Major nutritional problems in Nepal with 'Health policy 2004 data'

1. Assessment of nutritional
status of high risk groups
Prepared by :
BNS 2nd yaers
Roll no. 1-8

2. Introduction
• High risk groups are those population groups that are at considerably
higher risk of developing severe disease, than others.
• These include pregnant women, infants, children under 5 years of age,
elderly and patients with HIV/AIDS and chronic diseases, as well as
non-immune migrants, mobile populations and travelers.

3. Countinue
• Nutritional deficiency is a major public health challenge in Nepal.
• Nutritional deficiencies are occurring with varying degree of
manifestations.
• It has tremendous impact on the health of vulnerable population.
• Under nutrition is one of the major causes of disability, morbidity and
mortality in the country.

4. Major nutritional problems in Nepal

5. Major nutritional problems in Nepal
1. Protein energy malnutrition
2. Nutritional anemia
• Iron deficiency anemia
• Folic acid deficiency anemia
3. Mineral deficiencies
• Endemic goiter( iodine)
• Osteoporosis(calcium)
4. Vitamin A deficiency

6. Contd......
5. Intestinal warm infestation
6. Low birth weight

7. Protein energy malnutrition(PEM)
• PEM is identifying as a major health problem in Nepal .
• It is most frequently seen in infant and children of under 5 years.
• It is not only an important cause of childhood mortality and morbidity
but lead also to permanent impairment of physical and mental
growth of thse who survive.

8. Contd......
• Definition:
Protein Energy Malnutrition (PEM) is define as a range of
pathological condition arising out of coincidence lack of protein and
energy in varing proportions, most frequently seen in infants and young
children and usually associated with infections.

9. Contd.....
Situation of PEM in Nepal
• 51% of children below 5 years of age are affected by stunting, which
can be a sign of early chronic under nutrition.
• 48% of children are underweight.
• 10% of the children are wasted (thin for age), which can be an
indicator of acute under nutrition.
• Stunting is more common in the Mountain areas than in Terai, but
underweight and wasting are more common in Terai regions.
• 27% of woman fall below the cut-off point of BMI. (<18.5)

10. Contd....
•Causes( Children)
Inappropriate breastfeeding
Inadequate complementary feeding practices.
 Insufficient health services (Growth monitoring and
counseling)
Low birth weight.
 Infectious diseases.
Inadequate energy intake

11. Contd....
Causes( women)
• Inadequate energy intake
• Inadequate knowledge and practice of maternal feeding
• Heavy physical workload
• Lack of extra food intake during pregnancy and lactation

12. Contd...
Types of PEM
1. Mild PEM:
• Common in children between 9 months to 3 years of age.
• Usually seen in children who are in the weaning period.
2. Moderate PEM:
• Also known as "Runche".
• Commonly seen in the children between 1-4 years of age.
• The weight of the child is usually less than 70% of the
expected standard weight.

13. Contd.....
3. Severe PEM: There are 3 types of severe PEM
a) Marasmus:
• Pathological condition in which both protein and calories are low,
especially due to low intake of carbohydrate.
• Seen in 9 months to 3 years of children.
b) Kwashiorkor:
• When there is excessive deficiency of protein as compared to
deficiency of energy kwashiorkor result.
• Seen in 1 to 4 years age group.

14. Contd....
c) Marasmic - kwashiorkor:
• Mix form of PEM with the features of both marasmus and
kwashiorkor.
• weight less than 60% of the expected weight for his age and has
oedema

15. contd..

16. contd...
Management of PEM
1) Mild PEM:
• Awareness of PEM
• Grade the nutritional status of child on the basis of anthropometric
and clinical data.
• Find out the cause of malnutrition e.g. fever, chronic diarrhea, UTI,
TB, measles etc.
• Nutritional advice for proper feeding.

17. Contd..
2) Moderate PEM:
• Provision of diet adequately fulfilling the protein and energy diet of
child.
• Identification and treatment of any deficiency disease, infectious
illness, or their complication.
• Hospital admission is required if the child severely refused to eat.
3) Severe PEM:
• Severe PEM should preferably be admitted in the hospital.

18. Contd..
Preventive measures of malnutrition
• Health promotion
• Specific protection
• Early diagnosis and treatment.

19. 2. Nutritional anemia
Nutritional anemia includes:
i) Iron deficiencecy anemia
ii) Folic acid deficiency anemia

20. Contd...
i) Iron deficiency anemia

21. Contd...
• This is the condition of low HB or %of RBC is low in the total blood
below 10 gram or below 34%/litter blood.
• Commonly seen in developing countries and premature babys.

22. Contd...
Prevalence:
• Prevalence of anemia was higher in preschool children (78%) than in
women (67%).
• An astonishingly high rate of 90% was found in infants, 6-11 months
old.
• Among women, there is distinct variation between ecological zones,
with highest levels in the Terai, followed by the Mountains.

23. Contd....
• Only 32% of pre-school children and 29% of pregnant women
consumed an adequate amount of iron to fulfill their daily
requirements.
• Prevalence of anemia was also high (64%) in high school adolescents
who attended the Government Girl’s high school in Kathmandu valley.

24. Contd....
Caueses
• Inadequate intake of iron from daily diets
• Inadequate absorption of dietary iron
• Infestations such as hookworms and malaria
• High requirements of iron particularly during growth, pregnancy,
lactating and adolescence girl.
• Blood loss (menstruation, and injury)
• Vitamin A deficiency

25. contd...
Sign and symptoms
• Pale conjunctiva
• Easily fatigue
• loss of appetite
• Swelling especially face and eyes
• HB level below 11 gram or 34%
• Tachycardia, Tachypnea,Cardiac enlargement
• Nail become flat and spoon shape.

26. Contd..
Treatment
• 180 mg ferrous sulfate and 0.5 mg of folic acid until 2-3 months(60
mg elemental iron)
• For children - 60 mg of ferrous sulfate , 0.1mg of folic acid (20 mg of
elemental iron)

27. Contd..
Prevention
• Nutritional education.
• Iron supplementary diet to pregnant and lactating women.
• Early diagnosis and treatment of any kind of infectious diseases e.g
diarrhea,dysentery, worm infection.
• Deworming
• Fortification of flour, bread, and infant diet with iron.

28. ii)Folic acid deficiency anemia
• Folic acid deficiency ia an abnormally low level of vitamin B4, results
in anemia characterized bt red blood cells that are large in size but
few in number.
• It happens when body does not get enough folic acid.

29. Contd..
Causes
• Not eating enough foods with folic acid is the common causepoor
absorption of folic acid.gastric diseases, intestinal diseases
• some medicines interfere with folic acid. eg. alcohol, sulfasalazine,
• Diminished storage
• Increased requirement eg pregnancy, lactation, prematurity,
hemodialysis

30. Contd...

31. Contd..
Prophylactic therapy
• All women of reproductive age should be given 400microgram of folic
acid daily.
• Additional amount (4mg)should be given in situations where the
demand is high eg. pregnancy, lactation etc.

32. Contd....
Curative Treatment
• Daily administration of folic acid 4 mg orally which should be
continued for at least four weeks following delivery.

33. Contd...
Prevention
• Diet- Good dietary souces of folate are Mushrooms, butter, re beans,
soy, green leafy vegetables, broccoli, liver and kidney, wheat germ.
• Folic acid is a synthetic derivative of folate and is acquired by dietary
supplementation.
• Multi-vitamin dietary supplements contain folic acid as well as
other B vitamins.
• Fortification of rice is common. similarly fortification of flour,wheat,
corn flour, milk which help to reduce the neural tube defect.

34. Contd....
Complication
• Abortion
• Dysmaturity
• Prematurity
• Abruptio placenta
• Fetal malformation(harelip, cleft lip, neural tube defect such as spinal
bifida

35. 3. Minerals deficiency
• It includes:
i)Endemic Goiter(Iodine deficiency disorder)
ii) osteoporosis
iii)Vitamin A deficiency

36. i) Endemic goiter (Iodine deficiency Disorder)

37. Contd...
• This disease is accompanied by a progressive increase in the thyroid
gland with subsequent reduction of its functions.
• Endemic goiter is observed in people living in areas of iodine
deficiency in the environment, especially in soil and water.

38. Contd....
Current status of IDD in Nepal
• Currently only 63% of households in Nepal are using adequately
iodized salt.
• The prevalence of low Urinary Iodine Excretion is highest among
women in the Terai zone.
• Iodine deficiency is still high as a public health problem in that group.

39. Contd...
Causes
• Lack of iodine in food ( daily requirement 150 mg)
• Malabsorption
• Inabilities to secrete sufficient quantities of necessary hormones
result in increased secretion TSH stimulating gradual growth.
• Congenital metabolic defect that prevent synthesis of thyroid
hormone.

40. Contd.........
Signs and symptoms
• Duffuse or nodular thyroid enlargement
• feeling difficulty during swallowing.
• difficulty to turn head.
• caediovascular system disturbance.
• severe cases mental decline
• difficulty in breathing , resulting from pressure on the trachea.

41. Contd....
Management
• Use of iodized salt.
• Use of thyroid drugs in therapeutic doses.
• Treatment of hypothyroidism.
• Surgery ( Subtotal resection of the thyroid gland)

42. Contd...
Preventaion
 Providing the population with iodized salt and iodised food.
 public awareness.
 Drug ( thyroid drug in small doses)

43. ii) Osteoporosis(Calcium deficiency)

44. Contd.....
Definition
Osteoporosis is a systemic skeletal diseases characterized by
• low bone density
• a micro architecture deterioration of bone tissue
• that enhances bone fragility
• increases the risk of fracture
The word "osteoporosis" is from the Greek terms for "porous bones".

45. Contd....
Epidemiology
• It becames more common with age.
• It is more common in women than men due to low peak bone mass,
hormonal changes at menopause.
• In the developed countries, depending on the method of diagnosis,
2% to 8% of males and 9% to 38% of females are affected.Rates of
disease in the developing world are unclear.
• About 22 million women and 5.5 million men in the European
Union had osteoporosis in 2010.

46. Contd.....
• In the United States in 2010, about eight million women and one to
two million men had osteoporosis.
• White and Asian people are at greater risk.

47. Contd...
Risk factors for fracture
• Advancing age
• Previous fracture
• parental history of hip fracture
• Low body weight
• Glucocorticoid therapy

48. Contd.......
Modifiable risk factors
• Smoking
• Alcohol
• Low body weight
• low vitamin D and calcium
• lack of excercise.

49. Contd...
Signs and symptoms
• Usually asymtomatic
• Backache
• Pathogenic fracture of bone(spine, hip or wrist)
• Abnormal structure of bone

50. Contd...
Management
• Acute pain management : Analgesic - NSAID and /or opioids.
• Chronic pain: may require narcotic analgesic, frequent intermittent
rest in a supine or semi reclining position,
• If Hip fracture almost always require surgical repair.
• Long bone fracture often require either external or internal fixation.
• Fracture of vertebra, rib, and pelvic usually are managed with
supportive care.

51. Contd....
Preventions
• Adequate intake of food having calcium(like-Milk, Yogurt,
orange juice, Tofu with calcium, Cheese, darkand green leafy
vegetables, almonds, beans, icecream) and vitamin D(like-
Cod liver oil, liver , beef, mushroom, orange juice fortified
with vit-D, egg yolk)
• Recommendation that men age 50-70 consume 1000
mg/day of calcium and that women age 51 and older and
men age 71 and older consume 1200mg/day of calcium.

52. Contd....
• IOM dietary Reference intakes for vitamin D are 600IU/day until age
70 and 800 IU/ day for adult age 71 yaers and older.
• Regular weight bearing and muscle strengthening exercise.
• Abstinence from smoking and alcohol, caffeine
• Fruits and vegetables containing Mg is essential for healthy bone.

53. 4. Vitamin A deficiency
• Vitamin A is one of a group of fat soluble vitamins that are essential
for life and health.
• Three active forms : retinol, retinal and retinoic.
• It plays acritical role in vision, growth, reproduction, bone and brain
development.
• Deficiency diseases: Xeropthalmia, Keratinization, xerosis, infections,
poor teeth, weak bones.

54. Contd.......
• Vitamin A deficiency is a preventable cause of blindness.
• It is a well known cause of blindness and is associated with elevated
mortality among infants and children.
• People most at risk are children between 6 month to 6 years,
pregnant women, and lactating women.
• Xeropthalmia (Greek for dry eye ) is a medical condition in which the
eye fails to produce tears.One of the main causes of Xeropthalmia is
poor intake of vitamin A.

55. Contd.....
Current status of vitamin A deficiency in Nepal
• The overall prevalence of night blindness in reproductive aged women
and pregnant women was 4.7% and 6.0% respectively
• While 16.7% of women reported having night blindness during their
last pregnancy.
• The prevalence of night blindness was 0.27% among 12-59 months
children, and that of Bito’s spot was 0.33 % among 6-59 months
children.

56. Contdd.....
• In school-aged children, the prevalence of night blindness was 1.2%,
and Bito’s spot was 1.9%.
• Serum retinol levels revealed 16.6% of women and 32.2% of
preschool children had sub-clinical Vitamin A deficiency.
• Only 42% of pre-school children and 37% of women consumed an
adequate amount of vitamin A.

57. Contd..........
Causes
• Low intake of Vitamin A from daily diets
• Faulty feeding habits
• Mal absorption syndromes( cystic fibrosis, whipple's diaease,
Crohn's disease, ulcerative colitis )
• Worm infestation
• Increased VA requirement resulting from infectious diseases
• Poverty

58. Contd...

59. Contd...
Treatment
W.H.O's recommended doses
( for treatment of children over 1 year of age)
1) Immediately on diagnosis( Day 1) - 200,000 vit.A orally
2 ) The following day (Day 2) - 200,000 vit. A Orally
3) Four weeks later (week 4) - 200,000 vit. A orally

60. Contd...
W.H.O's recommended doses
( for treatment of children under 1 year of age or <8kg)
1) Immediately on diagnosis( Day 1) - 100,000 vit.A orally
2 ) The following day (Day 2) - 100,000 vit. A Orally
3) Four weeks later (week 4) - 100,000 vit. A orally

61. Contd..
Preventions
• Consumtion of food containing vit.A( like liver oils of
various fishes, whole milk, butter, ghee, egg yolk,
carrot, yellow orange fruits, mango, green leafy
vegetables)
• Food fortification with vit.A in wheat, sugar,milk
• Nutrition and health education( radio, TV, svhool etc.)

62. Contd......

63. Contd...
• Mothers should be advice about
Breastfeeding
weaning
liver, egg , cheese, butter, fish liver oil etc are the good sources of
vita.A .
• Immunization - Measles

64. Contd.....

65. 5) Intestinal Worm Infestation

66. Contd...........
• Basically infestation is the state of being invaded by pest or parasite.
So the worm infestation is referred to as an infestation of the host
specially human and animals by helminth.
• An intestinal worm infestation is a condition in which
a parasite infects the gastro-intestinal tract of humans and other
animals. Such parasites can live anywhere in the body, but most
prefer the intestinal wall.

67. Contd......
• There was no national data on worm infestation.
• It is estimated that more than 50% of the children and adolescents are
suffering from intestinal worms from the following studies.

68. Contd......

69. Contd.....
Causes
• Poor hygienic manner and environment
• Raw fish and meat
• Contaminated food and water
• Inadequate opportunities for taking deworming tablets

70. Contd......
Signs and symptoms
• Gastrointestinal conditions include :
inflammation of the small and large intestine
diarrhea/dysentery
abdominal pain
nausea /vomiting
• Loss of appetite
• weight loss

71. Contd....
• intestinal blood loss that can often result in anemia
• delayed growth in children
• Skin irritation around the anus .

72. Contd...
Treatment
• For rounfworm, hookworm,pinworm
Albendazole
Mebendazole
• For tapeworm
Albendazole
Prazaquantel
Nicolsamide

73. Contd........
Preventions.
• Increases environmental sanitation
• promote hand washing and shoe wearing habits
• Educate children at young ages at school and at home
• Interventions at schools, focusing on the construction of pit latrines
(ventilated and improved)
• Use clean drinking water and educate the students about hygiene.

74. Contd...
• Wash fruits and vegetables with clean water.
• Keep nail clean and short.
• Wash hand with soap especially before eating and after using the
toilet.
• Do not deficate in the open. Always use toilet.

75. 6) Low Birth Weight

76. Contd..........
Causes
• Small maternal size at conception (low weight and short stature)
• Low gestational weight gain
• Maternal anemia
• Maternal malnutrition
• Premature delivery
• Early pregnancy

77. Contd.
• Percentage of infant with low birth-weight is 21% in Nepal.
• Advocacy for antenatal check up and counseling at least 4 times
during prenatal period according to MOH policy have been
implemented.

78. Reference:
• National Nutrition Policy and Strategy retrieved from
http://dohs.gov.np/wp-
content/uploads/chd/Nutrition/Nutrition_Policy_and_Strategy_2004.
pdf retrieved on July, 2020.
• https://en.wikipedia.org/wiki/Intestinal_parasite_infection
• https://en.wikipedia.org/wiki/Osteoporosis
• https://en.wikipedia.org/wiki/Vitamin_A_deficiency