10. Kuliah PEM sm I - 2014

8/12/2019 10. Kuliah PEM sm I - 2014

1/57

8/12/2019 10. Kuliah PEM sm I - 2014

2/57

Malnutrition = imbalance between energyintake and energy expenditure

Under nutrition:

Protein energy

malnutrition / PEM Micro-nutrient deficiency /

hidden hunger

Over nutrition:

obesity

7/1/14igustilanangsidiartha

2

8/12/2019 10. Kuliah PEM sm I - 2014

3/57

3

EXCESS NUTRITION(Energy, fat, cholesterol, carbohydrate, salt, vitamins)

NORMAL NUTRITION

DEFICIENCYPRIMARY(Lack of food, poverty,

ignorance, refusal totake food, fad diet,alcoholism,drug addiction,loneliness etc)

SECONDARY(Malabsorption,

defective metabolism,increased destruction,increased excretion)

TISSUE DEPLETION

BIOCHEMICAL LESION

CLINICAL SIGNS

Blood and urinestudies: reducednutrient levels,abnormal metabolites,enzyme changes)

(Robinson & Weigley, 1984)

Pathophysiology of malnutrition


8/12/2019 10. Kuliah PEM sm I - 2014

4/57

Classification of PEM

Based on the severity of deficiency:

Mild

Moderate .. no specific clinical sign Severe PEM:

Kwashiorkor

Marasmus

Marasmic-Kwashiorkor

!7/1/14igustilanangsidiartha

4

8/12/2019 10. Kuliah PEM sm I - 2014

5/57

Characteristics of

Kwashiorkor and MarasmusKwashiorkor

Age usually over 18 months

Lacks protein-rich foods and othernutrients

Relatively more often in tropicalcountries

wet malnutrition

Any edema means severemalnutrition, child is not fat

Swollen belly from fatty liver, edemaand/or parasites

Marasmus

Usually under 1 year old

Lacks energy-rich foods andother nutrients

Often in dry climate/disaster/war

dry malnutrition

Classified as severe malnutrition

May be swollen belly fromparasites or weak muscle


5

8/12/2019 10. Kuliah PEM sm I - 2014

6/57

Clinical manifestation of Kwashiorkor

Mental changes: irritable,apathies

Flag sign

Moon face

Liver enlargement (fatty liver)

Crazy pavement dermatosis

Potbelly (swollen abdomen)

Edema


6

8/12/2019 10. Kuliah PEM sm I - 2014

7/57

Clinical manifestation of Marasmus

Loss of subcutaneous fat and

muscle wasting

Old man face / monkey face

Piano ribs

Baggy pant

Hungry


7

8/12/2019 10. Kuliah PEM sm I - 2014

8/57

Edema in kwashiorkor

Pitting edema

Pathophysiology:

Low protein intake

hypoalbuminemialow

plasma oncotic pressure

fluids extravasations to

interstitial tissue

Edema most commonly

occurs in the feet


8

8/12/2019 10. Kuliah PEM sm I - 2014

9/57

8/12/2019 10. Kuliah PEM sm I - 2014

10/57

Diagnosis

Based on:

Clinical:

Anamnesis

Physical examination

Anthropometry

Laboratory


10

8/12/2019 10. Kuliah PEM sm I - 2014

11/57

Clinical

Anamnesis:

Dietary history

A detail dietary history mustbe taken

Quality and quantity of foodingested must be assessed

Medical history

Antenatal and perinatalhistory

Family history of atopic

Previous illness andhospitalization

Physical exam

Symptoms and signs ofkwashiorkor and marasmus


11

8/12/2019 10. Kuliah PEM sm I - 2014

12/57

Anthropometry

Commonly use: body weight and body height

Indicator:

Weight for age (W/A) Height for age (H/A)

Weight for height (W/H)

For adolescent (10-18 years) and adult:

Body mass index (BMI): weight (kg) / height (m) square Criteria for severe malnutrition:

Adolescent: BMI for age less than 5thpercentile

Adult: BMI less than 16


12

8/12/2019 10. Kuliah PEM sm I - 2014

13/57

Criteria of diagnosis

Clinical Anthropometry Diagnosis

With edema W/H between -3SD

and -2SD

Kwashiorkor

With edema W/H < -3SD Marasmic-Kwashiorkor

Without edema W/H < -3SD Marasmus


13

8/12/2019 10. Kuliah PEM sm I - 2014

14/57

WHO growth standardchart

For example:

Boy, BW 7 kg,

H 75 cm

anthro < -3SD

Clinical sign

without

edema

Diagnosis

marasmus


14

8/12/2019 10. Kuliah PEM sm I - 2014

15/57

WHO growth standardtable

Boy, 7 kg

and 75 cm

Anthro < -

3SD

Clinical

sign with

edema

Diagnosis:marasmic-

kwashiork

or


15

8/12/2019 10. Kuliah PEM sm I - 2014

16/57

Laboratory

Blood analysis:

white blood cell, electrolytes, sugar,plasma protein

Urine analysis:

culture, ketone

Stool analysis:

for parasites

X-rayfor chest and heart

Tuberculintest for TB


16

8/12/2019 10. Kuliah PEM sm I - 2014

17/57

Management

general principles (ten steps)1. Treat/prevent hypoglycemia

2. Treat/prevent hypothermia

3. Treat/prevent dehydration

4. Correct electrolyte

imbalance

5. Treat/prevent infection

6. Correct micronutrient

deficiencies

7. Start cautious feeding

8. Achieve catch-up growth

9. Provide sensory stimulation

and emotional support

10. Prepare for follow-up after

recovery


17

8/12/2019 10. Kuliah PEM sm I - 2014

18/57

Initial treatment

Hypoglycemia

Blood glucose < 3 mmol/L or 5g/kg of body weight/d x 3 days

Most important determinant of recovery:

Amount of energy consumed: calories, protein,

micronutrients (K, Mg, I, Zn)


23

8/12/2019 10. Kuliah PEM sm I - 2014

24/57

Rehabilitation

Parental teaching

Correct feeding/food preparation practices

Stimulation, play, hygiene Treatment diarrhea, infections

When to seek medical care

Preparation for outpatient care

Reintegration into family & community

Prevent malnutrition recurrence


24

8/12/2019 10. Kuliah PEM sm I - 2014

25/57

8/12/2019 10. Kuliah PEM sm I - 2014

26/57

Criteria for outpatient care

Child

W/H reached -1SD

Eating appropriate amount of diet that mother can prepare at home

Gaining weight at normal rate

Vitamin & mineral deficiency treated/corrected Infections treated

Full immunizations

Mother

Able & willing to care for child

Knows proper food preparation Knows appropriate toys & play for child

Knows home treatment fever, diarrhea, respiratory tract infection

Health worker

Able to ensure follow up child & support for mother


26

8/12/2019 10. Kuliah PEM sm I - 2014

27/57

Follow up

Child usually remains stunted

Prevention of recurrence severe malnutrition

Follow up: 1,2,4 weeks, then 3 & 6 mos, then 2x/y

W/H no less than -1SD

Assess overall health, feeding, play

Immunizations, treatments, vitamin/minerals

Record progress


27

8/12/2019 10. Kuliah PEM sm I - 2014

28/57

Time frame for management


28

8/12/2019 10. Kuliah PEM sm I - 2014

29/57

Childhood Obesity

I Gusti Lanang SidiarthaSpesialis Anak Konsultan Nutrisi dan Penyakit Metabolik

Bagian Ilmu Kesehatan Anak FK UNUD/RSUP Sanglah

8/12/2019 10. Kuliah PEM sm I - 2014

30/57

Definition

Childhood Obesity is a condition where excess body

fat negatively affects a childs health or wellbeing.

Obesity results from excessive caloric intake,decreased energy expenditure and/or from a

combination of the two.


30

8/12/2019 10. Kuliah PEM sm I - 2014

31/57

Criteria for obesity based on BMI (WHO)

BMI (Body Mass Index) = Weight (kg) / Height (m)2

Underweight : < 18.5

Healthy weight : 18.524.9 Overweight (Grade I obesity) : 25.029.9

Obese (Grade II) : 30.039.9

Morbidly obese (Grade III) : 40 or above

Super obese (Grade IV) : > 50

for Adult


31

8/12/2019 10. Kuliah PEM sm I - 2014

32/57

forchildren and adolescence

Percentile of BMI-for-age and

gender

Underweight : < P-5

Healthy weight : P-5P-85

Overweight : P-85P-95

Obese : P-95P-97

Super obese : > P-97


32

8/12/2019 10. Kuliah PEM sm I - 2014

33/57

Classifications

Nutritional:

High

No mental retardation

No dismorphic

Normal bone age

Non-nutritional:

Endocrine: short

Hypothyroidism

Growth hormone deficiency

Genetic:

Prader-Willi

Turner

CNS conditions: hypothalamicdamage

Medications:

Glucocorticoids

Phenothiazine

Lithium, etc.


33

8/12/2019 10. Kuliah PEM sm I - 2014

34/57

Etiology

Heterogeneous and multifactorial

Environmental

Psychosocial

Genetic


34

8/12/2019 10. Kuliah PEM sm I - 2014

35/57

Genetics vs. Environment

Weight of adopted children correlate

better with biological parents

BMI of identical twins reared apart =together

Monozygotic twins more similar in fat

deposition and weight than dizygotic

twins.


35

8/12/2019 10. Kuliah PEM sm I - 2014

36/57

Environmental factors: Increased energy input

High caloric-density food

Supersized portions

Eating out

Working parents

Advertising


36

37

8/12/2019 10. Kuliah PEM sm I - 2014

37/57

Environmental factors: decreased energyexpenditure

TV: prevalence of obesity increases

2%/hour of viewing

Computers

Transportation

Inadequate safe areas for physical

activity

Sedentary lifestyle


37

38

8/12/2019 10. Kuliah PEM sm I - 2014

38/57

Complications

Diabetes type 2

Hypertension and heart

disease

Neurologic complications

Respiratory disease

Orthopedic condition

Psychosocial disorders

Hyperlipidemia

GI manifestations

Menstrual disorders


38

39

8/12/2019 10. Kuliah PEM sm I - 2014

39/57

Metabolic syndrome

Clustering of CV risk factors

related to insulin resistance

Including: Insulin resistance

Dyslipidemia

Hypertension

Obesity


39

40

8/12/2019 10. Kuliah PEM sm I - 2014

40/57

Obesity: respiratory diseases

Causes both restrictive and

obstructive disease

Sleep apnea 7-33%

Asthma ~ 30%


40

41

8/12/2019 10. Kuliah PEM sm I - 2014

41/57

Obesity: GI manifestations

Steatohepatitis

Fatty infiltration of the liver

Abnormal insulin metabolism

10% obese teens increased LFT

Can progress to fibrosis and cirrhosis

Gall bladder disease

Increased cholesterol excretion ~30% of gallstones in children


41

42

8/12/2019 10. Kuliah PEM sm I - 2014

42/57

Obesity: orthopedic conditions

Genu varum/valgus deformities

Blount disease

Bowing of legs

Tibial torsion

50-80% obese

Slipped capital femoral epiphysis (SCFE)

Femoral epiphysis slips off of metaphysis

60% obese

Associated with hypothyroidism,

hypogonadism & GH deficiency


42

43

8/12/2019 10. Kuliah PEM sm I - 2014

43/57

Neurologic complications: Pseudotumor cerebri

Increased ICP

Vomiting, diplopia, blurred vision

30-80% obese


43

8/12/2019 10. Kuliah PEM sm I - 2014

44/57

45

8/12/2019 10. Kuliah PEM sm I - 2014

45/57

Obesity: psychological disorders

Difficult to quantitate

Stigmatization

Low self esteem

Depression

Discrimination


45

46

8/12/2019 10. Kuliah PEM sm I - 2014

46/57

Management

Prevention is the Key and prevention easier than cure

Team work

Individualized goal of weight loss; lifelong weight control

Components:

Education & motivation

Diet modification: decrease energy intake

Increased activity: increase energy expenditure

Parents are role models

Medicines & surgery


46

47

8/12/2019 10. Kuliah PEM sm I - 2014

47/57

Education

Need to educate family

Parents impose their lifestyle

+ family support improves weight loss


47

48

8/12/2019 10. Kuliah PEM sm I - 2014

48/57

Dietary therapy

Weight loss determined by # calories consumed

relative to expended

Healthy diet:

55% carbohydrates

30% fat

15% protein

Avoid fad diets


48

49

8/12/2019 10. Kuliah PEM sm I - 2014

49/57

Dietary therapy

Fat vs Carbs

Carb converted to fat 30% of energy consumed

Little energy used in absorbing fats

Glycemic Index

High carb diets

Leads to increased serum insulin

Promotes excessive food intake


49

50

8/12/2019 10. Kuliah PEM sm I - 2014

50/57

Physical activity

Physical activity essential for weight loss

Physical activity decreases 50% during adolescence

(girls > boys)


51

8/12/2019 10. Kuliah PEM sm I - 2014

51/57

Pharmacotherapy

Anti-obesity drugs not approved for pediatrics

None of drugs tested for:

Long term use Pediatric age groups

Drug options:

Appetite suppressants

Serotonin agonists

Inhibitors of fat absorption

Anti-hyperglycemic agents


8/12/2019 10. Kuliah PEM sm I - 2014

52/57

53

8/12/2019 10. Kuliah PEM sm I - 2014

53/57

Bariatric surgery or weight loss surgery

Works in three basic ways:

1. Restricting how much food

the stomach can hold at anytime

2. Preventing the digestive

system from absorbing all

the nutrition in the food

3. Combination of these two

ways


54

8/12/2019 10. Kuliah PEM sm I - 2014

54/57

Surgery indications

BMI greater than 40 (obese

class III)

BMI of 35-40 for people withheart disease, diabetes, high

cholesterol, or obstructive

sleep apnea


55

8/12/2019 10. Kuliah PEM sm I - 2014

55/57

Types of weight loss surgery

Gastric banding and

gastroplasty (stomach

stapling): restrictive or

decrease the stomach sizefrom about six cups to one.

Gastric bypass (Roux-en-Y)

: reduces the size of the

stomach and prevent theabsorption of calories in the

small intestine.


56

8/12/2019 10. Kuliah PEM sm I - 2014

56/57

Risks of bariatric surgery

The risk of dying is less than 1%

Serious complications are rare

The risk including:

Vomiting from eating more than the stomach pouch canhold

The band disintegrating

Band and staples fall apart, reversing the procedure

Stomach contents leaking into the abdomen

Nutritional deficiencies and health problems: reducedabsorption of vitamin B-12, iron, and calcium.


57

8/12/2019 10. Kuliah PEM sm I - 2014

57/57

Thanks for your attention

Any question ?

Documents

10. Kuliah PEM sm I - 2014