Tatalaksana Gizi BurukTatalaksana Gizi BurukDr Brain Gantoro, M.Gizi, SpGKDr Brain Gantoro, M.Gizi, SpGKPEM.PEM. Nutrition Problems in Indonesia Protein Energy Malnutrition (PEM)Iron Deficiency AnaemiaIodine Deficiency (=GAKI)Zinc DeficiencyVitamin A DeficiencyOe!ity"#eoretical frame$or% of &utrition Prolem!."#eoretical frame$or% of &utrition Prolem!. &utrition 'rolem! (ood inta%eInfect Di!ea!e direct cau!e! (ood a)ailaility Mot#er * c#ild+ealt#indirectin #ou!e#old caring!er)ice cau!e!POO, (AMI-. * ED/0A"IO&1main(OOD 2"/(( * 3O4 OPPO,"/&I".'rolem E0O&OMI0 * PO-I"I0 0,I2I2core'rolemTypes of MalnutritionOvernutritionSecondary malnutritionMicronutrient malnutritionProtein Calorie malnutritionOvernutritionToo many calories leading to obesity, diabetes, hypertension and cardiovascular diseaseTransition diets now a consideration of !O due to increase worldwide in chronic disease due to dietary changeOn a global basis "# $ of all deaths attributable to chronic disease are already occurring in developing countriesPublic health implications are staggeringOvernutrition following fetal malnutrition has also been lin%ed to chronic disease ris% in adulthoodSecondary MalnutritionCondition that prevents proper digestion or absorptionOften accompanies and e&acerbates other types of malnutritionCausative conditions'oss of appetite(lteration of normal metabolism during infection)fever !*+)(*,S Prevention of nutrient absorption,iarrheal infection causing changes in -* epithelium,iversion of nutrients to parasitic agents themselves!oo%worms, tapeworms, schistosome wormMalariaChildren with Intestinal Parasites(courtesy of WHO)Prevention of nutrient diversionSanitary waste disposal and clean water important in reducing secondary malnutritionPrevention of transmission of parasites and diarrheal diseases!oo%worm ac.uired by wal%ing barefoot over contaminated soilOther roundworm infections use oral/fecal routeSoap an important factor in nutritional status0ducation of women e&tremely important in this regardMicronutrient Malnutrition,ietary ,e1ciencies of+itamin (*odine*ronOthers2 3inc, vitamins ,, C, and 4sProtein Calorie MalnutritionMore food needed for normal growth, health and activity5arely have protein de1ciency without caloric de1ciency due to the nature of the food supplies e&ception seen with cassava and plantain as staplesRole of calories*nvoluntary use2 breathing, blood circulation, digestion, maintaining muscle tone and body temperaturePhysical activityMental activity6ighting disease-rowthRole of protein 6or building cells that ma%e up muscles, membranes, cartilage and hairCarrying o&ygen7utrient transport(ntibodies0n8ymes needed for most chemical reactions in the body What happens to people when they have inadeuate a!ounts of food and nutrients"Metabolic changesPhysiologic changesPsychological changesMeta#olic Response to Starvation!unger subsides after 9/: days,efecation ceases after :/; daysority of people to =??/"?? ml)day4lood glucose levels drop to :@/A@ mg)d' without clinical signs of hypoglycemia7ausea occurs in about =): from %etone production from body fat brea%downSerum electrolytes do not change5enal conservation occurs promptly5arely see low potassium in prolonged fastMeta#olic Response to Starvation7egative nitrogen balance / =st @/" days =9/=@ grams of nitrogen per day is e&creted in the urine Bbased on =C?? %cal daily needsDS%eletal muscle is cataboli8ed to produce glucose BgluconeogenesisD, using about "@ grams per day of proteinEThis is e.ual to F lb of wet tissue per day(bout =A? gm)day of body fat is also usedMeta#olic Response to Starvation7egative nitrogen balance-radually slows so that at about = monthE9/; grams of nitrogen is loss per dayES%eletal muscle catabolism decrease signi1cantlyG Only for cells that have to have glucoseG Central nervous systemG 5ed blood cellsG hite blood cellsMeta#olic Response to Starvation-radual shift in metabolic fuels6irst glucose is produced from protein brea%down to provide energyThen fat brea%down and metabolism provides %etones for all tissues e&cept C7S, 54C and 4CE4rain will eventually use %etones but red blood cells have no mitochondria, so must use glucoseSerum fatty acid levels increaseSerum albumin is normal until late in starvationProduction of $etonesMeta#olis!Meta#olic Response to Starvation!ormonal changesPlasma insulin decreasesPlasma cortisol and growth hormone stay the same and glucagon increasesThese changes are responsible for the mobili8ation and o&idation of fat storesChanges in sympathetic nervous system and metabolism of thyroid hormone lowers basal metabolic rateMeta#olic Response to Starvationeight loss=st wee% ?H"/=H: %g)day, much of which is salt I water loss(fter =st wee% ?H:/?H@ %g)day4asal Metabolic 5ate I Total 0nergy 0&penditure J in prolonged starvationSee J activity, sleepJ body temperatureProtein Energy Malnutrition di!ea!e 5 clinical condition! cau!ed y energy * 'rotein deficiency1 u!ually accom'anied y deficiency of ot#er nutrient!. Primary 6 7 nutr inta%e 88 7 9uality 5 9uantity of nutr 88 2econdary 6 7 nutr need!5out'ut ::O/"P/"6Infection0#ronic diarr#ea5Mala!or'tion+y'ermetaoli!metc.I&P/"6InfectionPo)ertyOrganic di!.etc.Energy balance: negativeProtein Energy Malnutrition &utr.!tatu! = !'ectrum 6

;t5+t undernutrition normalo)ernutrition= ?= @@= @A= B 7C2D 7A2D DA2D DC2D PEM !e)ere moderate mild o)er$eig#t oe!e7K$a!#ior%or mild7Mara!mu! moderate7M7K !e)ere!u'erClassification PEM1 GOMEZ (1!""# $%&' Mac(arren (1)""# Clinical * laboratory+ ,-e $ellcome ,rust Party (1./#Clinical * ant-ro0ometric ($%1 $aterlo2 (1.+# $%3! $3O (1# Clinical * ant-ro0ometric (Z4score#0la!!ification (;+O1 @???) MEPModerate PEM 2e)ere PEM2ymmetrical oedema77 D(oedematou! malnutrition);5+ 7C8 Z7!core 87A 8 7C Z7!core(