day
Iron: 6-12 mg/day
Iodine: 6- 15 mg/day
Zinc: 10-15 mg/day
magnesium: 80- 270mg/day
Potassium: 1- 2 mEq/kg/day
Sodium: 2- 3 mEq/kg/day
Relation of malnutrition to
diseases:
Poor diet plays a role in the manifestation
of malnutrition ,but has an important role
in a variety of disorders which affect the
human host . Certain communicable
diseases are observed in epidemic form in
periods of greatest food deficiencies
.diarrheal diseases may be mentioned as
an example in such situations ;other
disorders may be related to the respiratory
system and skin .
The character of the diet is important in the
pathogenesis of metabolic disorders.an
example is the portal cirrhosis of liver in
person with diet deficient in proteins and in
water soluble vitamins .this disease occurs
in alcoholics ,it has been found to be
prevent among the hindu in south india
,who because of religious taboos ,abstain
from alcoholbut whose diet is low in
protein and water = soluble vitamins .
Certain degenerative diseases may be
conditioned in their occurrence by the
type and quantity of food consumed
.malnutrition resulting in obesity is
associated with earlier development of
atherosclerotic changes in large blood
vessels .death rate due to cardiovascular
diseases are higher in obese persons
than those with normal weight .
Carcinoma may be related with
malnutrition ,the evidence of such
relationship is indicated by relatively high
mortality due to liver carcinoma among
the bantus of south Africa ,whose diet
largely consists of corn and fermented
milk .in this native case liver cancers
accounts for a large proportion of all
deaths due to malignant disease. Other
evidence also suggest that aflatoxins in
food are associated with occurrence of
carcinoma of liver in humans.
The national nutritional survey found that
48% of children below five years of age
were malnourished and 65% had
anemia .pregnant and lactating women
were also found to have nutritional
problems .34 % were underweight and
45% were anemic. These rate indicated
that they and their babies are more likely
to have health problems which could
result in preventable deaths .
Low birth weight and goiter are two
other common nutritional problems
.many of these nutritional problems
and related deaths could be
prevented by teaching families .
It is defined as a range of pathological conditions
arising from simultaneous deficiency of proteins and
calories and commonly associated with infections .
It occurs more frequently in young and adult children .
It is a state of malnutrition occurring in individuals
whose diet are deficient in proteins and calories often
precipitated by other factors ,particularly bacterial and
viral infections .
Its manifestation range from nutritional marasmus to
kwashiorkor.
Malnutrition :
A pathological state ,general or specific
,resulting from ,a relative or absolute
deficiency ,or ,an excess in the diet , of one
or more essential nutrients .
It may be clinically manifest, or ,detectable
only by biochemical and physiological tests
Five groups:

Five different forms of malnutrition have

been distinguished :
i.starvation ,
ii.under nutrition ,
iii.specific deficiency ,
iv.imbalance
v.over nutrition .
Starvation :
It is the result of a serious ,or total ,lack of nutrients
needed for the maintenance of life .adequate
nutrition has two components – necessary
nutrients and energy in the form of calories .it is
possible to ingest enough energy without a well –
balanced selection of individual nutrients and
produce diseases that are noticeably different from
those resulting from an overall insufficiency of
nutrients and energy . Although all foods are a
source of energy for organism ,it is possible to
consume a seemingly adequate amount of food
without getting the required minimum of energy.
Factors
Poverty
Famine due to man –made or natural disaster .
Crop failure
Chronic gastro intestinal infections .
Medical conditions predispose to starvation e.g anorexia
nervosa ,fasting ,coma stroke.
The body will combat malnutrition by breaking down its own
fat and eventually its own tissue ,a whole host of symptoms
can appear .The body's structure , as well as its functions,
are effected .the wasting of the tissues during starvation
greatly affects the chemical composition of the body ,the
most obvious change is the disappearance of over 70% of
the body fat.
 In health (kg ) After starvation (kg)
Protein 11.5 8.5
Fat 9 2.5
Carbohydrates 0.5 0.3
Extra cellular water 15 15
Intra cellular water 25 19
Minerals 4 3.5
In children ,chronic malnutrition is marked by
growth retardation .
Anemia is the first sign to appear in an adult .
Edema of the lower extremities is next ,due to
drop in the protein content of the blood .
Loss of resistance to infection follows next ,along
with the poor wound healing .
There is also progressive weakness and difficulty
swallowing .
At the same time ,the signs of specific nutrients
deficiencies may appear .
Treatment & prognosis:
If the degree of malnutrition is severe ,the intestine may not
tolerate a fully balanced diet .they may in fact ,may not be
able to absorb adequate nutrition at all .carefully prepared
elemental diets or intravenous feeding must begin the
treatment .
The treatment back to health is long and first begins with
liquids .gradually ,solid food are introduced and a daily diet
of 5000 calories or more is instituted .people can recover
from severe degrees of starvation to a normal stature and
function .
Children may suffer from permanent mental retardation or
growth defects if their deprivation was long and extreme.
Acute and chronic under
nutrition :
There are two main patterns of under
nutrition found in children .
these are
i. stunting and wasting
Different processes produce these two patterns and
they are assessed using separate anthropometric
indices.
In children acute nutritional deficit and or disease e.g
diarrhea produce wasting ,characterized reduction in
weight for height or arm circumference or both.
Prolong nutritional deficit or disease resulting in
stunting ,characterized by a reduction in height for
age .wasting and stunting are associated with
different functional consequences
Weight for height is a powerful predictor of short term
mortality as is the mid upper arm circumference .
Height for age predicts longer term mortality .the nutritional
assessment of adults is more problematic .
In 1988,the international dietary energy consultative group
proposed a definition of chronic adult under nutrition calling
it “chronic energy deficiency ”(CED).
Chronic energy deficiency was defined as a steady state in
which a person is in an energy balance although at a cost
either in terms of increased risks to health or as an
impairment of functions and health.
It is defined as a range of pathological conditions
arising from simultaneous deficiency of proteins and
calories and commonly associated with infections .
It occurs more frequently in young and adult
children .
It is a state of malnutrition occurring in individuals
whose diet are deficient in proteins and calories
often precipitated by other factors ,particularly
bacterial and viral infections .
Its manifestation range from nutritional marasmus
to kwashiorkor.
Malnutrition

It is defined as a pathological state resulting from

relative or absolute deficiency of one or more
essential nutrients.
Primary Malnutrition: Due to inadequate food
Secondary Malnutrition:
Infections
Malabsorption
Congenital diseases
Metabolic
Psychosocial deprivation
MALNUTRITION RISK FACTORS

Social Medical/Nutritional

Mother: Low birth weight,

Working, ill and Twin,
incompetent Lactation failure(mother
Father: & baby ),
Unemployed, ill Mixed feeds or bottle
feeding, improper
dilution,
Late start of weaning
foods,
MALNUTRITION RISK FACTORS

Social Medical/Nutritional

Parental loss: Chronic or recurrent

Death, desertion, diarrhea,
divorce, separation Recurrent respiratory
Drug addiction in infections,
family. Measles, TB,
More than 2 children whooping cough,
under 5 years of age Recurrent otitis media,
Incomplete
vaccination
MALNUTRITION RISK FACTORS

Social Medical/Nutritional

Previous Others (congenital

infant/child death defects e.g. cleft lip
Large family size and palate)
i.e. more than 5
children
Malnutrition

Classifications
It is classified according to clinical signs,
anthropometric measurements and biochemical tests.
Most of the classifications are based on expected
body weight and height of the children for their age.
If the weight of the child is less than expected for his
age or for his height, he is considered malnourished.
If a child’s height is less than expected for his age he
is considered stunted.
Growth charts are used for this purpose.
Malnutrition
Classifications
Gomez Classification
1st degree malnutrition: If weight is 75%- 90% of
the expected body weight for age.
2nd degree malnutrition: If weight is 60%- 75% of
the expected body weight for age.
3rd degree malnutrition: If weight is below 60% of
the expected body weight for age.
Malnutrition
Wellcome
Classification

Weight for age Edema Edema

present absent
Below 60% of Marasmic Marasmus
expected body kwashiorkor
weight

Between 60-80% Kwashiorkor Ponderal or

of expected growth
body weight retardation
Malnutrition
Waterlow
Classification

Height for Weight for age as %age of expected body

age as %age weight
of expected <80% 80-120% >120%
height

<90% Chronic Stunted but Stunted

malnutrition no and obese
malnutrition
>90% Acute Normal Obese
Malnutrition
WHO Classification

Well Mild Moderate Severe

Nourished Malnutrition Malnutrition Malnutrition
Sm.edem No No No Yes
a
Weight 90-120% 80-89% 70-79% <70%
for (+2 to -1 z) (-1 to -1 z) (-2 to -3 z) Severe
height wasting

Height for 95-110% 90-94% 85-89% <85%

age (+2 to -1z) (-1 to -2 z) (-2 to -3 z) Severe
stunting
MIDARM CIRCUMFERENCE
MALNUTRITION MIDARM
CIRCUMFERENCE(cm)
Absent 14 – 16.5 cm

1st n 2nd degree 12 – 14 cm

malnutrition
3rd degree malnutrition < 12 cm
MIDARM CIRCUMFERENCE

Quac Strip :
Up to green colour  normal (14
cm)
Yellow colour  Borderline
malnutrition (14 – 12 cm)
Red colour Severe Malnutrition (<
12cm)
SKINFOLD THICKNESS

Harpenden Skin fold caliper is used

for measuring skin fold thickness
between scapulae or over the triceps.
Normal range  4.6 – 7.2 mm in
infants
9 – 11 mm in
children
CHILD’S MEDICAL HISTORY
Usual diet before current episode of illness
Breast feeding history
Food and fluids taken in past few days
Recent sinking of eyes
Duration and frequency of vomiting and diarrhea
and it’s appearance
Time when urine was last passed
Contact with measles or TB patients
Any deaths of siblings
Birth weight
Milestones reached
Immunization
CHILD’S PHYSICAL
EXAMINATION
Weight and length or height, edema, pallor
Enlargement or tenderness of liver, jaundice
Abdominal distention, bowel sounds
Signs of circulatory collapse
Temperature (hypothermia or fever)
Thirst
Corneal lesions due to Vit A deficiency
Ears, mouth, throat and skin for evidence of
infection or purpura
Respiratory rate, type of respiration, for signs of
CHF
Appearance of faeces
CLINICAL FEATURES OF
MALNUTRITION
Three distinct syndromes are recognized in
severely malnourished children i.e. marasmus,
marasmic kwashiorkor and kwashiorkor
Marasmus:
Gross loss of subcutaneous fats leading to loose
hanging skin folds in the axillary, inguinal and
buttock region. Loss of buccal pads of fat giving
“wise old man” look of the face with prominent
eyes and rib cage. Associated with rickets, Vit A n
B deficiencies. Thrush and monilial diaper rash co
exist with irritability and hunger.
Monilial diaper rash:
CLINICAL FEATURES OF
MALNUTRITION
Kwashiorkor:
Occurs between 1 – 5 years of age. There is
generalized edema, growth failure (wasting
masked by edema). Child is lethargic and
irritable. Fine, sparse, discoloured, straight
and easily plucked hair. Anemia due to low
iron and folic acid stores, hookworm
infestation, malaria. Diarrhea due to infection
or lactose intolerance. “Flaky paint” dermatitis,
hypo or hyper pigmentation on covered areas.
Ulcers or open sores, Vit deficiencies,
enlarged liver.
Flaky paint” dermatitis
CLINICAL FEATURES OF
MALNUTRITION
Kwashiorkor Marasmus
Under weight (60-80%) Weight < 60%
Edema present Edema absent
Subcutaneous fat + Muscle wasting /no fats
Puffy moon face Monkey face
Hair changes + Normal hair
Apathetic or lazy , ill Alert face
looking
Poor appetite Good appetite
“flaky paint” dermatitis Normal skin
CLINICAL FEATURES OF
MALNUTRITION
Complications of kwashiorkor:
Hypothermia, hypoglycemia, cardiac
failure, infections, Vit. A deficiency, severe
anemia, dermatitis
Biochemical changes:
Hypo proteinemia, ketonuria, diabetic
glucose tolerance curve, aminoaciduria,
low serum cholesterol, Vit. K deficiency,
hypokalemia, hypoglycemia
Marasmus
Marasmus
Marasmus
Marasmus
Kwashiorkor
MANAGEMENT
There are three steps of management:
Initial treatment including treatment of life
threatening problems, correction of
deficiencies and metabolic abnormalities and
start of feeding.
Rehabilitation including intensive feeding,
emotional and physical stimulation, mother’s
training.
Follow up to monitor feeding and growth of
child and prevent relapse.
MALNUTRITION
Initial treatment:
FOR MILD TO MODERATE MALNUTRITION:
This can be treated as out patient.
Find out and treat the cause of malnutrition.
Treat acute problems such as diarrhoea, dehydration,
septicemia, infections, pneumonia, malaria etc.
Give two extra feeds till the weight gain starts.
Give one extra feed for mild malnutrition.
Give Vit. A 100,000 units to infant < 1 year of age and
200,000 units to children > 2 years of age. In case of
deficiency give same dose on day 1, 3 and 14.
MALNUTRITION
Give zinc sulphate as 5mg / kg / day.
Give magnesium sulphate as 5mg / kg / day.
Give folic acid 5 mg on day 1, then 1 mg daily.
Give Vit. D 400 units / day.
Give Vit. B complex syrup.
Start iron when the patients condition improves as
3 - 6 mg / kg / day.
For persistent diarrhoea do stools R/E, pH and
reducing substances and give lactose free formula
or KYB diet.
MALNUTRITION
FOR SEVERE MALNUTRITION:
These children should be admitted in the hospital.
Treat dehydration, hypoglycemia, hypothermia,
infections, septicemia, congestive heart failure,
anemia, worm infestation, malaria etc.
Start liquid blended diet orally or by NGT if child is
very sick.
Caloric intake is calculated as 150 Kcal / kg / day
for the present weight.
Start with 80 Kcal / kg / day liquid diet.
Increase the quantity gradually till it is 120 Kcal /
kg / day by the end of two weeks.
MALNUTRITION
Weight gain should start within a week at least by
5 gm / kg / day.
When weight gain is consistent for 3 days, child is
able to take feeds orally and is free of infection,
mother has been educated to feed properly then
the child can be shifted to rehabilitation area.
MALNUTRITION
Rehabilitation:
It starts when the child’s appetite has returned.
It’s aim is to encourage the child to eat as much as
possible.
To encourage breast feeding.
To stimulate emotional and physical development.
To prepare the mother to look after the child after
discharge.
There should be no fever, no diarrhoea, no
vomiting, no edema, no low hemoglobin < 8 gm%
and weight gain more than 5 gm / kg / day for 3
consecutive days.
MALNUTRITION
Education about preparing weaning foods, amount
and type of food, preparation of ORS in case of
diarrhoea, importance of immunization.
The victims of the protein – calorie malnutrition
need proper food and special care for a long
period to promote satisfactory development
.Special rehabilitation centers need to be
established for such cases .
Supplies of proteins : to eliminate protein – calorie
malnutrition ,infants and children must receive
enough food of the right kinds particularly
proteins. A committee of the economic and social
councils of the united nations has emphasized
the importance of “ the protein gap ” in connection
with population explosion
Follow Up:
Weight monitoring at 1 week, 2
weeks, 1 month, 3 months and 6
months and from then on every 6
months up to the age of 3 years.
Record of immunization, growth and
feeding schedule, vitamin and iron
supplements should be kept.
Prevention :
It is important to provide treatment is essential .
Special importance must be attached to maternal and
child centers through which better child feeding practices
can be encouraged ,largely by educating mothers .the
demonstration of suitable food mixtures and preparations
to be given to children is particularly valuable .
Prevention consists of supply of food of good quality
proteins in the food e.g milk ,egg ,fish . When weaning
infants ,proteins should be added to their diet . Treatment
of the condition is done by administration of dry skimmed
milk ,which remains the principal therapeutic agent in
protein – calorie malnutrition.
PREVENTIVE MEASURES
HEALTH PROMOTION ;
MEASURES DIRECTED TO pregnant and lactating
women (education ,distribution of supplements)
i. Promotion of breast feeding
ii. Development of low cost weaning foods that are
readily available.
iii. Measures to improve family diet .
iv. Nutrition education .
v. Family planning and spacing of birth
vi. Family environment must be improved .

saira afzal
Specific protection :

i. Childs diet must contain proteins

and energy rich in food .milk ,eggs
,fresh fruits should be given as much
as possible .
ii. Immunization
iii. Food fortification .
VITAMIN B1 or thaimine def:
Vitamin B1 plays an important role in carbohydrates
metabolism .it is essential for the formation of co –
carboxylase .if co- carboxylase in insufficient
,pyruvic acid accumulates in the blood ,producing a
variety of symptoms .
Symptoms :
i. Neurological symptoms : neurasthenia ,loss of
attention ,irritability ,followed by peripheral ploy
neuritis ,tender ness and weakness of calf muscles
,loss of ankle jerk reflex , in severe cases there may
be wrist or ankle drop and muscular atrophy.
ii. Cardiac symptoms :
Cardiac symptoms:
Tachycardia
Shortness of breath
Dizziness
Irregular heart beat later there is edema of extremities .
Serous effusion
Enlargement of liver
Congestive heart failure resulting in sudden circulatory
failure .
Gastro – intestinal symptoms :loss of appetite
,indigestion ,vomiting
Neurological symptoms:
neurasthenia ,
loss of attention ,
irritability ,
followed by peripheral ploy neuritis ,
tender ness and weakness of calf
muscles ,
loss of ankle jerk reflex ,
in severe cases there may be wrist or
ankle drop and muscular atrophy.
Prevention:
If lightly milled or unpolished rice is
substituted for polished rice ,beri beri
will be prevented because outer layer of
rice contain thiamine or enriched rice
should be used .a diet rich in thiamine
should be taken e.gg tomatoes ,green
leafy vegetables ,fish ,meat ,eggs ,milk
,yeast ,nuts .
Daily requirement : 1-3 mg
Treatment :10 -15 mg thiamine daily .
vitamin B3 def:
PELLEGRA is due to deficiency of niacin mainly .it is
also controlled by the amount of amino acids
tryptophan in the diet .
Symptoms : glossitis ,gastro intestinal disturbances
( gaseous eructation ,indigestion ,alternating diarrhea
,constipation nausea ,vomiting ) and skin lesions (knees
and elbows show dry scaly ,pigmented areas ,skin is
cracked and scaly ,there may be acute erythema
,desquamation ,secondary infections and pigmentation )
Prevention: take food e.g milk ,yeast ,meat ,liver
,kidney ,peanuts .
Treatment :150 – 500 mg ,niacin daily until lesions clear
Pellegra :
PELLEGRA is due to deficiency of niacin mainly .it is also
controlled by the amount of amino acids tryptophan in the
diet .
Symptoms : glossitis ,gastro intestinal disturbances
( gaseous eructation ,indigestion ,alternating diarrhea
,constipation nausea ,vomiting ) and skin lesions (knees and
elbows show dry scaly ,pigmented areas ,skin is cracked
and scaly ,there may be acute erythema ,desquamation
,secondary infections and pigmentation )
Prevention: take food e.g milk ,yeast ,meat ,liver ,kidney
,peanuts .
Treatment :150 – 500 mg ,niacin daily until lesions clear .
Vitamin C DEF:
It is characterized by debility ,anemia ,spongy gums
,tendency to hemorrhage .it is caused by lack of fresh fruits
and vegetables in the diet .
Infantile scurvy occurs in artificially fed infants usually under
one year of age ,the child does not move his limbs voluntarily
because of pain ,there are hemorrhages' under the
periosteum of the bones producing swelling ,there may be
enlargement of costochondral junctions ,resembling rickets .
Prevention : all infants should be given source of vitamin c
from the first month of life .it may be given as 1-2 oz.
unheated orange juices : if it is not tolerated 40 mg ascorbic
acids may be used .
Treatment of infantile scurvy :300 mg daily by mouth ,the
dose may be reduced after one week .
MACROCYTIC ANEMIA :
This group of macrocytic anemia of pregnancy
pernicious anemia ,sprue , celiac disease .
They occur as a result of defective blood
formation ,which may be due to failure to
receive ,absorb or utilize vitamin B 12 or folic
acid or absence of intrinsic factors .
Treatment : folic acid 15 mg daily causes
regeneration of erythrocytes , and is
administered in macrocytic anemia of
pregnancy .maintenance dose of folic acid is 5
mg daily .
Microcytic anemia /pernicious
anemia :
Parental administration of 50 mg of vitamin B12 twice a
week ; maintenance dose 50 mg twice a month .
Iron deficiency anemia :it produces hypochromic
microcytic anemia .there is a deficient intake of iron,
blood loss or increased iron demands so that the body
stores of iron is depleted and anemia occurs .
Symptoms :pallor ,weakness ,fissures of the angles
,irritability ,heart murmurs or indigestions .
Prevention :includes iron in the diet ,or stop blood loss .
Treatment :iron salts ,0.3 gm ferrous sulphate three
times a day after meals
Macrocytic anemia :
This group of macrocytic anemia of pregnancy
pernicious anemia ,sprue , celiac disease .
They occur as a result of defective blood
formation ,which may be due to failure to receive
,absorb or utilize vitamin B 12 or folic acid or
absence of intrinsic factors .
Treatment : folic acid 15 mg daily causes
regeneration of erythrocytes , and is
administered in macrocytic anemia of pregnancy
.maintenance dose of folic acid is 5 mg daily .
NUTRITIONAL
NUROPATHIES:
The nervous system is liable to damage through lack of
essential nutrients in the diet .the energy for its functioning is
derived from carbohydrates ,and the energy exchanges are
controlled by enzymes systems in which vitamins play an
essential role .in some deficiency diseases ,e.g. beri beri ,lesion
of peripheral nerves are a prominent features in pellagra ,metal
disturbance indicates bio chemical abnormalities in the
CNS.Three kinds of effects may be distinguished .
i. Functional impairment :In which there are no perceptible
changes in nerve structure :denudation of myelin sheath of the
nerves ;and more complete demyelination associated with
destruction of the nerves cells and fibers. The first of these
respond to therapy. With the other two recovery depends on
the extent of damage that has occurred .if it is severe it is likely
to be permanent and irreversible .
 Two conditions that are significant
are
i. Painful feet syndrome ,the burning
feet
ii.Retrobulbar neuritis or nutritional
amblyopia .
Burning feet is a painful disease ,beginning with aching
and throbbing it progress to sharp paroxysmal stabling
pains which radiates upwards as far as knees and cause
intense agony .the spasms are usually worse at night
.no objective signs of nerve involvement are revealed by
clinical examination ,and the pathological lesions which
underlie the condition are not known .
It is also associated with stomatitis ,retrobulbar
neuritis . It can be effectively treated with yeast
concentrates and mixture of B complex ,pantothenic
acids gives excellent results .
Retrobulbar NEURITIS (Retrobulbar neuritis is a form of
optic neuritis(INFLAMMATION OF OPTIC NERVE) in which the
optic nerve, which is at the back of the eye, becomes inflamed. The
inflamed area is between the back of the eye and the brain.)
shows itself by a progressive failure of sight due to
pathological changes in the nervous system concerned
with the vision which extends from the retina through
the optic nerve and tract to the cortex of the brain .
Treatment with the yeast preparations and vitamin B
concentrates ,combined with an all round improvement
in the diet ,restore the vision in mild cases .in severe
cases the condition may be irreversible despite
treatment and permanent optic atrophy may result .
 obesity in adults An emerging
problem:
It is an nutritional emergency .
In 1997 ,WHO ,expert consultation on
obesity ,(Geneva 3-5 June 1997)forewarned
the global community that inability to adopt
appropriate and adopt appropriate and
timely strategies to stem the pandemic
would result in exposure of millions of
people in both developed and developing
world to various non communicable
diseases and other health problems
OBESITY :
It is defined as abnormal growth of
the adipose tissues due to
enlargement of the fat call size or
an increase in the fat cell number
or a combination of both . Or
It refers to an excess amount of fat
and is arbitararily considered to be
present when the fat content of the
body is > 25% of the body mass in
males and >30% in females .
Overweight is defined as an excess amount
of the body weight that includes chosen as >
130%nof relative weight ,according to life
insurance” build and mortality tables ”.
Overweight is defined as an excess amount of
the body weight that includes muscle,bone,fat
and water .
Some of the people such as body builders and
atheletes with a lot of muscles cab be
overweight with out being obese.ideal weight
is based on stamdards with the lower mortality
risk in life insurance experience
Obesity is often expressed in
terms of body mass index (BMI) .
A BMI of 30 or more in males and
28.6 or more in females indicates
obesity
Facts and figure :

Globally there are 1.5 billion of over

weight adults, at least 300 million of
them clinically obese.
Over 60 million ,American adults 20
years + ,according toleast data from
national centre for health statistics,are
obese .among children and teens 6-19
yrs ,over 9 million are considered
overweight.
illyas ansari ,7th edition .
Current obesity trends globally range from 5% in
china,japan ,and certain African nations ,to over 75% in urban
samoa.
According to estimates of international diabetes federation
2004 ,more than 2.5 million deaths each year are attributed
to obesity , a figure expected to double by 2030.
Some half a million people in north America and western
Europe die from obesity related disorders every year .

illyas ansari 7th edition

Obesity in Pakistan:

National health survey 1990-1994

revealed
Obesity BMI >30 and overweight
BMI>25 ARE COMMON among females
than males for all age and urban /rural
sub groups.
The higest level is least among women
45 – 64 yrs of age living in urban areas ,
40% of whom are obese or overweight.
The group which is least affected is
young 15 – 24 yrs from rural ,males
of whom only 3% are obese or over
weight .
Levels of obesity /over weight tend to
increase with age , peaking in the 45
0 64 yrs of age group , then decline
among the elderly 65+ .
In all age and sex groups, higher
levels of obese / overweight are
observed for urban compared to rural
population .
Among the 25 – 44yrs age group , 9%
of the rural males are obese or over
weight compared to 22% of urban
males .
Among the 25 -44 yrs age group ,14%
of the rural females are obese or over
weight compared to 37% of the urban
females.
Obesity generally increases with
economic class, affecting 15% males
of low economic class to 40% of
those with high economic status.
Hypertension is highly prevalent
among obese and over weight
Pakistanis ,among obese females
over 45 yrs od age ,65% from urban
areas and 48% from rural areas are
hypertensive .from the same age
group ,58% males in both rural and
urban areas are affected .
The association between body weight
status and diabetes is very clear in
Pakistan
According to 5” report on the “ world
nutrition situation ” compiled by united
nations system standing committee
on nutrition 2004,the rates of adults
over weight and obesity in pakistan
are as following .
TABLE :

BMI > 25% BMI < 25%

BOTH SEXES 1380 3.40

MALES 1157 1.80

FEMALES 18.97 5.93

The number of undernourished
people in Pakistan is 26.8 million i.e.
19 % of the population .
Causes of obesity :

Genetic
Environmental
Psychological factors
Obesity is considered to the poly genic
.
Much recent research has focused on
possible abnormalities in the “leptin
system”.
The gene “POMC” and melanocortin –
4 receptors .
In one study ,adults who were adopted
as children were found to have body
weights close to their biological
parents than to their adaptive parents.
The environmental facilitators for mass
obesity include greater availability of
food(freezers ,fast food culture)changing
dietary composition (more fat , more
refined sugars ,more alcohol) changing
eating style(more snacks than regular
food ,excessive soft drinks
,chocolates)which encourage over eating
in relation to physiological needs.
The major and alarming cause appears to
be significant increase in sedentariness.
The amount of physical inactivity has
drastically increased due to energy saving
devices (use of cars ,lifts ,escalators
,washing machines dishwashers , remote
control ,cordless telephones ,computers
,push chairs ,leisure hours ,games ,pre-
prepared meals) .the present state of
affairs was forewarned by aneel keys ,in
1949 ,who categorized pointed out “while
our calorie intake goes up ,out output goes
down “.
The wonderful advances of
technology not merely free us from
back – breaking toil ,they make it
almost impossible to get a decent
amount of caloric using exercise.
How to measure obesity :

It can be measured by various

methods including
i. BMI(Body mass index)
ii. Waist circumference
iii.X- ray absorptiometry (DEXA)
 BMI has become the medical
standard used to measure over
weight and obesity .the WHO
department of nutrition for health and
development (NHD) .
has developed the following cut off
points:
i. Over weight > 25kg/m2
ii. Pre – obese 25 – 29.99 kg/m2
iii. obesity 30 kg/m2
These values are different for different
ethnic groups in particular Asian
population.
Obesity in children:
Childhood obesity has gained
prominence due to increasing
prevalence in china ,japan ,Malaysia
,Thailand south Africa ,the middle
east , the Caribbean and Latin America
as well as affluent west .
An estimated 22 million under five
children have been found to be over
weight world wide .the problem is
global, increasingly extending into
developing world.
A recent global analysis showed a
rising trend in childhood over weight
in 16 out of 38 countries (42%)with
more than one survey.
In the report submitted to WHO ,the
“inter national obesity task force
"expressed serious concern over the
rapidly growing problem by releasing
projected figures of some 155 million
affected school age children for 2002.
According to 2008 ,170 million children
aged <18 years globally were classified as
over weight or obese. This estimate
includes more than 25% of all children in
some countries ,more than double the
proportions from the start of the epidemic.
In U.S it is most common nutritional
disorder in children. Developing countries
are also affected as the prevalence rises
among children of urban dwellers.
saira afzal ,text book of community medicine and public
health ,
An interesting example is from china
where because of more than 20 years
of “ strict one child policy ”and
continuing improvement in economic
status ,the growing income is often
spent on “ the only one child” with
resultant sharp rise in child obesity
adding to “little emperors". According to
the statistics of shanghai preventive
medical association ,nearly 30% of the
city’s children are over weight with
almost half of them obese.
BMI for children,also referred as BMI for
age ,is gender and age specific.
BMI changes drastically with age in
children as body fat changes with
growth ,and between girls and boys with
maturity.
BMI- for -age -,gender specific growth
charts used for children and teens 2-20
years of age.
saira afzal ,text book of community medicine and oublic
health
Impact of obesity on economics:

The co-existence of under weight and

over weight in an increasing number
of developing country settings, is a
matter of growing concern for the
economists and the health care
providers.
The tale of dual burden of malnutrition ,first recognized
in brazil ,china ,Russia. Has extended to many spots
on the globe.in shanty towns of brazil and India over
weight and under weight co – exist in 30 % of house
hold.
In Egypt over 10% of house holds contain a stunted
child and an over weight mother.
There is growing evidence that infant under – nutrition
increases the risk of over –nutrition later in life.
Childhood stunting predispose to obesity. The dual
burden widens the scope of nutritional problem and
has a serious impact on the already stretched financial
resources of the developing world.
Risk factors for child hood
obesity :
Obesity in one or both parents
Infant of diabetic mother
Children from single parent families
and families with fewer children.
Impact of obesity on health:

There is scientific evidence that

people with mostly abnormal fat
(apple or android) are at greater risk
of developing serious diseases like
diabetes mellitus and cardiovascular
diseases than people whose fat is
mainly on buttocks and thighs (pears
or gyneoids).the severity depends on
site of fat rather than size.
The association of obesity with increased
morbidity and eventually mortality was first
described by father of medicine-
Hippocrates(460-377 BC) who said”
sudden death is more common in those
who are naturally fat than in the lean”.
Framingham study has shown loss of 3.1
years in over weight men and 3.3 years in
over weight women compared with normal
weight individuals.in obese women and
men, these shortened life years are more
pronounced reaching 5.8 and 7.1 years
respectively.
The adverse metabolic effect of over weight
and obesity on blood pressure,triglyceroids
and insulin resistance have been well
documented.
The debilitating problems includes
respiratory problems notable obstructive
sleep apnoea,musculoskeletal
problem,dermatological
problems,reproductive / endocrine
abnormalities.
Osteo arthritis in knee in old age and slipped
capital femoral epiphysis in obese children
may at time be serious enough to warrant
surgical intervention.
Obesity has important influence on
heat tolerance .obese individuals
exercising in hot environment produce
greater increase in heart rate and in
rectal temperature than do the lean
one. The insulating effect of
subcutaneous fat obstruct the transfer
of metabolic heat from core to surface.
The U.S army men who died of heat
stroke during basic training in World
War II were more likely to be obese
than their peers.
Management of obesity :

Dietary modification
Behavioural modification
Physical activity
Pharmacotherapy
Bariatric therapy
Strategies for preventing
obesity:
It is most realistic and most effective
approach for dealing with the major
and growing concern of obesity.the
key point for such are as follow:
Health promotion :health counselling
regarding the health hazards of
obesity at family ,group ,community
levels remain the corner stone of
prevention.
In Bolivia(one of the poor country of latin
America ) greatest increase in weight was
seen among less educated women .this is
true for most of the developing countries.it
has been documented that over weight and
obese children enter adult hood with a
raised risk of adult obesity of up to 17
folds ,after adjusting for parental
obesity.the primary prevention there fore
start from infancy.
 The association of infant feeding patterns and
obesity has been confirmed in one of the largest
and most recent studies on obesity in U.S,by
grummer – Strawn and mei,which answered the
frequently asked questions.
Q1: Does breast feeding protect against pediatric
over weight ? The study found that the duration of
breast feeding showed a dose response protective
relationship against the risk of over weight .these
findings confirmed the similar results of a meta
analysis conducted by dewey .the work in other
centres of Germany ,Scotland and Czech republic
on the subjects aged 4 years to adulthood
revealed that “the more breast feeding and human
milk provided – the less over weight” .
Dietary modification :

Low caloric diet .diet must includes

fruits and vegetables .nuts and whole
grains and excludes fatty and sugary
foods.
Weight loss programme recommend
diets consisting of 1200 – 1500 calories
per day,in the following proportion :60%
carbohydrates
30% protein and 10% fat portion.
saira afzal
Individuals must be screened and medically
supervised while on diet (the degree of weight loss
being dependent on individuals ability to adhere to
dietary recommendations)
Studies have shown that meals replacement are
often more effective than very low calorie
diet,resulting in an effective than very low calorie
diet resulting in increase in weight loss and
enabling dieters to maintain their weight loss.

saira afzal
Behavioral modification :
Many eating and exercise habit combine to promote weight
gain , keeping a food diary that record times ,places and
activities and emotion may link to period of over eating or
inactivity will reveal areas need modification .
Life style modification is best achieved when individuals is
motivated ,enthusiastic and supported to achieve goals .
Patients are helpedto acoid eating while on their feet
,watching Tvor playing games .eat home cooked rather than
fast food s.
Motivated to walk rather than use cars ,reduce TV
,COMPUTER GAMES and use of energy saving devices .

saira afzal
Physical activity :

Exercise is the single best predictor to

achieve long term weight control.
Regular exercise leading to weight
loss and improve blood pressure
control,sugar level control and other
obesity related complications.

saira afzal
Pharmacotherapy:
Anti obesity drugs be used only.
i. In individual aged 18 – 75 yrs with BMI of 30
kg/m2 ot more
ii. In individuals with BMI of > 27 kg/m2 with existing
risk factors such as diabetes ,cardiac ,sleep
apnoea or hypertension .
iii. in individuals with a BMI of >30 kg /m2 in whom at
least 3 months of managed care (supervised
diet,exercise,behaviour modification) fail to lead to
significant reduction in weight loss.

saira afzal
 Two drugs have been liscensed for use in the treatment of obesity:
i. Orlistat – prevent fat digestion and absorption to GIT lipases,useful
for those with high intake of fat.
ii. Sibutramine- reuces appetite and increases thermogenesis
recommended for those who cannot control their appetite.
These drugs should not be used as sole therapy for obesity .their use
require strict regular monitoring and must be discontinued if weight
loss is < 5% after 12 weeks of use or weight gain recurs while on
the drugs.
iii.Anti obesity drug treatment should not be used beyond a year and
never beyond 2 years as few studies have examined the
consequences of their long term use.
iv.Gradual reversal of weight loss is known to occur on stopping
pharmacotherapy.

saira afzal
• Appetite suppressants:
i. nor adrenergic (schedule iv)
ii. Phentermine (adipex ,fastin)
iii. Di ethylepropion (tenuate)
• Nor adrenergic (schedule III)
i. BENZPHETAMINE (didrex)
ii. Phendimetrazine (bontril)
Serotonerg
• Fenfluramine ,dexfenfluramine
Mixed noradrenergic & serotonergic
• Sibutramine (medical)
• Nutrient absorption reducers
lipase inhibitor
• Orlistat (xenical)

saira afzal ,text book of community medicine and public

health
Bariatric surgery:
surgery may be a weight –loss option for patient who are
severely obese i.e. B MI > 40 kg/m2 or those with BMI > 35
kg/m2 who suffer from serious medical complication .
There are two surgical procedures for reducing body
weight: gastroplasty and gastric by pass : both reduce the
stomach to a small pouch that markedly limits the amount of
food that can be consumed at any one time.
There is 25 to 30 % over the first year post operatively with
rapid normalization of blood pressure and glucose in
patients with hypertension and diabetes .this is maintained
for about 5 years after surgery .however ,long term
monitoring is needed and surgery is not without attendant
operative risk.

saira afzal
Avoidance of obesogenic
environment:
In schools children were exposed to
obesogens.
Discouraging the fast food culture ,
Provision of safe cycling scheme for
children
Avoidance of sedentary habits at
home and at work should be
advocated.
Life style modifications:
Motivation and active participation from the family and
community are prerequisities.the need for sensible eating
and increased physical activity must be comprehended.
The Australian package “building a healthy ,active Australia
launched by Australian prime minister on 29th June 2004
recognized the need for a balanced approached to nutrition
and physical activity to promote healthy habits for life”.
Further more the “life style prescription initiatives”
progressed through the “ focus on prevention package ”
made available from june 2005 ,aims to make it easier for
general practioners /family physicians to encouraged their
clients to adopt healthier life.a life style prescription is a
written aadvise that id given to the patients recommending
healthy behaviour change.
Early identification and prompt
interventions:
Periodic health examination for early
recognition of undersirable weight
gain ,relative to linear growth ,is
essential through out childhood.the
WHO ,multicenter growth reference
study was designed to provide data
how children should grow rather
thandescribing their growth in a
particular time and place.
Ideally the growth of all children should be
monitored up to 18 years.the case finding
activities should be targeted to
communities rather than
individuals.adequate measures need to be
taken to established barriers against the
aetiological agent in a given
environemtn.prompt intervention to arrest
the progression of obesity is the most cost
effective approach.
Treating obesity:

Eating less and physically more active.

Sustainable reduction in weight should
be the ideal attainable goal.the weight
loss of 5- 10 % maintable long term .is
associated with significant benefits on
the basis of data from Scottish
intercollegiate guide lines network.
 Potential benefits of 10kg of weight loss can be
enumerated as following:
A. Morbidity
i. Diabetes mellitus:50 % reduction in FBS.
ii. Hypertension
• 10mmHg reduction in systolic blood pressure.
• 20 mmHg reduction in diastolic blood pressure.
Iii .lipid profile :
• 10% reduction in total cholesterol.
• 15% reduction in LDL.
• 30% reduction in triglyceriods
• 8% increase in HDL.
iv. Respiratory :
•Significant reduction in sleep apnoea.
•Significant decrease in breathlessness.
v.gynaecological:
•Improved ovarian function and fertility in PCOS.
B.Morbidity :
•30% reduction in diabetic related deaths.
•40% reduction in obesity related cancers .
•20% reduction in total mortality.