1

Topic: Basic Concepts of Nutrient

Nutrients: Nutrients are chemical constituents of food or other substance
necessary for growth and normal functioning of the body.
Types of nutrients:
Based on daily requirement:
1. Macronutrients: Nutrients that are needed in relatively large amount
(several grams per day). Examples- protein, fat, carbohydrate,
macrominerals, fibers.
2. Micronutrients: Nutrients that are needed in much smaller amount
(micrograms to milligrams per day). Examples- vitamins, microminerals.
Based on dispensability (nutritional types):
1. Essential nutrients: Nutrients which are not synthesized in the body (or at
least in sufficient amount) and therefore must be supplied with diet.
Example- carbohydrate, essential amino acids, essential fatty acids,
vitamins, minerals, dietary fibers.
2. Nonessential nutrients: Nutrients which under normal condition are
synthesized in the body in sufficient amount and therefore are not
essential in diet. Examples- nonessential amino acids, nonessential fatty
acids.
* All nutrients are essential for the body but not essential in the diet.
Nutrition: Nutrition is the science that relates food to health.
Or
Nutrition is the science that studies the process by which living organisms take
in and use food for the maintenance of life, growth, reproduction, functioning
of organs and tissues, and production of energy.
2

Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake

of energy and/or nutrients. The term malnutrition addresses 3 broad groups of
conditions:
o Undernutrition, which includes-
▪ wasting (low weight-for-height),
▪ stunting (low height-for-age) and
▪ underweight (low weight-for-age);
o Micronutrient-related malnutrition, which includes-
▪ micronutrient deficiencies (a lack of important vitamins and
minerals) or
▪ micronutrient excess; and
o Overweight, obesity and diet-related noncommunicable diseases (such as
heart disease, stroke, diabetes and some cancers).
3

Topic: Food
Food: Anything which is consumed to satisfy hunger and or to provide nutrients
necessary for growth and normal functioning of body.
Staple food: Food that forms the basis of the diet in terms of both quantity and
frequency of consumption and that provides the highest proportion of energy.
Types of food:
1. Energy yielding/calorigenic food, e.g. carbohydrate, fat
2. Body building food, e.g. protein
3. Protective food, e.g. vitamins, minerals.
Energy content of food: Energy released by food on complete oxidation in the
biological system.

✓ 1 kcal = 4.184 Kilojoule

✓ Vitamins and fibers are non-calorigenic (have no energy value).
Daily energy source:
▪ Carbohydrate: 60% (55-75%)
▪ Fat: 30% (15-30%)
▪ Protein: 10% (10-15%).
Nutritional value of food: Nutritional value of food is a measure of essential
nutrients present per unit of that food.
4

Topic: Diet, Balanced diet, Glycemic index

Meal: The food consumed at regular intervals or at a specified time.
Diet: Diet is what a person habitually eats and drinks to meet specific
requirements of the individual.
Balanced diet: A diet that contains all the nutritive factors in proper proportion
for adequate nutrition.
Or
A diet that contains all the proximate principles of food in proper proportion for
adequate nutrition of a definite individual with respect to age, sex, occupation,
life style and disease condition etc.
Factors important in preparation of balanced diet:
✓ Age
✓ Sex
✓ Occupation
✓ Life style
✓ Physical activity
✓ Physiological conditions like pregnancy, lactation
✓ Pathological conditions like disease, following trauma/surgery
✓ Availability
✓ Economic condition (affordability)
✓ Social and religious status, cultural habit
✓ SDA
✓ Inclusion of fibers, adequate fruits and vegetables
5

Distribution of energy sources for preparing balanced diet:

From-
o Carbohydrate: 60% of total energy intake
o Fat: 30% (saturated fat: less than 10%, Trans fat: Less than 1%) of total
energy intake
o Protein: 10% of total energy intake
o Free sugar: Less than 10% (ideally is less than 5%) of total energy intake

✓ Salt: Less than 5 g (equivalent to about one teaspoon) per day. Salt should be
iodized.
Typical balanced diet for a medical student (healthy adult, mild to moderate
activity) should usually include:
Cereals 500 g
Pulses 70 g
Vegetables 200 g
Fruits 30 g
Milk 100 g
Fat 40 g
Egg 30 g
Fish and meat 30 g
Sugar 40 g
Water 1.5 L
6

Glycemic index (GI) of food is the rise in blood glucose concentration after a test
meal of 50 g carbohydrate rich food compared to that after 50 g glucose as
reference meal.
GI of a food indicates how rapidly blood glucose level rises after eating that food.
Measurement of GI:
Fasting and several postprandial blood glucose levels are measured following
equal amount of test meal and reference meal and then plotted in graph.
GI =
Area under blood glucose response curve for test food (AUCT)
Area under blood glucose response curve for reference food (AUCG)
GI ranges from 0-1 (0-100%)
GI of some common foods:
Food GI (%)
Glucose 100
Potato 80-90
Bread, polished rice 70-80
Banana, brown rice 60-70
Milk, ice cream 35-40

▪ GI of glucose, galactose, maltose, lactose = 1.0, as readily absorbed

▪ GI of Fructose, sucrose <1, as less readily absorbed
▪ GI of starch varies from near 0 to near 1, due to variable rates of starch
hydrolysis
▪ GI of carbohydrates can be lowered if ingested with protein, fat & fibers.
▪ Complex carbohydrates have low GI compared to simpler ones.
▪ Low GI foods are good for health as they-
o Safeguard pancreatic β-cell function
o Create sense of satiety to limit calorie intake.
▪ High GI foods are associated with obesity, DM etc.
7

Topic: Essential dietary components

Essential dietary components: Components that must be supplied with diet for
growth and normal functioning of body. These includes the 7 proximate
principles (basic components) of food:
1. Carbohydrates
2. Protein (contains essential amino acids)
3. Fat (contains essential fatty acids)
4. Vitamins
5. Minerals
6. Dietary fibers
7. Water.
Carbohydrate:
Sources: Starch (rice, potato, wheat)
Sucrose (table sugar, molasses)
Lactose (milk sugar)
Dietary fibers (fruits and vegetables)
RDA: 300-500 g/day in adult. Intake below 100 g/day causes ketosis.
Importance/functions:
▪ Principal source of energy (60%)
▪ Structural component in tissues
▪ Synthesis of nonessential amino acids and fat
▪ Protein and fat sparer
▪ Prevents ketosis and negative nitrogen balance
8

Dietary fiber: The edible, non-digestible and non-calorigenic carbohydrate

fraction of diet. They are derived from plant source, undergo partial
fermentation in colon and almost totally excreted with feces.
Properties of dietary fibers:
o Non-digestible (resistant to hydrolysis by human digestive enzymes)
o Non-calorigenic
o Derived from plant source
o Fermented by colonic bacteria producing SCFA (acetate, propionate,
butyrate) and gases (CH4, CO2, H2).
o Almost totally excreted with feces
o Hydrophilic
o Viscous
o Bind with bile acids, cholesterol and carcinogen, toxins and facilitate their
excretion
o Bind with minerals (iron, calcium, copper, zinc) and prevent their
absorption
Two types of dietary fibers-
According to solubility:
o Insoluble fibers: Cellulose, hemicellulose, some resistant starch, lignin
o Soluble fibers: Some hemicelluloses, pectin, gum, mucilage, FOS, cutins
According to chemical nature:
o Non-starch polysaccharide: Cellulose, hemicellulose, pectin, gum,
mucilage. From cereals, fruits, vegetables
o Resistant starch: From grains/seeds, raw potatoes, green banana,
cornflakes
o Fructo-oligosaccharide (FOS): From onion, garlic
o Lignin, cutins: From woody vegetables
RDA: 20-35 g/day.
9

Importance/functions of fibers: Fibers

o Increase the bulk of food, satisfy hunger, gives a sense of fullness. Thus,
decrease calorie intake, helps lose weight and prevents obesity.
o Improve bowel movement, soften stool, prevent constipation.
o Decrease the risk of atherosclerosis by reducing absorption of lipids
especially cholesterol.
o Improve glucose tolerance and thus risk of diabetes.
o Decrease incidence of diverticulitis, colonic cancer, hemorrhoids etc.
o Prevents absorption of toxins and carcinogens.
10

Protein:
Classes according to biological value-
✓ Reference protein: A theoretical concept of the perfect protein with
biological value of 100%. Egg protein is very near to this.
✓ First class protein: Proteins with high biological value. Contains all the
essential amino acids in required proportions. Usually animal proteins.
✓ Second class protein: Proteins with relatively low biological value.
Relatively deficient in certain essential amino acids. Usually plant
proteins.
❖ Complementary protein: Combination of different dietary proteins, each
complementing other to increase the total biological value to make a
more complete protein. Example- cereals (lack threonine and lysine) +
pulses (deficient in cysteine and methionine).
Sources: Animal- fish, meat, egg, milk
Plant- pulses, cereals, corn, soya
RDA: Adult- 1 g/kg/day, infant and children- 2 g/kg/day.
Importance/functions of protein:
o For growth and maintenance of optimal health
✓ Replaces the catabolized protein
✓ Maintains nitrogen balance
✓ Restores proteins degraded during wear & tear
✓ Keeps the catalytic, regulatory and defense machinery running
o Minor source of energy (10%)
o Can be converted to carbohydrate and fat
11

Fat
According to chemical nature:
1. Saturated fat: TAG contains mainly saturated FA.
Animal source: meat, milk, milk products (butter, ghee)
Plant source: coconut oil, palm oil
2. Unsaturated fat: TAG contains mainly unsaturated FA.
Animal source: fish, fish oil
Plant source: Vegetable oil (soya, sunflower, peanut, olive)
3. Trans fat: TAG contains mainly trans FA. Trans fats are partially
hydrogenated vegetable oils manufactured and used in food industry
(baked food like cakes, cookies and many others).
Example: margarine, dalda
Sources: Animal source: egg, fish, meat, milk, milk products (butter, ghee)
Plant source: vegetable oil (soya, sunflower, peanut, olive,
mustard), margarine, dalda
RDA: 50-100 g/day.
Importance/functions of fat:
o Source of energy (30%)
o Supply essential FAs and necessary for absorption of fat-soluble vitamins
o Improves taste and palatability of food
o Protein sparer
Metabolic and clinical effects of dietary fat:
Types Metabolic effects Clinical effects
Saturated fat ↑ LDL Risk of atherosclerosis,
coronary artery disease,
cerebrovascular disease,
colonic cancer
Unsaturated fat ↓ LDL, ↑ HDL Prevent atherosclerosis,
CAD, CVD
Trans fat ↑ LDL, ↓ HDL Risk of atherosclerosis,
CAD, CVD
12

Topic: Total calorie calculation, DRI, RDA, MR, BMR, SDA

Metabolic Rate (MR) is the rate of energy expenditure by an individual.
Basal Metabolic Rate (BMR) or Resting Metabolic Rate (RMR) or Basal Energy
Expenditure (BEE) is the rate of energy expenditure by an individual in basal
condition (when at rest, but not asleep, under controlled conditions of thermal
neutrality, measured about 12 hours after the last meal, and depends on weight,
age, and gender etc.)
Basal condition is characterized by-
▪ Complete physical and mental rest (voluntary activity at a minimum)
▪ Awake
▪ Overnight sound sleep
▪ 12 hours fasting
▪ Comfortable environmental temperature and pressure.
Here energy is spent for basic physiological processes like-
✓ Cardiac activity
✓ Respiratory activity
✓ Neural activity
✓ Ion transport (e.g. Na+-K+ pump)
✓ Temperature regulation
✓ Muscle tone maintenance
✓ GIT movement
✓ Renal function
✓ Synthesis of biomolecules, enzymes, hormones etc.
13

Factors affecting Metabolic Rate / Energy requirement:

o Age: higher in young
o Sex: more in male
o Race/genetics: high is Eskimos
o Height, Weight, Body surface area: increases with increase in these
factors
o Life style: more in those physically active, e.g. athletes
o Nutritional status: decrease in starvation
o Pregnancy and lactation: increase BMR
o Disease: increases in fever, infection, cancer, burn, trauma, surgery
o Endocrine status: T3, T4, catecholamine, and growth hormone increase
BMR
o Environment/climate: increases in cold climate.
14

Calculation of energy needs:

a) Basic energy need: BMR + Physical activity
b) Recommended energy need/total energy equivalent (TEE): Basic energy
need + 10% for SDA
Calculation of BMR/RMR/BEE (60-70% of TEE) by Harris–Benedict equation:
• For male:
BMR = 66.5 + (13.7 × weight in kg) + (5 × height in cm) – (6.8 × age in years)
kcal/day
• For female:
BMR = 655 + (9.5 × weight in kg) + (1.8 × height in cm) – (4.7 × age in years)
kcal/day
Recommended Energy Need/Total Energy Expenditure (TEE):
Total Energy Expenditure (TEE) is the rate of entire energy expenditure by an
individual. It depends on the BMR, the energy required for physical activity, and
the energy cost of synthesizing reserves in the fed state.
TEE (in kcal/day) = BMR + % of BMR for physical activity + 10% of total for SDA
Average BMR:
o For adult male: 2000 kcal/day
o For adult female: 1600 kcal/day
% of BMR for physical activity:
o For Light (sedentary) activity: 25-50% of BMR, e.g. medical student
o For Moderate activity: 50-100% of BMR
o For Heavy activity: ≥100% of BMR
15

Examples of TEE calculation (in kcal/day):

Adult male
BMR % of BMR for physical activity Total 10% of total for SDA TEE
2000 25% (Light) 2500 250 2750
2000 50% (Moderate) 3000 300 3300
2000 100% (Heavy) 4000 400 4400
Adult female
BMR % of BMR for physical activity Total 10% of total for SDA TEE
1600 25% (Light) 2000 200 2200
1600 50% (Moderate) 2400 240 2640
1600 100% (Heavy) 3200 320 3520

Specific Dynamic Action (SDA) or

Specific Dynamic Effect or
Calorigenic Effect of Food or
Thermic Effect of Food (TEF) or
Diet Induced Thermogenesis (DIT)
✓ It is the energy required to digest (e.g. secreting digestive juices), absorb
(active transport of the products of digestion), metabolize nutrients, and
synthesize reserves (of glycogen, triacylglycerol, and protein) in the fed
state.
Or
It is the extra heat production over and above the actual calorie value of
a given food when the food is metabolized within the body.
✓ SDA of protein, fat and carbohydrate is 30%, 4% and 6% respectively.
✓ A commonly used estimate of the thermic effect of food is about 10% of
one's basic energy requirement.
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Dietary Reference Intakes (DRI): Daily intake of a nutrient required to maintain

optimum health, growth and prevent deficiencies.
Components of DRI:
Components of DRI are 4 nutrient-based values that apply to the apparently
healthy general population. These includes:
1. Recommended Dietary Allowance (RDA)
2. Estimated Average Requirement (EAR)
3. Adequate Intake (AI), and
4. Tolerable Upper Intake Level (UL).
1. Recommended Dietary Allowance (RDA): The daily intake of a nutrient that
meets the nutrient needs of almost all (97% to 98%) individuals in a group. So,
risk of inadequacy = 2-3%.
2. Estimated Average Requirement (EAR) The daily intake of a nutrient that
meets the nutrient needs of one half (50%) of individuals in a group.
(i.e. on average 50% of people will require less, and 50% will require more). So,
risk of inadequacy = 50%.
3. Adequate Intake (AI): The daily intake of a nutrient that is
expected to meet or exceed the needs of most individuals in a group
or
assumed to be adequate for most individuals in a group.
4. Tolerable Upper Intake Level (UL): The highest daily intake of a nutrient that
is unlikely to have any risk of adverse effects for most individuals in group.
❖ Usually nutrient requirement is quantified by RDA and EAR. If these are not
available for a nutrient, the AI can be used.
17

Topics: Minerals
Two types (based on daily requirement):
1. Macrominerals (bulk elements): Minerals that are needed in relatively
large amount (>100 mg/day). Examples- Na, K, Ca, Mg, P, S, Chloride
2. Microminerals (trace elements): Minerals that are needed in much
smaller amount (<100 mg/day). Examples- iron, iodine, Zn, Cu, Mn, Mo,
Cr, Co, Se, Fluoride
Sources of macrominerals:
Na Table salt, sea fish, sea foods, meat, tomato, carrot, mango, papaya
K Milk & milk products, fish, meat, banana, green coconut, pineapple,
oranges, tomato, green vegetables, dates, nuts, beans
Ca Milk & milk products, egg, small fish, meat, green vegetables
Mg Fish, meat, banana, beans, nuts, green vegetables
P Milk & milk products, egg yolk, sea fish, sea foods, meat, dates, beans, nuts

Sources of microminerals:
Fe Egg, fish, meat, liver, green banana, guava, leafy vegetables
I Iodized salt, sea fish, sea foods, sea shore fruits & vegetables
18

Function, RDA, deficiency & toxicity features of macrominerals:

Mineral Function RDA Deficiency Toxicity
Na ECF volume 2.5-4.5 g Volume depletion Volume overload
Osmotic pressure Hypotension Hypertension
Neuromuscular function
(RMP, AP)
K ICF volume 2.0-4.0 g Cardiac arrhythmia Cardiac arrhythmia
Osmotic pressure Cardiac arrest Cardiac arrest
Neuromuscular function Muscle weakness / Muscle weakness /
(RMP, AP) paralysis paralysis
Acid-base balance
Ca Bone & teeth 0.8-1.0 g Cardiac arrhythmia Cardiac arrhythmia
Neuromuscular function Cardiac arrest Cardiac arrest
Contraction Tetany & seizure CNS depression
Secretion Rickets Soft tissue
Coagulation Osteomalacia calcification
Second messenger Osteoporosis Nephrocalcinosis
Renal stone

Mg Bone & teeth 0.3-0.4 g Convulsion / seizure CNS depression

Neuromuscular function
ATPase
Glucose 6-phosphatase
Hexokinase
Pyruvate kinase
Creatine phosphokinase
P Bone & teeth 1.2-1.4 g Rickets Poor mineralization
DNA, RNA Osteomalacia Vascular calcification
Energy metabolism, Renal impairment
storage & transfer (ATP)
Phospholipid
Acid-base balance
Second messenger
(cAMP, PIP3)
19

Function, RDA, deficiency & toxicity features of microminerals:

Mineral Function RDA Deficiency Toxicity
Fe Hemoglobin M: 10-20 mg Anemia (hypochromic Hemo-
Myoglobin F: 15-30 mg microcytic) chromatosis
Cytochrome oxidase P&L: 40 mg
Peroxidase
Catalase
I T3, T4 150 µg Hypothyroidism Thyroid
Goiter impairment
Zn Cell division 15 mg Growth failure Gastroenteritis
Cell growth Impaired healing
Wound healing Dermatitis
Healthy skin Poor immunity
Intact GIT mucosa Hypogonadism & infertility
Immune function
Gonadal function
Cognitive function
↑ Insulin action
Bactericidal action
Alcohol dehydrogenase
Carbonic anhydrase
Carboxypeptidase
Superoxide dismutase
Cu Cytochrome oxidase 2-4 mg Anemia Wilson’s
Catalase Neurological defect disease
Superoxide dismutase Muscle weakness
Increases iron Hypopigmentation
utilization
Mn Arginase 2-9 mg - -
Pyruvate carboxylase
Superoxide dismutase
Synthesis of
glycoprotein &
proteoglycan
Mo Xanthine oxidase 75-250 µg - -
Aldehyde oxidase
Cr ↑ Insulin action 10-100 µg impaired glucose tolerance -
Co Component of vit. B12 5-8 µg Vit. B12 deficiency -
Se Glutathione peroxidase 50-100 µg Myopathy -
Antioxidant
F ↑ hardness of bones, 3 mg Dental caries -
teeth
Prevents tooth decay
20

Iron balance:

Iron metabolism
21

Iron absorption

Inorganic iron is absorbed in the Fe2+ (reduced) state, and hence, the presence
of reducing agents enhances absorption. The most effective compound is
vitamin C. Alcohol and fructose also enhance iron absorption. Inorganic iron is
transported into the mucosal cell by a proton-linked divalent metal ion
transporter, and accumulated intracellularly by binding to ferritin.

Heme iron from meat is absorbed separately and is considerably more available
than inorganic iron.

The absorption of both inorganic and heme iron is impaired by calcium—a glass
of milk with a meal significantly reduces iron availability.
Iron leaves the mucosal cell via a transport protein ferroportin, but only if there
is free transferrin in plasma to bind to. Once transferrin is saturated with iron,
any that has accumulated in the mucosal cells is lost when the cells are shed.
When body iron reserves are adequate, hepcidin (a peptide) is secreted by the
liver which downregulates expression of the ferroportin gene leading to
decreased synthesis of ferroportin and decreased iron absorption.
22

In response to hypoxia, anemia, or hemorrhage, the synthesis of hepcidin is

reduced, leading to increased synthesis of ferroportin and increased iron
absorption.
As a result of this mucosal barrier, only ~10% of dietary iron is absorbed, and
only 1 to 5% from many plant foods.
Antioxidants
Vitamins
Beta-carotene or provitamin A
Vitamin C
Vitamin E
Minerals as metal cofactors of enzymes
Superoxide dismutase (copper/zinc in cytosolic SOD, manganese in
mitochondrial SOD)
Glutathione peroxidase (selenium)
Catalase (iron/copper)
Nutrients to take / avoid taking together
▪ Pair: Fat + Fat soluble vitamins
▪ Pair: Fiber + Fat (to reduce fat absorption)
▪ Pair: Iron + Vitamin C
▪ Pair: Vitamin D + Calcium
▪ Pair: Vitamin B12 + Folate
▪ Pair: Vitamin D + Omega-3s
▪ Avoid: Iron + Calcium
▪ Avoid: Fiber + Minerals
23

Topic: BMI, Overweight, Obesity, MS

Body mass index (BMI) is defined as a person's weight in kilograms divided by
the square of height in meters (kg/m2).

Overweight and obesity are conditions with abnormal or excessive fat

accumulation that may impair health.
For adults, WHO defines overweight and obesity as follows:
• overweight is a BMI greater than or equal to 25; and
• obesity is a BMI greater than or equal to 30.
For children, age needs to be considered when defining overweight and obesity.
Causes of obesity:
Genetic:
▪ Polygenic disorder (many genes responsible)
▪ Mutation of leptin gene / leptin receptor gene → decreased secretion /
action of leptin (hormone from adipose tissue) → appetite center is not
suppressed → increased food intake → obesity
▪ Positive family history
Environmental:
▪ Prenatal overnutrition (maternal obesity, gestational diabetes)
▪ High energy diet, overeating
▪ Lack of physical activity (e.g. sedentary life style)
▪ Endocrine disorders: Hypothyroidism, Cushing’s syndrome
▪ Drugs: steroid, anti-depressant, anti-convulsant, anti-psychotic
24

Complications / hazards of obesity:

▪ Cardiovascular: HTN, IHD, HF etc.
▪ Cerebrovascular: stroke
▪ Pulmonary: dyspnea, obstructive sleep apnea, asthma
▪ Musculoskeletal: osteoarthritis, back pain, gout etc.
▪ Obstetrical: GDM, preeclampsia, eclampsia
▪ Metabolic: dyslipidemia, atherosclerosis, fatty liver, insulin resistance,
DM, hypogonadism, infertility
▪ Malignancy, depression
Diagnosis of obesity:
1. Anthropometric measurement:
Parameter Normal Obesity
BMI (kg/m2) 18.5-24.9 ≥ 30
Waist-to-hip-ratio Male: < 0.90 Male: > 0.90
Female: < 0.85 Female: > 0.85
Waist circumference (cm) Male: < 90 cm Male: ≥ 90 cm
Female: < 80 cm Female: ≥ 80 cm
2. Measurement of body fat content by:
o CAT scan
o MRI
o DEXA
2 main types of obesity:
Upper body obesity / central obesity Lower body obesity / generalized
/ abdominal obesity / visceral obesity obesity
Increased fat in trunk, waist, abdomen Increased fat in lower extremities
around hips, thighs (subcutaneous
fat predominates)
Android / apple shaped fat distribution Gynoid / pear shaped fat distribution
More common in male More common in female
More associated with metabolic Less associated with metabolic
syndrome syndrome
W-H ratio increased W-H ratio normal
25

The metabolic syndrome (MS) is a constellation of interrelated metabolic risk

factors that appear to directly promote the development of atherosclerotic
cardiovascular disease (ASCVD).
Proposed Criteria for Clinical Diagnosis of Metabolic Syndrome

o To measure waist circumference, locate top of right iliac crest. Place a

measuring tape in a horizontal plane around abdomen at level of iliac
crest. Before reading tape measure, ensure that tape is snug but does not
compress the skin and is parallel to floor. Measurement is made at the
end of a normal expiration.
o For Asian populations, except for Japan, WC thresholds ≥ 90 cm in men
and ≥ 80 cm in women.
26

Topic: Nutritional disorders

Common nutritional disorders:
1. Protein Energy Malnutrition (PEM) / Protein Calorie malnutrition (PCM)
▪ Kwashiorkor
▪ Marasmus
▪ Marasmic kwashiorkor
2. Night blindness
3. Scurvy
4. Rickets & Osteomalacia
5. Nutritional anemia
▪ Iron deficiency anemia
▪ Megaloblastic anemia
6. Iodine deficiency disorders
7. Overweight & obesity
8. Coronary artery disease
WHO / Welcome Trust Classification of PEM:
Kwashiorkor: is a type of PEM characterized by weight-for-age 60-80% of normal
with edema. (Predominantly protein deficiency)
Marasmus: is a type of PEM characterized by weight-for-age <60% of normal
without edema. (Predominantly calorie deficiency)
Marasmic kwashiorkor: is a type of PEM characterized by weight-for-age <60%
of normal with edema. (Both protein & calorie deficiencies are significant)
Prevention of PEM:
✓ Growth monitoring
✓ Female education
✓ Family spacing
✓ Breast feeding
✓ Immunization
✓ Food supplementation
✓ Oral rehydration
27

Difference between Marasmus and Kwashiorkor

Point Marasmus Kwashiorkor
Definition Weight-for-age <60% of Weight-for-age 60-80% of
normal without edema normal with edema
Stunting + Wasting
Cause Mainly calorie deficiency Mainly protein deficiency
Typical scenario War, famine with extreme Weaned from
shortage of foods breastfeeding → sugar
drinks or starch diets
Usual age <1 year 1-4 years
Prevalence More common Less common
Physiological state Catabolism Very low anabolism
Growth retardation Marked Moderate
Muscle wasting Marked Mild
Subcutaneous fat Very low Low
Pathogenesis Low energy → Fat and Low protein → low
Muscle wasting oncotic pressure →
edema
Limbs Wasted Wasted but masked by
edema
Abdomen Distended but not ascetic Hepatomegaly (fatty liver)
Appearance Old man/ Monkey facies Moon face appearance
Baggy pant appearance Puffy Sugar baby
Appearance
Skin and hair Dry scaly skin Flaky paint skin
Hypopigmented hair Flag sign (alternating
hypo and hyper
pigmentation of hair)
Appetite Good Poor
Mental status Alert / restless Apathetic and irritable
Serum A/G ratio Low Very Low
Infection Low High
Response to Good Poor
treatment
28

Nutritional assessment
Nutritional assessment can be done using the ABCD methods.
A. Anthropometry
B. Biochemical/laboratory methods
C. Clinical methods
D. Dietary methods.
❖ Anthropometry
▪ Weight-for-age (low in underweight)
▪ Weight-for-height (low in wasting) = usually acute malnutrition
▪ Height-for-age (low in stunting) = usually chronic malnutrition
▪ BMI (underweight, overweight, obese)
▪ W-H ratio (central/generalized obesity)
▪ Waist circumference (central/generalized obesity)
▪ Head circumference (especially important in child below 2 years)
▪ Mid Upper Arm Circumference (MUAC)
▪ Triceps skin fold thickness
▪ Arm-span
❖ Biochemical and other laboratory methods
▪ Serum albumin
▪ Serum iron, ferritin
▪ Serum folate, vitamin B12
▪ Vitamin D
▪ Complete blood count (CBC)
▪ Peripheral blood film (PBF)
▪ Prothrombin time (PT)
▪ Plasma glucose
▪ Serum lipid profile
▪ Urine (sugar, protein, blood)
▪ Stool (blood, ova, parasites)
▪ Insulin-like growth factor 1 (IGF-1)
▪ Thyroid profile
▪ Radiology
29

❖ Clinical methods
▪ Thinness
▪ Edema (kwashiorkor)
▪ Paleness, tiredness, shortness of breath (anaemia)
▪ Goiter (iodine deficiency)
▪ Bitot’s spots (vitamin A deficiency)
▪ Skeletal deformities (in rickets)
▪ Spongy bleeding gum (scurvy)
▪ Dermatitis (niacin, zinc deficiencies)
❖ Dietary methods: Dietary history including (amount, type, frequency, habits,
cultural dietary norms, restrictions, food allergies etc.)
❖ Others: Medical history, drug history, immunization history.