Malnutrition

DEFINITIONS

Malnutrition can occur because of lack of nutrition (undernutrisi) or because of excess nutrients (overnutrisi).
Both are caused by an imbalance between the needs of the body and the intake of essential nutrients.

The development of malnutrition through 4 stages:

1. Changes in levels of nutrients in the blood and tissue
2. Changes in enzyme levels
3. Abnormalities in organ function and tissue
4. Emergence of symptoms and death.

Body's need for nutrients increases in some specific life stages, namely:
- In infancy, early childhood, youth
- During pregnancy
- During lactation.

At older ages, the need for more nutrients is low, but the ability to absorb gizipun often decreases. Therefore, the risk of malnutrition during this period is greater and also in the community with a low economic level.

NUTRITIONAL STATUS ASSESSMENT

To assess the nutritional status of a person, ask about food and health issues, conducted a physical examination and certain laboratory tests.
Blood tests performed on the measurement of levels of nutrients and materials are dependent on levels of nutrients (eg hemoglogbin, thyroid hormone and transferrin).

To determine a history of eating someone, ask what foods eaten in the last 24 hours and types of food such as what is usually eaten. Made notes about the list of foods eaten for 3 days.
During the physical examination, observe the overall appearance and behavior, as well as body fat distribution and organ function.

Lack of nutrients can cause various health problems. For example, gastric bleeding may cause anemia due to iron deficiency.
Someone who has been treated with high doses of vitamin A for acne, can experience headaches and double vision as a result of toxicity of vitamin A.

Various body systems can be affected by nutritional disorders:

1. The nervous system can be affected by a deficiency of niacin (pellagra), beri-beri, lack or excess of vitamin B6 (piridoksin) and vitamin B12 deficiency
2. Tasting and can be influenced pembauan zinc deficiency
3. Cardiovascular system can be influenced by:
- Beri-beri
- Obesity (obesity)
- High-fat foods causes hiperkolesterolemi and coronary heart disease
- Foods rich in salt can cause high blood pressure
4. Gastrointestinal tract affected by pellagra, lack of folic acid and lots of drinking alcohol
5. The mouth (tongue, lips, gums and mucous membranes) is affected by lack of vitamin B and vitamin C
6. Enlargement of the thyroid gland caused by iodine deficiency
7. Bleeding tendencies and symptoms such as rashes on the skin red, dry skin and swelling due to fluid retention (edema) may occur in vitamin K deficiency, deficiency of vitamin C, vitamin A deficiency and beri-beri
8. Bones and joints can be affected ricketsia, osteomalacia, osteoporosis and lack of vitamin C.

Nutritional status of a person can be determined in several ways, namely:

1. Measuring height and weight, then compared with the standard tables.
2. Calculate body mass index (BMI, Body Mass Index), ie weight (in kilograms) divided by height (in meters).
Body mass index between 20-50 is considered normal for men and women.
3. Measuring skinfold thickness.
Fold of skin on the back of the upper arm (triceps fold) pulled away from the arm, so that the layer of fat under the skin can be measured, usually by using calipers (KALIPER).
The number of fat under the skin is 50% of body fat.
Normal fat folds is approximately 1.25 cm in men and about 2.5 cm in women.
4. Nutritional status can also be obtained by measuring the circumference of the upper arm to estimate the amount of skeletal muscle in the body (Lean Body Mass, the body mass of lean).

X-rays can help determine bone density and condition of the heart and lungs, can also find digestive tract disorders caused by malnutrition.

In severe malnutrition, calculate examination complete blood cell types as well as blood tests and urine to measure levels of vitamins, minerals and waste metabolites such as urea.

Examination of skin can also be done to assess certain types of immunity.

RISK FACTORS

Infants and children are the greatest risk for experiencing malnutrition because they require large amounts of calories and nutrients for growth and development.
They can experience iron deficiency, folic acid, vitamin C and copper because of inadequate food.
Lack of protein, calories and other nutrients can lead to protein-calorie deficiency (CTF), which is a form of severe malnutrition, which will inhibit the growth and development.

The tendency to bleeding in the newborn (hemorrhagic disease in newborns), caused by a deficiency of vitamin K, and can be fatal.

In line with the growth, the food needs of children will increase, because their growth rate also increases.

In pregnant women or lactating women, increased nutrient requirements to prevent malnutrition in infants and themselves.
Given folic acid during pregnancy to reduce the risk of developmental disorders of the brain or spine (spina bifida) in infants.
Although the women users of the Pill are more likely to suffer from folic acid deficiency, there is no evidence that the baby will suffer from folic acid deficiency.

Babies come from mothers who drank alcohol would be impaired physical and mental balance (fetal alcohol syndrome), due to alcohol abuse and malnutrition causes, may affect fetal growth.

Infants who received breast milk exclusively, may have vitamin B12 deficiency, if the mother is a vegetarian.

At the parents can occur from malnutrition due to:
- Feel lonely
- Physical and mental decline that began
- Less moving
- Chronic disease.
Absorption of nutrients in the tuapun have decreased, allowing occur various problems such as anemia due to iron deficiency, osteoporosis and osteomalacia.

The aging process is accompanied by loss of muscle mass that has nothing to do with disease or lack of food. Decreased muscle mass is about 11 kg for men and 5.5 kg for women.
The calculation is based on:
- Reduced speed of the process of metabolism
- Reduction in total body weight and
- Increase in body fat of about 20-30% in men and 27-40% in women.
Because of these changes and because of reduced physical activity, older people require fewer calories and protein.

In people who have a chronic disease that causes malabsorbsi, tend to have difficulty in absorbing vitamins that are fat soluble (A, D, E and K), vitamin B12, calcium and iron.
Liver disease disrupt the storage of vitamin A and B12, and affect the metabolism of protein and glucose (a type of sugar).
Patients with kidney disease tend to have deficiencies of protein, iron and vitamin D.

Most vegetarians are ovo-vegetarian lakto, ie they do not consume meat and fish, but consume eggs and dairy products. The only risk of such a diet is iron deficiency.
Ovo-vegetarians tend lakto live longer and have a smaller risk for chronic disease than people who eat meat.
But their health better, also the result of avoiding the use of alcohol and tobacco, and they tend to exercise regularly.
Vegetarians who consume no animal products (vegans), have an increased risk for vitamin B12 deficiency. Oriental-style food and other fermented foods (eg fish oil), can meet the need for vitamin B12.

- Many foods can increase the stated health or lose weight. But the restrictions are very strict diet, based on the science of nutrition is not healthy, because it may cause: Lack of vitamins, minerals and protein
- Disturbance of heart, kidney and metabolic
- Death.
Calorie intake is very low (less than 400 calories / day) can not maintain health in a long time.

Addicted to alcohol or drugs can damage one's lifestyle so that adequate food intake are not met, and there is interference in the absorption and metabolism of nutrients.
Alcoholism is a form of drug addiction are most commonly found, which gives a serious effect on one's nutritional status. Consumption of alcohol in a very large amount is a poison that will destroy the network, especially in the digestive tract, liver, pancreas and nervous system (including the brain).
Alcoholism is the most common cause of deficiency of vitamin B1 (thiamine) in the USA and also cause a deficiency of magnesium, iron and other vitamins.

Feeding

If the substance can not be given food by mouth, can be given through a tube is inserted into the digestive tract (enteral nutrition) or intravenously (parenteral nutrition).
Both ways can be used to provide food to people who do not want or can not eat, or not able to digest and absorb nutrients.

Through Feeding tube

Penberian food through the tube is used in various circumstances, including the healing of burns and gastrointestinal inflammatory diseases.

A thin plastic tube (pipe nasogastrik) is inserted through the nose, down the esophagus until it reaches the stomach or small intestine.
If the hose should be used for a long time, can be directly inserted through a small incision in the abdominal wall, into the stomach or small intestine.

Fluid that is inserted through this tube contains nutrients needed such as proteins, carbohydrates, fats, vitamins and minerals. 2-45% of the total caloric needs, come from fat.

Problems arising from feeding through the tube is very rare and not too serious:
- In some patients there diarrhea and upset stomach
- Throat can become irritated and inflamed
- Food can be inhaled into the lungs. Is a serious complication, but it rarely happens. Can be prevented by placing the head on a higher position to reduce regurgitation or by entering the liquid slowly.

In Intravenous Feeding

Intravenous feeding is used when patients can not receive a sufficient number of food through the pipe nasogastrik.
Patients who get food through intravenous are:
- Patients who experience severe malnutrition and will undergo surgery, radiation therapy or chemotherapy
- Patients with severe burns
- Paralysis digestive tract
- Diarrhea or persistent vomiting.

Provision of food through an IV tube is able to supply some of the required nutrients or total patients (total parenteral nutrition).
There are several fluids that can be given and can be modified for patients with kidney or liver disease.

Total parenteral nutrition intravenous tubes require a larger (catheter). Because it is used veins (vein) larger, such as the subclavian vein.

Someone who undergo total parenteral nutrition monitored closely for changes in body weight, urinary excretion of water and signs of infection.
When blood sugar levels become too high, can be added to the liquid insulin is given.

Infection is a risk because the catheter is usually used for a long time and the fluid that flows in it has a high sugar content, where bacteria can grow easily.

Total parenteral nutrition can cause other complications:
- If too many calories, especially fat, the liver can be enlarged.
- Excessive fat in the veins can cause back pain, fever, chills, nausea and reduced the number of platelets. But this happens in less than 3% of patients.
- Long-term use can cause bone pain.

FAMINE

Hunger can be the result of:
- Fasting
- Anorexia nervosa
- Diseases of the digestive tract weight
- Stroke
- Koma,

Body against hunger by solving its own network and use it as a source of calories. As a result, the internal organs and muscle damage is progressive and body fat (adipose tissue) is running low.

An adult can lose half the weight and the children more than half the weight.
Losing weight is proportional to the most occur in the liver and intestines, and in the heart and kidneys, and at least in the nervous system.

The most obvious signs of weight loss is a loss of fat in the body normally stores fat, reduced muscle size and prominence of the bones.

The skin becomes thin, dry, inelastic, pale and cold.

The hair becomes dry, rarely / thin and easy to fall off.

Most body systems will be affected and a total starvation could be fatal in 8-12 weeks.

How Hunger Affects Body Systems.

System	Effect
Digestive System	-- Reduce gastric acid production -- Oft & Diarrhea can be fatal
Cardiovascular System (Heart & Blood Vessel)	-- Reduce the size & amount of blood the heart pumped reply, slowing the heart rate & blood pressure -- Eventually cause heart failure
Respiratory System	-- Breathing slows, reducing lung capacity -- Eventually causing respiratory failure
Reproductive System	-- Reducing the size of the ovaries (in women) & testicles (in men) -- Loss of sexual desire (libido) -- Cessation of the menstrual cycle
Nervous System	Apathy & easily offended, even though intellectual undisturbed
Muscular system (Muscle)	Low ability to conduct training or work, because the decrease in muscle size & strength
Hematologis System (Blood)	Anemia
Metabolic System	-- Depression in body temperature (hypothermia), often causing death -- The collection of fluid in the skin, mainly due to the loss of fat under the skin
Immune System	Disruption of the ability to fight infection & wound healing

Refunds food intake as usual takes time depending on how long the person is experiencing severe hunger and how the organs are affected by hunger.
Diminished digestive tract during starvation, and can not work the first time direct. Liquids such as juice, milk and soup are recommended for patients who can eat by mouth for the first time to eat.

After several days of liquid diet can be replaced with a more solid foods and calories gradually increased from 500 calories / day.
Usually the crushed solids are given in small portions at a time to avoid diarrhea.

Patients should be increased 3 or 4 pounds a week until normal weight is reached.
In the beginning some people must get their food through the pipe nasogastrik.
Intravenously feeding is required if the patient experienced persistent malabsorption and diarrhea.

LESS CALORIE PROTEIN

Among the severe hunger and adequate nutrition, there are varying levels of inadequate nutrition, such as the Less Calories Protein (CTF), which is the cause of death in children in developing countries.

Rapid growth, infection, injury or chronic illness, may increase the need for nutrients, especially in infants and children who previously had suffered from malnutrition.

Less calories, protein, calories consumption caused by an inadequate, which resulted in kekurangn protein and mikronutrisi (nutrients required in small amounts, such as vitamins and minerals).

There are three types of CTF, namely:

1. CTF Dry: if someone looked thin and dehydrated
2. CTF Wet: if someone looks swollen because of fluid retention
3. CTF Intermediate: if someone is in dry conditions between the CTF and the CTF wet.

Dry CTF called marasmus, is the result of the almost complete starvation.
A child who has marasmus, get very little food, often because the mother can not give milk.
Her body was very thin due to loss of muscle and body fat.
Almost always accompanied by the occurrence of infection.
If the child has an injury or infection is widespread, prognosanya bad and can be fatal.

Wet CTF called kwashiorkor, which in Afrikaans means 'first child, second child'.
The term is based on the observation that the first child suffering from kwashiorkor when the second child was born and shifts the first child of breast-feeding mother. The first child has been weaned is getting the amount of food that fewer nutrients than breast milk, so do not grow and develop.
Protein deficiency in kwashiorkor are usually more obvious than the lack of calories, which resulted in:
- Fluid retention (edema)
- Skin diseases
- Changes in hair color.
Children who suffer from kwashiorkor usually have undergone weaning, so he was bigger than a child suffering from marasmus.

CTF medium-marasmik called kwashiorkor.
Children who suffer from the CTF is holding some liquid and have more body fat compared with people with marasmus.

Kwashiorkor is more rare and usually occurs in the form of marasmik-kwashiorkor.
Kwashiorkor tends to occur in countries where the fibers and food used for weaning babies (eg potato tubers, cassava, rice, potatoes and bananas), which contains slightly more protein and very starchy, ie, in rural Africa, Caribbean, Pacific islands and Southeast Asia.

In marasmus, as happened in the starvation, the body destroy / break its own network to be used as a calorie:
- Reserve carbohydrates stored in the liver been spent
- The protein in the muscle is split to produce new proteins
- Reserve the fat broken down to produce a calorie.
As a result the whole body is going through depreciation.

In kwashiorkor, the body is only able to produce a new protein. Consequently protein levels in the blood is reduced, causing fluid build up in the arms and legs as edema.
Cholesterol levels also decreased and occurred fatty liver enlarged (the collection of excessive fat in the liver cells).

Lack of protein will disturb:
- Growth of body
- Immune system
- The ability to repair tissue damage
- Production of enzymes and hormones.

In marasmus and kwashiorkor frequent diarrhea.

The development of behavior in children who suffer from severe malnutrition is very slow and mental retardation can occur.
Usually, children who suffer from marasmus looks more pain than older children suffering from kwashiorkor.

A baby who suffered from CTF usually get their food through an IV during the first 24-48 hours in the hospital.

Antibiotics are usually given through intravenous fluids, in babies who have severe infections.

When was possible, the formula given by mouth.

The number of calories provided increased gradually, so that the babies at the hospital has 6,5-7 kg weight, will show your weight by 3.5 kg in 12 weeks.

Prognosis

More than 40% of children who suffer from CTF died.
Deaths that occurred on the first day of treatment is usually caused by:
- Electrolyte disturbances
- Infection
- Hypothermia (body temperature is very low)
- Heart failure.

Trance (stupor), jaundice (yellow fever), skin bleeding, low blood sodium levels and persistent diarrhea is a bad sign.
A good sign is the loss of apathy, edema, and increased appetite.

In kwashiorkor healing go faster.

Long-term effects of malnutrition in childhood is unknown.
If the children are treated properly, the immune system and the heart will heal perfectly. But in some children, the absorption of nutrients in the gut remains impaired.

Weighs experienced mental disorders associated with the length of children suffer from malnutrition, weight and age of child malnutrition at the time suffered from malnutrition.
Mental retardation is mild to stay until the child reaches school age, and maybe more.

CAUSE

- Malnutrition is a condition where a lack of nutrients ensensial, which may be caused by a lack of intake due to bad food or poor absorption from the intestine (malabsorbsi)
- Use of excess of nutrients by the body
- Loss of nutrients through diarrhea abnormal, bleeding, kidney failure or excessive sweating.
Excess nutrients is a situation where there is excess of nutrients essential.
This can happen because:

1. Overeating
2. The use of vitamins or other dietary supplements excessive
3. Lack of activity.

People who have a risk of nutritional deficiency:

1. Babies and small children bad appetite
2. Teenagers in a period of rapid growth
3. Pregnant women and lactating women
4. Parents
5. Patients with chronic diseases of the digestive tract, liver or kidneys, especially if weight loss occurs up to 10-15%
6. People who diet for long-term
7. Vegetarian
8. Patients with drug or alcohol dependence is not enough to eat
9. AIDS sufferers
10. Use of drugs that affect appetite, absorption of nutrients or expenditure
11. People with anorexia nervosa
12. Patients with a long fever, hyperthyroidism, burns or cancer.

People who have experienced excess risks of nutrition:

1. Children and adults who eat a lot but do not do sports
2. Excess weight> 20%
3. Foods containing high fat and high salt
4. People who consume nicotine acid (niacin) high dose, for treating hypercholesterolemia
5. Women who take vitamin B6 (piridoksin) high doses, to treat premenstrual syndrome
6. People who take high doses of vitamin A, to treat skin diseases
7. People who take iron or other minerals in high doses, without a prescription from a doctor.