Major nutritonal problem in Nepal

1. Assessment of nutritional status
of high risk groups
Prepared by :
BNS 2nd year
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
Protein energy malnutrition
Nutritional anemia
• Folic acid deficiency anemia
• Iron deficiency anemia
Mineral deficiencies
• Endemic goiter( iodine)
• Osteoporosis(calcium)
Vitamin A deficiency

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

8. Nutritional status of children In Nepal: NDHS 2016
• 36% of children under age 5 are stunted (short for their age), 10% are
wasted (thin for their height), 27% are underweight (thin for their age),
and 1% are overweight (heavy for their height).
• 55% of children are breastfed within 1 hour of birth, and 66% of
children under age 6 months are exclusively breastfed.
• Complementary feeding: 83% of children age 6-8 months are
breastfed and receive complementary foods. Only 1 out of 4 (25%)
children are feed with three times recommended diet.

9. Cont…
• Coverage of vitamin A and deworming in children:63% of children
age 6-23 months ate foods rich in vitamin A. 86% of children age 6-59
months received a vitamin A capsule and 76% of children age 12-59
months received deworming medication.
• Anemia in children: More than half (53%) of the children age 6-59
months are anemic. 35% children age 6-23 months ate iron rich foods
while 8% of children age 6-59 months received an iron supplement in
the week.

10. Nutritional status of adults : NDHS 2016
• 11% of women age 15-49 are short (less than 145 cm), and 17% are
thin (BMI less than 18.5).
• Another 22% of women are overweight or obese (BMI >25.0).
• Among men, 17% are thin (BMI <18.5), and 17% are overweight or
obese (BMI >25.0). (15% overweight and 3% obese)

11. Cont…
• Intake of iron supplements and deworming in women: 42% of
women age 15-49 with a child born in the past 5 years took iron tablets
for at least 180 days, and 69% took deworming medication during the
pregnancy of their last child.
• Anemia in women: 41% of the women age 15-49 are anemic.
• Salt iodization: 95% of households use iodized salt for cooking.

12. Protein energy malnutrition(PEM)
• Definition: PEM is defined as a group of clinical condition that
may result from varying degree of protein deficiency and energy
(calorie) inadequacy and usually associated with infections.
• It is most frequently seen in infant and children of under 5 years

13. Situation of PEM in Nepal
• Stunting (36%) can be a sign of early chronic under nutrition.
• Underweight (27%)
• Wasted (10%) can be an indicator of acute under nutrition.
• 1% of the children are overweight
• Stunting is more common in the Mountain areas (47%) than in Terai,
but underweight(33%)t and wasting (12%) are more common in Terai
regions.

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

15. 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

16. Contd......
Types of PEM
1. Mild PEM:
2. Moderate PEM:
3. Severe PEM:
a) Marasmus:
b) Kwashiorkor:
c) Marasmic - kwashiorkor

17. contd..

18. 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.

19. 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.

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

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

22. 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 baby.
• Iron deficiency leading to anemia is very common among women
(15-49 years) and children (6-59 month) in nepal.

24. Prevalence:
 The prevalence of anemia was higher among children age 6-23 months
(68%) than among older children age 24-25 months (52%), 36-47
months (45%), and 48-59 months (36%).
 The prevalence of anemia is higher among children who did not
receive deworming medication in the past 6 months than in children
who received deworming medication (57% versus 45%).
 Anemia prevalence is higher in rural (56%) compared with urban
(49%) areas, and in terai (60%) compared with mountain (57%) and
hill (40%) ecological zones.

25. Contd....
Causes
• 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

26. Contd......

27. Contd..
Treatment
• Underlying causes such as hookworm infestation should be treated
• 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)

28. Contd.......
• Avoid giving iron with milk or caffeinated drinks because milk and
caffeinated drinks prevent the absorption of iron.
• Provide ascorbic acid such as orange juice , lemon juice and other
foods that are high in vitamin C can help in iron absorption.

29. Contd..
Prevention
• Nutritional education [ Good sources of iron include: red meats,egg
yolks, green leafy vegetables, dried peas and beans, dried fruits and
raisins. Provide these foods or drinks rich in vitamin C (tomatoes,
broccoli, orange juice, strawberries, etc.)
• Try cooking food in a cast iron pan, which can help enrich the food
with iron.
• Iron supplementary diet to pregnant and lactating women and
Deworming
• Early diagnosis and treatment of any kind of infectious diseases e.g
diarrhea,dysentery, worm infection.

30. Contd.......
• Fortification of flour, bread, and infant diet with iron.
• Iron -folate distribution programme for female adolescent and
deworming programme in school.
• Cow’s milk is low in iron, and its iron is poorly absorbed . So
strict avoidance of cow's milk in the first 12 months of life
is essential in preventing iron deficiency anemia.
• Distribution of iron/folate tablets to pregnant women and
lactating mothers through hospital, PHC,HP,ORC and FCHVs.

31. ii)Folic acid deficiency anemia
• Folic acid deficiency is an abnormally low level of folic acid(vit.B9)
results in anemia characterized by red blood cells that are large in
size but few in number.
• Folic acid also known as folacin or folate which is essential for the
maturation of red blood cells.
Causes:
• Not eating enough foods with folic acid, Poor absorption of folic
acid (gastric diseases, intestinal diseases).
• Increased requirement e.g pregnancy, lactation, prematurity,
hemodialysis.
• Excessive alcohol intake

32. Contd...

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

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

35. Contd...
Prevention
• Diet- Good dietary souces of folate are Mushrooms, butter, beans,
green leafy vegetables, broccoli, liver and kidney, wheat germ.
• Multi-vitamin dietary supplements contain folic acid as well as other B
vitamins. E.g. Bal Vitae
• Fortification of rice is common. similarly fortification of flour,wheat,
corn flour, milk which help to reduce the neural tube defect.

36. 3. Minerals deficiency
• It includes:
i)Endemic Goiter(Iodine deficiency disorder)
ii) osteoporosis( calcium deficiency disorder)

37. i) Endemic goiter (Iodine deficiency Disorder)

38. 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.

39. Contd....
Current status of IDD in Nepal
• Currently 95% of households in Nepal are using adequately iodized
salt.
• The proportion of households with iodized salt is lowest in mountain
ecological zone (90%), in Province 6 (85%), and in the lowest wealth
quintile (84%).

40. Contd...
Causes
• Lack of iodine in food ( daily requirement 150 mg for adult, 120mcg
for children 6-12 years)
• Malabsorption
Signs and symptoms
• Duffuse or nodular thyroid enlargement
• feeling difficulty during swallowing.
• difficulty to turn head.

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...
Prevention
 Providing the population with iodized salt and iodised food.
 Even mild deficiency during pregnancy can have effects on delivery
and the developing baby, all pregnant and breastfeeding women should
take a multivitamin containing at least 150 μg iodine per day.
 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 8 million women and 1-2 million
men had osteoporosis.

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

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

49. 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.

50. Contd...
• Other calcium deficit Disorders are:
Tetany characterized by muscle cramps , numbness abd tingling in
limbs.
Rickets:
• Rickets is the softening and weakening of the bones in
children,usually because of an extreme and prolonged vitamin D
deficiency.
• Vitamin D is essential in promoting absorption of calcium and
phosphorus from the gastrointestinal tract which helps to build
strong bones.

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)
• The National Osteoporosis Foundation recommends that
women aged 50 or younger and men 70 or younger should
get 1000mg of calcium/day.Men and women older than
that should get 1200mg daily.

52. Contd....
• IOM dietary Reference recommends intakes for vitamin D are
600IU/day until age 70 and 800 IU/ day for adult age 71 years 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.
• Exposed to sunlight.
• Encourage the family member of child to increase intake of vitamin D
fortified food, dairy product such as milk, yoghurt, cheese etc.

53. 4. Vitamin A deficiency
• Vitamin A is one of a group of fat soluble vitamins that are essential
for life and health.
• It plays a critical role in vision, growth, reproduction, bone and brain
development.
• It is found in animal and plant food. In animal source found as pre
formal vitamin A- Retinol and in plant as pro vitamins - Carotene.
• Requirement:
-900 mcg for adult male
-700 mcg for female

54. Contd.......
Deficiency
Clinical manifestation
A)Occular manifestation
Xeropthalmia
• A leading cause of blindness among children characterized by
abnormal dryness of the conjunctiva and cornea of the eye, with
inflammation , typically associated with vitamin A deficiency.
• People most at risk are children between 6 month to 6 years,
pregnant women, and lactating women.

55. Contd.......
• WHO classification of Xeropthalmia
Night blindness
Conjunctival xerosis
Bitot spot
Corneal xerosis
Keratomalacia
Corneal scar

56. Contd.....
B. Extraoccular Manifestation
• Dry, scaly skin especially over the outer aspect of the limbs, called
follicular hyperkeratosis, toad skin or phrynoderma.
• Hypertrophy or even atrophy of tongue.
• Increase susceptibility to infection due to squamous metaplasia of
respiratory, urinary and vaginal tract epithelium as a result of impaired
immune response.
• Growth failure
• Anorexia

57. Contd..........

58. Prevalence : Nepal National Micronutrient
Status Survey Report 2016
• Vitamin A deficiency prevalence ranged from none in Western and
Far-western region to 7 % each in Central and Eastern region.
• 1 % of children in the Mountain and Hill and 7 % in the Terai
suffered from vitamin A deficiency. Higher prevalence of Vitamin A
deficiency was observed among children with mothers with no
education (14 %).

59. Contd.....
• Vitamin A deficiency among non-pregnant women varied by
ecological region ranging from none in the Mountain to 1 % in Hill
and 5 % in the Terai.
• The proportion of women reporting night blindness increases with
increase age where 1 % among 15-19 years had night blindness and
12 % among 40-49 years had it.

60. 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

61. 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

62. 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

63. 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.)

64. Contd......

65. 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

66. 5) Intestinal Worm Infestation

67. Contd...........
Defination:
• 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.

68. Prevalence – NNMSS Report 2016
• Overall, 12 % children 6-59 months had any worm infestation with
11% having ascaris lumbricoides and around 1% each having
trichuris trichura and hookworm.
• The infestation of any soil transmitted helminth varied by
developmental region and ranged from 16 % in the Far-western
region to 8 % in the Eastern region.
• It also varied by ethnic caste group and ranged from 19 % each
among the Terai Dalit, Newar and Muslim caste groups and 7 %
among the Hill Dalit.

69. Contd......
• Almost 1 in 5 (19 %) nonpregnant women 15-49 years had
worm infestation with 18 % having ascaris lumbricoides,
0.1 % having trichuris trichura, while 0.9 % having
hookworm.
• The range of any worm infestation was 23 % among non-
pregnant women in the Far-western region and eight %
among women in the Eastern region.
• Further it ranged from 34 % among women in the Muslim
caste group to around 9 % among women in the Terai
Brahmin/Chhetri and Terai Janajati groups.

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

71. Contd......
Signs and symptoms
• Gastrointestinal conditions include :
inflammation of the small and large intestine
diarrhea/dysentery
abdominal pain
nausea /vomiting
• Loss of appetite, intestinal blood loss that can often result in anemia
• weight loss, 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
• Any infant with a birth weight of less than 2.5 kg within 1hour of birth
regardless of gestational age.

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.
Present status of LBW
• Among children with a reported birth weight (61%), 12% were of
low birth weight (less than 2.5 kg).
• The percentage of babies with a low birth weight decreases with
increasing mother’s age at birth. The percentage of babies with a
low birth weight is highest (16%) among mothers under age 20,
followed by mothers age 20-34 (11%).

78. Contd......
Preventions
• Advocacy for antenatal check up and counseling at least 4 times
during prenatal period according to MOH policy have been
implemented.
• Make significant lifestyle changes.(avoid smoking, alcohol, strenuous
exercise)
• Keep pre-existing medical illness under control
• Maintain healthy weight gain and good nutrition.
• Control of infection.

79. Preventive measures of Major Nutritinal
problems:
• Health promotion- Provision for early exclusive and extended breast
feeding with adequate complimentary feeding after 6 months of age.
• Specific protection- full coverage of supplementary supplies like
Bal vita, Vit. A capsules, iron and folic acid tablets, iodized
salts,sarvottam pitho etc.
• Early diagnosis and treatment of nutritional deficiencies in high
risks groups with proper assessment and treatment modules.
• Education and counselling on proper nutrition during first five years
of life, pregnant women, adolecents boys and girls.

80. The ongoing government programs include:
• Child growth monitoring for children less than 5 years of
age
• Maternal, Infant and Young children health and nutrition
(MIYCHN)
• Integrated management of acute malnutrition (IMAM)
• Distribution of micronutrient powders (locally branded as
Baal Vita) to children 6-23 months in 15 districts and to
children 6-59 months in select earthquake affected districts

81. Cont…
• School health and nutrition program
• Mass distribution of biannual vitamin A capsule (children 6-59
months) and deworming tablets (children 12-59 months)
• Distribution of iron-folic acid tablets to pregnant and post-partum
women
• Distribution of insecticide treated mosquito nets in malaria endemic
areas
• Multisectoral nutritional programme

82. Contd.....

83. Reference:
• National Nutrition Policy and Strategy retrieved from
http://dohs.gov.np/wp-
content/uploads/chd/Nutrition/Nutrition_Policy_and_Strategy_2004.p
df retrieved on July, 2020.
• Ghimire b.(2011)Textbook of community health nursing, 1st
edition.Heritage publishers and distributors.
• https://en.wikipedia.org/wiki/Intestinal_parasite_infection
• https://en.wikipedia.org/wiki/Osteoporosis
• https://en.wikipedia.org/wiki/Vitamin_A_deficiency
• Data retrieved from NDHS 2016 and NNMSS Report 2016.