Kewaspadaan gizi

buruk
Dr. joko wahyu wibowo MKes
Immunocompetence in protein
energy malnutrition
Reduced delayed cutaneus hypersensitivity
respons to commons microbial antigens
Decreased number of thymus dependent T-
lymphocytes and CD-4 cells
Reduced bactericidal capacity of neutrophils
Lower mucosal secretory IgA antibody titer
Depressed complement system
Lymphoid involution
 Penyebab KKP
Defisiensi kalori dan protein : causa multifaktorial:
Konsumsi kurang
Gangguan absorbsi
Gangguan utilisasi
Infeksi
Infestasi cacing
Ekonomi negara kurang
Pendidikan/pengetahuan rendah : umum/ gizi/ kesehatan
Hygiene kurang
Banyak anak
Produksi/distribusi pangan tidak lancar
IRON / anemia
 Absorption
iron status regulated through absorption

Increase
- Acid in stomach
- Heme iron
- High body demand
- Low body stores of
iron
- Meat protein factors
(MPF)
- Vit C (converts ferri to
ferro)
Decrease
- Phytic acid (dietary fibre)
- Oxalic acid
- Polyphenols (tea, coffee)
- Full body stores of iron
- Excess of other minerals
(Zn, Mn,Ca)
- Reduction in stomach
acid
- Antacid
 Transport

- Transferrin is a protein that transports iron in the blood

- When iron stores are adequate all iron binding sites are saturated
-Transferrin can be used as an indicator of overload or deficiency
- Almost all cells in the body have transferrin receptor (TfR)
- Serum soluble Tfr (sTfR) is a good indicator of deficiency.
Internalisasi besi
 HEME-CONTAINING PROTEINS

Hemoglobin

Myoglobin

Cytochromes

Catalase

Some peroxidases
 Iron Losses

average iron loss of 1 mg / day in men and post menopausal

women
sweat and urine = negligible
exfoliation of the skin and GIT
menstruation
 Deficiency and excess

Deficiency Excess

IDA high prevalence Haemochromatosis

Reduced cognitive genetic disorders
functioning Fe deposits cause cell
Reduce capacity for damage in pancreas, liver
physical work
and heart
Increased maternal
mortality
Leads to diabetes, liver and
heart failure
Stages :
normal- depletion of
storage- IDE IDA.
Tahap deplesi besi dan
indikatornya
Diagnosis defisiensi besi berdasar feritin
dan sTfR
 Public health programs

supplementation
fortification
dietary modification
food processing :
reduce inhibitory factors
education
Elements of successful iron
supplementation programs
Fig.1. Elements of successful iron supplementation programs

Policy making

Tablet Supply Delivery System Consumer demand

Adequate budget Accessible to Good Quality

Data Base Target group Supplements
Ordering number Motivated, Well- Communications
In target group + Trained To educate Public
25% surplus Approachable and Promote
Timely ordering staff Program
Distribution
System

Coverage Compliance

Do intended Do recipients take

Recipients get the supplements
Supplements?

Impact

Reduction of Iron
Deficiency anemia

Monitoring and Evaluation

 Broek dan Lestky 2000

Among anemic pregnant women only 53%

showed biochemical evidence of iron
deficiency.
That is the maximum proportion of people
among whom anemia could be expected to
respond to the administration of iron
 Vitamin yang berperan dalam kejadian anemia

Vitamin B12
Defisiensi vitamin B12 dapat menyebabkan folat
tertahan dalam bentuk 5-methyltetrahydrofolate
karena aktivitas dari enzim methyonine sintase
tergantung vitamin B12
terjadi defisiensi folat fungsional yang
berkembang menjadi pengurangan folat vitamers
yang dibutuhkan untuk sintesis dTMP dan terjadi
reduksi availibilitas kelompok denovo methyl
yang dibutuhkan untuk methylasi CpG, dan
mengganggu ekspresi DNA
Effek klinis awal dari gangguan defisiensi vitamin
B akan menyebabkan anemia megaloblastik.
 Langsung pakai obat tambah
darah untuk mengatasi anemia ?
 Vitamin A deficiency:
consequences
Night blindness - ancient Egypt,
Greek and Assyrian medical literature
Early deaths
High rates of respiratory and
diarrheal diseases
Affects immunocompetence
Cured with animal and fish liver or
plants with green and yellow pigments
 Vitamin A Deficiencies
A deficiency in
vitamin A results in
night blindness.
The most serious
deficiency results in
a condition known
as Xeropthalmia, a
severe form of
conjunctivitius or
blindness.
19
 Vitamin A deficiency -
summary
Vitamin A deficiency is highly prevalent
It has severe consequences especially
in the young
Supplementation, fortification and
dietary changes have all been used
successfully to reduce its prevalence
The cost of the programs is not high if
integrated into existing child care
services
 Micronutrient
Deficiencies
Vitamin Deficiency Diseases
Retinol (Vitamin A)
xerophthalmia / night blindness
Ascorbic acid (Vitamin C)
a
scurvy or scorbutus Pellegr
Calciferol (Vitamin D) rickets.
Niacin (Vitamin B3) pellagra Beriberi
Thiamin (Vitamin B1) beriberi

Mineral Deficiency Diseases

Iron anemia
Iodine goiter
Go i te r
21
 Macro-nutrient
Deficiencies
Macronutrient deficiencies diseases in chlidren often result
from a lack of protein

Kwashiorkor is a specific
wasting away often
occurring in infants at
weaning. It results from a
lack of protein in the diet
Marasmus is a wasting away of
the body tissues from the lack Kwashiorkor
of calories as well as protein in
the diet. The child is fretful
rather than apathetic and is
skinny rather than swollen Marasmus
with edema.
22
Iodine deficiency (ID)
Iodine must be obtained from
the environment
Thyroid hormones, thyroxin and
triiodothyronine (T4 &T3)
contain 4 and 3 iodine atoms,
respectively.
Adults need 100-150 g/daily
Children require less in total,
but more per Kg body weight
 Iodine deficiency:
consequences
The following are affected by
iodine deficiency:
Thyroid size; enlargement
(goiter)
Mental and neuromotor
abilities
Reproductive results
Physical growth
 Consequences of ID
Neuromotor and cognitive impairment are
the most important effects of ID
Where ID is severe and mothers have severe
ID, endemic cretinism is found
results include:
cognitive impairment
learning, speech deficits
psychomotor problems
Reproductive effects
Rates of reproduction may be lower
Fetal and postnatal survival lower
Motor performance in childhood impaired
 Prevention of ID -
fortification
Salt fortification
Unique in micronutrient supplementation
as no dietary changes required
Fortified product more expensive
Social marketing to create demand
Mass media campaigns
Universal salt iodization is the goal
Level of fortification 25-50 mg
iodine/Kg
 Vitamin D
A serious deficiency in vitamin D results
in a condition known as Ricketts.
Ricketts is characterized by bone
softening an malformation.

Child with Ricketts

and two years after
treatment

27
 Recommendations
Management of Malnutrition
Definitions/Entry criteria for Severe
Malnutrition
Children: Weight for height Z-score < -2
Adults: BMI < 17 kg/m2
Pregnant women: First trimester: BMI
< 20
Second trimester BMI < 21
Third trimester : BMI < 22
 Nutrigenetics
Definition
Effects of individual genetic variation in
response to nutrient
Most common form of variation
Any two individuals share 99% of their
DNA sequence
1. Single nucleotide polymorphism (SNP)
2. Changes in single base pair
3. Occur ~ 1 in every 1000bp of human
genome
SNPs may alter regulation of gene
expression, mRNA processing (splicing,
half-life etc) and protein activities