MALNUTRITION IN THE PHILIPPINES

Edgar M. Gerodias, R.N.,ECF,PCM, Hep. B Prec. CAP I, FMD

Joanna Ruth Palermo, R.N., ICF,PBL, AIDS Prec., TB Stage V, FMD

Common Malnutrition Problems in the Philippines

Protein -Energy Malnutrition (PEM) - A lack of energy and protein which results in growth redardation. Iron Deficiency Anemia (IDA) - A deficiency in iron wherein hemoglobin concentration is below the normal level which results in short attention span, reduced ability to learn and irritability.

Common Malnutrition Problems in the Philippines

Vitamin A Deficiency (VAD) - Lack of vitamin A that may result to xeropthalmia (dryness of the eye), nightblindness (inability to see in dim light) eyes sensitive to bright light, rough dry skin and membranes of nose and throat , low body resistance to disease, poor growth, and blindness in severe cases. Iodine deficiency Disorders (IDD) - Lack of iodine in the body which results in goiter, mental retardation, deaf-mutism, difficulty in standing or walking normally, and stunting of the limbs.

Common Malnutrition Problems in the Philippines

Vitamin A Deficiency (VAD) - Lack of vitamin A that may result to xeropthalmia (dryness of the eye), nightblindness (inability to see in dim light) eyes sensitive to bright light, rough dry skin and membranes of nose and throat , low body resistance to disease, poor growth, and blindness in severe cases. Iodine deficiency Disorders (IDD) - Lack of iodine in the body which results in goiter, mental retardation, deaf-mutism, difficulty in standing or walking normally, and stunting of the limbs.

Simple Goiter

This condition is characterized by an enlargement of the entire gland, or of one of its two lobes, caused by a deficiency of iodine in the diet.

The Food Fortification Program RA 8976

Republic Act 8976 or the Food Fortification Act of 2000 was signed into law on November 7, 2000 for full implementation on November 7, 2004, to address the problem of micronutrient malnutrition This law is complimentary to RA 8172 or the ASIN Law (An Act Promoting Salt Iodization Nationwide), passed in December 1995, mandating the iodization of all salt sold in the country.

Key Provisions of the Law:

Rule IV: The Philippine Food Fortification Program Sec. 1 The Philippine Food Fortification Program shall cover all imported or locally processed foods or food products for sale or distribution, for human consumption in the Philippines.

Key Provisions of the Law:

Sec. 2 The Philippine Food Fortification Program shall consist of two systems: Voluntary food fortification

Mandatory food fortification for specific food products enumerated in Sec. 6 of RA 8976 and those that may be required by the National Nutrition Council.

Key Provisions of the Law:

Sec. 3 The Implementing Rules and Regulations shall apply to all manufacturers, or producers, importers, traders, tollees, retailers, repackers of food products covered by Sec. 2 of Rule IV of the IRR, as well as restaurants and food service establishments where such food products are encouraged to be served.

Sangkap Pinoy

a term used by the DOH for micronutrients added to food to enhance its nutritional quality These micronutrients are vitamin A, iron and iodine, which cannot be synthesized by the human body, and therefore must be provided through the diet. The intake of these micronutrients through the Filipino diet is often inadequate and is responsible for the micronutrient malnutrition afflicting a majority of the population.

SANGKAP PINOY SEAL

Sangkap Pinoy Seal (SPS) is a mark of DOH recognition of a food product that is properly fortified with either vitamin A, iodine or iron or a combination of these micronutrients and that complies with regulations of the Bureau of Food & Drug (BFAD) of the DOH for quality, labeling and addition of fortificants.

SANGKAP PINOY SEAL Approved Products

NOODLES
No. 1 2 3 4 PRODUCT Dolphin Plus Vermicelli Bihon Excellent Insant Mami FORTIFICANT Iron, Iodine

Chicken, Beef
Goodah Instant Noodles Beef, Chicken Lucky Me Instant Mami

Vitamin A, Iron
Vitamin A, Iron

Chicken, Beef
Pancit Canton, Chicken and egg, Pancit Canton with Kalamansi 5 MAGGI Rich Mami Noodles

Vitamin A, Iron
Vitamin A

Beef, Chicken, Chicken Asado

Vitamin A

NOODLES
6 Maggi Noodle Buddies Buttered Corn, Cheezy Bacon 7 8 9 10 11 Saucy-Mi (Original, Toyomansi, Hot & Spicy, Beef & Onion, and Instant Pancit Palabok Ho-Mi Canton (Classic, Toyomansi, Chili Anghang, and Pinoy Beefsteak) Ho-Mi Instant Mami (Chicken & Garlic, Beef Wanton and Beef Brisket) Nooda Crunch Ready to Eat Noodle (Cheese, Barbeque, and Pizza) Payless Instant Mami Chicken, Beef, Pancit Canton with Chilimansi, Beef Bulalo Vitamin A Vitamin A Vitamin A Vitamin A Vitamin A Vitamin A

SNACK FOODS
12 Granny Goose Tortillas Barbecue, Cheese, Chili, Cheese Party flavored, Corn Snack Vitamin A, Iron & Iodine Vitamin A, Iron & Iodine Vitamin A, Iron & Iodine Vitamin A Vitamin A Vitamin A

13

Granny Goose Nibbles

Cheese, Ham and Cheese, Sizzling Hot Cheese, Corn Snack

14

Granny Goose Kornets

Natural, Barbecue, Cheese

15 16 17 Clover Chips Cheese flavor Oishi Prawn Crackers Oishi Kirei Yummy Flakes

SNACK FOODS
18 19 Oishi Boogyman Vegetable Crunch Oishi Cheese Barrel Vitamin A Vitamin A

20
21 22 23 24 25 26

Oishi Rinbee Cheese Sticks

PeeWee Crunchy BBQ and Pizza flavored snack Cheez-it Tasty Snack Cracker Moby Caramel Puff Moby Chocolate flavored Snack Ri-Chee Crunchy Snacks Milk flavored Kenken Puffcorn Honey Caramel, Chocolate

Vitamin A
Vitamin A, Iron Vitamin A, Iron Vitamin A Vitamin A, Iron Vitamin A Iron

27

Regent Golden Sweet Corn

Iron

SNACK FOODS
28 29 Regent Snack Rice Cracker- Vegetable Flavor Regent Cheese Ball - Cheese flavored snack Iron Iron

30
31 32

Regent Cheese Ring - Cheese flavored snack

Regent Ebisen Prawn Crackers Tomi Corn Chips Chicken, Sweet Corn, Keso

Iron
Iron Vitamin A, Iron

33

Humpy Dumpy Corn Chips Buttered Corn on a cob, Chili & Garlic Mexican Barbecue Royal Cheese

Vitamin A, Iron

SNACK FOODS
34 Fastsnax Corn Snacks Barbecue Fries Cheeseburger 35 Jack 'n Jill Mr. Chips Nacho Cheese, Sweet Corn 36 37 38 Jack 'n Jill Chiz Curls Roller Coaster Potato Rings Cheese flavor Maggi No Cook Rice Porridge Guinataang Monggo, Champorado, Goto, Arroz Caldo Vitamin A, Iron Vitamin A, Iron Vitamin A Vitamin A, Iron Vitamin A

SUPPLEMENTARY FOODS FOR INFANTS

39 Cerelac infant Cereals Rice-soya, Wheat, Wheat-Banana, Rice, Squash & Spinach, Choco-Cereal Vitamin A, Iron & Iodine

40

Gerber Infant Cereals

Brown Rice, Brown Rice with Soya, Mix fruit with soya, Chicken Stew with vegetable and milk, Cream of Chicken with rice & milk, Cream of brown rice with milk, Green mongo

Vitamin A, Iron

41

Nutri-Pak Champorado, Monggo, Beef, Chicken, Raisin-Nuts, Guinataan

Vitamin A

BISCUITS
42 Goya Knick Knacks Coated Biscuit

Chocolate, Milk
Magic Flakes Crackers Sandwich Butter Cream, Chocolate, Orange, Peanut Butter, Artificial Coconut Flavor

Vitamin A, Iron

43

Vitamin A

BREADS
44 Arlee's Power Bread Loaf, Bun Sandwich Bread Egg and Milk, Wheat, Raisin, Sandwich White Vitamin A, Iron

45

Vitamin A

46

Goldilocks Fresh Bake buns and rolls, pandesal, Vitamin A dinner rolls, buns

SANDWICH SPREAD
47 Miracle Whip Spread Sandwich Spread, Salad & Sandwich Spread, Vitamin A Ham and Bacon Spread

48

Miracle Whip All-Purpose Dressing

Regular all-purpose Reduced Fat all-purpose dressing

Vitamin A

49

Star Margarine Classic, Mantekeso, Sweet Blend & Garlic

Vitamin A, Iodine
Vitamin A

50

Dari Crme Margarine Classic, Buttermilk

51

Minola Margarine

Vitamin A

CHEESE PRODUCTS
52 Eden Pasteurized Filled Cheese Spread Vitamin A, Iodine
Vitamin A, Iodine Vitamin A, iodine Vitamin A

53 Kraft Cheddar-Cheese Spread Kraft Chiz Whiz Processed Cheese 54 Spread Cheezee Pasteurized Processed 55 Filled Cheese (in block form and jar)

MILK

Alacta Grow Milk for older 56 kids

Vitamin A, Iron

57

Lactum Powder Regular, Chocolate

Vitamin A, Iron & Iodine

CHOCOLATE DRINKS

58

Ovaltine Chocolate Beverage Vitamin A, Iron, Powder Iodine

FRUIT DRINKS
59 Eight O'Clock Orange Instant Drink Mix Tang Juice Drink Mangga (instant drink mix full sugar & instant drink mix hybrid) Orange, Mandarin-Orange, Pineapple, Grape, Pomelo, Soursop Magnolia Fruit Drinks Mango, Orange, Pineapple Magnolia Ice Tea Drinks lemon
Fruit C Orange Juice Drink

Vitamin A

60

Vitamin A

61

Vitamin A

62
63

Vitamin A
Vitamin A

MEAT AND FISH PRODUCTS

64 65 555 Sardines Regular, Hot Toyo Canned Sardines Vitamin A Vitamin A

66
67 68 69 70

Seorita Canned Sardines

Mekeni Picnic Premium Hotdog Swift Mighty Meaty Hotdog Boomboom Hotdog Regular, Jumbo Purefoods Beefies Hotdog

Vitamin A
Vitamin A Vitamin A Vitamin A Vitamin A

CONDIMENTS

71

Papa Banana Catsup

Vitamin A

DIAMOND SANGKAP PINOY SEAL

In 2004, the Diamond Sangkap Pinoy Seal was introduced to be used solely for staple products mandated for fortification, namely cooking oil, wheat flour, rice, refined sugar and salt. Currently there are 71 products under the Diamond SPS

DIAMOND SANGKAP PINOY SEAL

RICE Iron-Fortified Rice SALT First Choice Iodized Salt Fidel Iodized Salt SUGAR Azukal Pure Cane Sugar Vitamin A Iodine Iodine Iron

GARANTISADONG PAMBATA

a campaign to support various health programs to reduce childhood illnesses and deaths by promoting positive child care behaviors A program of the Department of Health in partnership with the Local Government Units and other government and non-government organizations

GARANTISADONG PAMBATA

GP is done twice a year one week in April and one week in October. Second week of October was designated as "Garantisadong Pambata" week.

GARANTISADONG PAMBATA SERVICES

Giving VIT A capsules (VAC) supplement to all 1259 months old children.

Catch up immmunizations (children who missed the routine immunizations like BCG, OPV, DPT, Measles)
Distribution of iron supplements to infants and pregnant women

GARANTISADONG PAMBATA SERVICES

Promotion of child positive caregiving behaviors like

exclusive breastfeeding of infants from 0-6months old, feeding infant micronutrient rich complementary foods starting 6 months old, use of iodized salt daily, Buying and eating fortified foods, brushing of teeth properly and regularly, letting children play safe toys no smoking in front of preschooler

Marasmus speaks:
I am derived from a word meaning withering or wasting Hence, my physical manifestations are related to my meaning

Kwashiorkor reacts:
I come from the African language meaning the sickness of the older child when the next baby is born. This corresponds to the weaning time of the older child. Therefore, I am the result of the misfortune in the family

Etiology:
Marasmus -due to a diet very low in calories (CHO, fats and protein) -BALANCED STARVATION Kwashiorkor -a deficiency of PROTEIN with adequate or even excess of calories.

Age Incidence:
Marasmus -often the result of unsuccessful BF or insufficient BM supply with little or no other food given. BF may be given on: a. Scheduled b. Per Demand

Marasmus -failure to gain weight leads to loss of weight which leads to emaciation -the face becomes shrunken (old mans face), muscle wasting best seen and felt at the buttocks, thighs , upper arms and scapular region (winged scapula)

Kwashiorkor -usually occurs in a breastfed child until he is weaned gradually into starchy diet, without high protein foods -it is highly probable that deficiencies of other nutrients such as Vit. A, B complex, other minerals and etc. are frequent contributing factors

Clinical Features
Diagnostic Edema-is a cardinal sign (meaning syndrome should not be diagnosed in its absence) -1st detected at the anklegeneralized but more marked on the subcutaneous tissues of the dependent parts such as legs, forearms, penis, scrotum, the lower back, and the lower face (moonface)
1.

-protruding abdomen is due to hypotonia of the abdominal muscles and the intestine and edema of the abdominal wall -muscle wasting can be demonstrated functionally by testing the infants ability to hold his head when gently pulled from a lying to a sitting position

Psychomotor changes -looks miserable and does not smile -motor development is retarded Irritability-psychological trauma d/t maternal withdrawal assoc. with weaning from the breast plays an impt. role

Mental changes -1st 3 years of life is very critical in brain development

2. Common Signs -certain signs though not necessary for diagnosis are common and are usually present singly or in combination a. Hair changes-occasionally serve to indicate the duration of the deficiency: long scanty, pale,pluckability records a prolonged period of deprivation

FLAG SIGN-alternate light and dark bands in the hair indicates alternating periods of protein adequacy and deprivation b. Depigmentation of the skin-there is general lightening of the color of the pigment of the skin due to interference in melanogenesis c. Anemia-nutritional anemia -the hemoglobin content of the blood is lower than the prescribed value for a given age group as a result of deficiency of folic acid or B12 like hookworm infestation

3. Occasional Signs of Kwashiorkor a. Flaky Paint Rash or Enamel Dermatoses -seen in advanced cases; if present it is pathognomonic of the disease -these are patches of skin turn reddish, then purplish with macules and vesicleslater they become dry, peel off, leaving a raw, weeping areas like burns

-seen mostly in the hidden parts of the body like buttocks, groins and trunk. Grave Prognosis: Hepatomegaly-there is usually enlargement of the liver which has a smooth surface and edge Marasmus and Kwashiorkor are assoc. with Vit. A deficiency

Difference Between Marasmus and Kwashiorkor

Marasmus
Muscle Wasting Growth Retardation Apathetic, Quiet Good Appetite Diarrhea

Kwashiorkor
Poor appetite Diarrhea Diffuse depigmentation Flaky-paint/enamel or dermatosis

Moonface Hepatic Enlargement

Kwashiorkor Ching!

Kwashiorkor Triple Treat!

Mr. Marasmus 2007! Bongga!

Pathophysiology of Diarrhea in Malnutrition

Types of Diarrhea: 1. Infectious Diarrhea 2. Non- Infectious Diarrhea Infectious Diarrhea- PCM inflicts profound damage on the GIT particularly the stomach and duodenum.

Infectious Diarrhea-damage further the intestinal pits which has already been weakened by malnutrition Vicious Cycle malnutrition malabsorption diarrhea

2. Non-Infectious Diarrhea Malnutritionatrophy of the intestinal villi which contains the brush borderdissacharide: Lactose) enzyme lactase is secreted in the outermost layer of the brush borderin severe casessucrase and maltase TOTAL DISSACHARIDE INTOLERANCE or malabsorption

Lactose Intolerance -80% of the malnourished child. The intake of regular milk which contains lactose promote and perpetuate diarrhea Intake-1 hour after ingestion, vomiting, abdominal cramps.

How to confirm the dx. Of lactose intolerance: Aspirate watery-portion of the feces and test for -ph, reducing substance pH=<6 acidic Reducing substance= trace to +1

TREATMENT OF PCM

1.

Evaluate the Clinical Condition - determine the presence of any medical emergency, make a clinical diagnosis and treat accordingly.

Ex. Severe dehydration secondary to Infectious Diarrhea

Dehydration: REPLACEMENT 50 ml/kg BW 100ml/kg BW 150ml/kg BW

Mild 5% weight loss Moderate 10% weight loss Severe 15% weight loss

Treat with antibiotics

TREATMENT OF PCM
2. Assess the Nutritional Status - make Nutritional diagnosis 3. Rehabilitate the malnourished child a.) refer to malward if warranted - institute medical and nutritional management b.) home basis - enroll in teaching programs if necessary

TREATMENT OF PCM

4. Institute follow-up measures such as:

Weighing Medical

and nutritional advice Immunization, deworming , sanitation advice, family planning advice food production information

Income- generating activities

HOW TO RE-INTRODUCE MILK FEEDINGS

Since early introduction of full-strength milk which contain lactose will provoke and perpetuate diarrhea, milk feedings should be resumed with extreme caution.

HOW TO RE-INTRODUCE MILK FEEDINGS

After 2-3 days without milk, a very dilute mixture of milk preparation is given : S26 or Bona 1:2 dilution 1 part milk : 2 parts water 1:7 1:6 1:2 (1 2 days) By starting gradually, exacerbation of diarrhea due to lactose intolerance is AVOIDED

HOW TO RE-INTRODUCE MILK FEEDINGS

To increase the caloric content of the dilute milk, one may add sugar (sucrose or pure glucose) provided there is no intolerance to them. For patients who are not tolerant to milk Re-feeding - Give NON LACTOSE FORMULA: Al 110 glucose Isomil and Nutratigen sucrose Sobee - Dextrimaltose Nursoy soya

DIETARY MANAGEMENT OF MALNOURISHED CHILD

- the essence of dietary management is to give the child HIGH CALORIC, HIGH PROTEIN DIET aiming at 100 200 cal/kg BW/ day

4-8 gm protein/kg BW/ day mode: feed frequently

DIETARY MANAGEMENT OF MALNOURISHED CHILD

- Starting them on a full diet will definitely cause a relapse of their diarrhea: NPO for 24 48 hours IVF 50 75 cal/kg/day 2 gm/kg/day of protein No bouts of diarrhea

DIETARY MANAGEMENT OF MALNOURISHED CHILD

Increase 200 mg/day of calories Increase protein 8gm/day

Until weight gain is OPTIMAL (2-4 weeks) Maintain CHO = 110 120 cal/kg/day PROTEIN = 4 8 gm/BW/day

DIETARY MANAGEMENT OF MALNOURISHED CHILD

PROGNOSIS: most of the clinical features and pathologic changes are REVERSIBLE but if SEVERE malnutrition occurs early in life, specially before 6 months of age, when psychomotor and brain development is critical the changes noted maybe IRREVERSIBLE.

A child should never be the result of chance, but should always be the product of a responsible gift of love of its parents to each other and to the Creator Himself