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Session Three: Malnourishment in Children

 Dr Alex Tang

 
1.      Good Nutrition

a.       Food Guide Pyramid

b.      MyPyramid Food Guide Pyramid (2005) USDA

                                                   i.      Grains (orange)

                                                 ii.      Vegetables (green)

                                                iii.      Fruits (red)

                                               iv.      Milk (blue)

                                                 v.      Meat and beans (purple)

                                               vi.      Oils

                                              vii.      Discretionary calories

                                            viii.      Exercise

MyPyramid was released in April 2005. MyPyramid retains all the food groups from the original Pyramid, but it also includes a graphic representation of physical activity—an important additional recommendation for a healthy way of life. The recommendation are in four overarching themes.

(1) Variety.

      Eat foods from all food groups and subgroups

(2) Proportionality

         In the Dietary Guidelines adopting a “balanced eating pattern, such as the USDA food guide* or the DASH eating plan*” is recommended.  Additional recommendations encourage consumption of more fruits, vegetables, whole grains, and fat-free or low fat milk products than are now consumed by most Americans.

         In MyPyramid the proportionality message is portrayed by the varying thickness of the food group bands. These widths suggest that a person should choose more from the bigger wedges and vice versa.  However, these bands do not suggest exact proportions.  They are just a general guide for proportions of food one should consume.  The actual amounts that are recommended vary by age, sex, and activity level. 

(3) Moderation

         In the Dietary Guidelines, choosing foods that “limit intake of saturated and trans fats”, choosing meat, poultry, beans, and milk products that are “lean, low-fat, or fat-free,” and selecting “foods and beverages with little added sugars” is recommended.

         In MyPyramid, moderation is depicted by the narrowing of the bands from bottom to top. Foods within a food group can vary in the amounts of solid fats and added sugars they contain. The bottom, wider portion of each band represents the foods in the most nutrient dense form—that is, containing little or no solid fats and added sugars.  The top, narrow end of each band represents foods within the group with more solid fat and added sugars. For example, an apple would be at the bottom of the fruit band, sweetened applesauce higher in the band, and apple pie towards the top.

(4) Physical Activity

         In the Dietary Guidelines, regular physical activity is recommended to promote health and mental well-being.

         In MyPyramid, steps up the side of the Pyramid and a person actively climbing the steps are included to represent the advice to engage in regular physical activity. Physical activity is important to every day living and can improve one’s health by reducing the risks for many diseases.

Two additional messages on the MyPyramid graphic are personalization and gradual improvement.  These two concepts were included to foster behavioral change among consumers and encourage implementation of the new food guidance system. 

         Personalization is depicted by the name “MyPyramid” and by the person climbing the steps.  In addition, the web site allows people to find their own personal recommended food intake amounts.  Calorie and nutrient needs differ so a personalized food intake pattern based on age/gender and physical activity can be obtained on MyPyramid.gov.  MyPyramid.gov allows a person to relate the food guidance to their own lifestyle for improved health.

         Gradual improvement is portrayed by the slogan “steps to the healthier you,” which suggests changes can be made in stages or steps over time.  These changes include awareness of what one is actually eating, a reminder to vary food intake and to exercise.  No matter how small the step in the right direction, gradual improvement to one’s health can be made.

 

2.      Assessment of nutritional status

a.      What is malnutrition?

World Health Organisation (WHO)

 

“the cellular imbalance between supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions.”

 

b.      Nutritional assessment

                                                   i.      Anthropometry

1.      weight

2.      height

3.      mid-arm circumference

4.      skinfold thickness

                                                 ii.      Laboratory

1.      low plasma albumin

2.      low concentration of specific minerals and vitamins

                                                iii.      Food Intake

1.      dietary recall

2.      dietary diary

                                               iv.      Immunodeficiency

1.      low lymphocyte count

2.      impaired cell-mediated immunity

 

3.      Characteristics of malnourished child

a.      General

                                                   i.      Less active

                                                 ii.      Apathetic

                                                iii.      Delayed wound healing

                                               iv.      High mortality from illnesses

b.      Severe protein-energy malnutrition

                                                  i.      Marasmus

1.      weight less than 60% of mean for age

2.      wasted, wizened appearance

3.      no edema

4.      withdrawn, apathetic

                                                ii.      Kwashiorkor

1.      body weight is 60-80% of mean

2.      generalised edema present

3.      thickened skin

4.      distended abdomen and enlarged liver

5.      angular stomatitis

6.      hair-sparse and depigmented

7.      diarrhea

8.      hypothermia

c.       Micronutrient deficiencies

                                                   i.      Iron-fatigue, anemia, pallor

                                                 ii.      Iodine-goitre, developmental delay

                                                iii.      Vit D-poor growth, rickets, low calcium

 

4.      Ways to overcome malnourishment in children

a.      Urgent for severe protein-energy malnutrition

                                                   i.      Correction of dehydration, electrolyte imbalance and infection

                                                 ii.      Treatment of hypothermia

                                                iii.      Feeding 2 to 4 hourly

b.      General measures

                                                   i.      Dietary

1.      Three meals and two snacks each day

2.      increase number and variety of food offered

3.      increase energy density of usual food (add cheese, margarine, cream etc)

                                                 ii.      Behavioural

1.      have regular meal as a family

2.      praise when food is eaten

3.      gently encourage child to eat but avoid conflict

4.      never force-feed

5.      Obesity

a.       BMI = weight in kg/height in metre²

                                                   i.      BMI >95th percentile predicts a persistence of obesity into adulthood and abnormalities in blood lipids

                                                 ii.      BMI >91st percentile is overweight.

b.      Complications

                                                   i.      Bow legs, abnormal foot structure

                                                 ii.      Hypoventilation syndrome (daytime somnolence, sleep apnea, snoring, hypercapnia, heart failure)

                                                iii.      Gall bladder disease

                                               iv.      Diabetes mellitus

                                                 v.      Hypertension

                                               vi.      Abnormal blood lipids

                                              vii.      Low self esteem

                                            viii.      Body dissatisfaction

c.       Treatment

                                                   i.      Weight maintenance

                                                 ii.      Healthier eating

                                                iii.      Increase in habitual physical activity to 30-60 minutes of moderate or vigorous physical activity per day

                                               iv.      Reduction in physical inactivity (watching tv, etc) to less than average of 2 hours per day.

6.      Reflection

 

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