nutrition in early childhood

1. Nutrition in Early Childhood Dr. Sheela Sharma MBBS, MD (Obstetrics and Gynaecology)

3. ENERGY One gram of carbohydrate or 1 gram of protein provides 4 kcal or 16.7 KJ; while 1 gm of fat releases 9 kcal or 37.7 KJ. Infants require (up to 1 year of age) on an av 103 kcal /kg/day.

4. Calorie requrement in Boys and Girls Age boys girls 1 to 2 years 1200 1140 2 to 3 years 1410 1310 3to4 year s 1560 1440 4to5years 1690 1540 5to6years 1810 1630 6 to 7 years 1900 1700 lm8years 1990 1770 8 to 9 years 2070 1830 9 to 10 years 2150 1880 10 to 11 years 2140 1910 11 to 12 years 2240 1980 12m 13 years 2310 2050 13 to 14 years 2440 2120 14 to 15 years 2590 2160 15 to 16 years 2700 2140 16 to 17 years 2800 2130 17 to 18 years 2870 2140

5. Proteins Protein is the second most abundant substance in the body, next to water. These are made up of twenty different amino aclds. The proteins differ in their arrangement and quantity of amino acids. A few amino acids can be adequately synthesized in the body (non-essential amino acids), while others must be supplied in the diet (essential amino acids). Essential amino acids include leucine, isoleucine, lysine, methionine, phenylalanine. threonine, tryptophan and val~r;. Histidine and arginine are essential during infancy because the rate of their synthesis is inadequate for sustaining the growth.

6. Proteins (contd�) Functions of protein. (i) Protein helps the child to mw as the constituent amino acids are necessary /B , . . . for the synthes~osf tlssues m the body.( ii) Protein is essential for the formation of digestive juices. hormones, plasma proteins, enzymes, vitamins and hernoglobin etc. (iii) Proteins also act as powerful buffers to maintain acid base equilibrium in the body. (iv) It is also a source of energy for the body. Excess protein, not used for building tissues or providing energy, is convened by the liver in to fat and stored in body tissues.

7. Proteins (contd�) Requirements: Protein requirements of children given table (next slide). Indian estimates are higher as these are calculatedin terms of the proteins actually present in Indian diets. An average adult requires 1.0 g/kg body weight of protein daily. During later half of pregnancy, an additional protein intake of 15 g per day is required. During lactation, an additional daily intake of 25 g during the fist six months

8. Protein requirement table: 2-3 months 2.25 3 4 months 1.82 4-5 months 1.47 5-5 months 1.34 6 9 months 1.30 9-12 months 1.25 1-2 years 1.15 2-3 years 1.25 3 4 years 1.13 4 � yeas 1.09 5-5 years 1.06 6 9 yeaan 1.0 10-12 years 1.48 13-15 years 1.0

9. NPU These protein requirements are given in terms of mixed vegetable protein contained in Indian diets, the net protein utilization (NPU) of which is assumed to be 65. If the protein in the diet is obtained from animal sources like egg, meat, fish or milk, lower intake of protein will usually be sufficient. The NPU of a protein is the proportion of ingested nitrogen that is retained in the body under specified conditions. NPU is a combined measure of digestibility and the efficiency of utilization of the absorbed amino acids.

10. Protein Quality Protein Quality A complete protein contains all of the essential amino acids in relatively the same amount as humans require for maintenance of good health and optimal growth. Protein in the food is obtained either from the animal or vegetable sources. The proteins of animal origin generally have a higher content of essential amino acids. 'These are, therefore, classified as biologically complete protein. Proteins from vegetable sources are often biologically incomplete, as these usually lack one or more of the essential amino acids. However, proteins of !,egetable origin may be used together in a judicious combination so that limiting essential amino acidin one of these is compensated for by an excess of that amino acid in the complementing protein. Proteins of rice and potato are considered good vegetable proteins.

11. Protein Quality A high quality protein should be complete as well as digestible. This is measured best by the biological value of the protein. Biological value (BV) is calculated as thc fraction of absorbed nitrogen retained in the body for growth or maintenance. Egg protein is considered a referenceprotein in this context as it is complete and well digested. The biological value of egg protein is 100. BV of milk, rice and fish are 75, 67 and 75 respectively. The combination of vegetable proteins may provide all the essential amino acids as in the reference protein. For example protein from !egumes has an excess of which can compensate for the low lysine content of wheat protein.

12. LIPIDS Lipids are a concentrated source of energy and provide insulation to the body. These also act as carriers for fat soluble vitamins. A healthy European or American obtains 35 to 40 percent of his caloric needs from fats. Diet of persons in the less affluent societies may provide less than 10 percent of calories from fat. Lipids include triglycerides

13. LIPIDS (contd�) LIPIDS: TRIGLYCERIDES (FATS AND OILS); PHOSPHOLIPIDS(LECITHIN); STEROLS(CHOLESTEROLS) TRIGLYCERIDES: SATURATED FA (animal sources + COCONUT: solid at room temp); UNSATURATED FATTY ACIDS (vegetable nuts+ seed sources: liquid at room temp); UNSATURATED FA: Mono saturated FA (oleic acis); PUFA;

14. PUFA PUFA: OMEGA 6 FA (linoleic acid + arachidonic acid); Omega 3 FA (linolenic acid+EPA+DHA); PUFA can not be adequately synthesized in the body hence should be supplemented in the diet;

15. FUNCTIONS OF PUFA Important component of cell membranes; They lower the blood cholesterol and triglyceride concentration.

16. LIPIDS (CONTD�) Deficiency of EFA in the diet may result in growth retardation, reproductive failure, skin disorders, increased susceptibility to infections, decreased myocardial contractility, renal hypetension and hemolysis. Selective deficiency of omega-6 fatty acids leads to skin changes while lack of omega-3 results in neurological and visual symptoms.

17. LIPIDS (CONTD�) Lecithin is the most important phospho lipid. It is a major constituent of cell membranes. Lecithins are not essential in diet as they can be synthesized in the body by liver. Phospholipids also act as emulsifying agents.

18. LIPIDS (CONTD�) cho l e s t e r o l is a lipid essential for good health. Cholesterol deficiency does not usually occur as it can also be synthesized in the human body in the liver from carbohydrates, protein or fat. It is an important constituent of cell membrane. Cholesterol can be transformed into related compounds like hormones, bile and vitamin D. Cholesterol is found only in animal foods including eggs, liver, kidney, cheese and ghee. EPA are essential for transport and breakdown of cholesterol. Excess cholesterol is stored and may lead to atherosclerosis.

19. LIPIDS (CONTD�) Recommended intake. Total fat intake should provide no more than 30 percent of daily energy intake. Saturated fats should not exceed 10 percent of total fat intake. A minimum of 3 percent of energy should be derived from linoleic and 0.3 percent from linolenic acid. Cholesterol intake should be limited to a maximum of 300 mg per day. Excess fat contributes to obesity, NIDDM, cancer, hypertension and atherosclerosis; it is better to avoid excess of total fats, saturated fats and cholesterol, in that order of priority.

20. LIPIDS (CONTD�) LIPIDS in circulation are bound with proteins that serve as transport vehicles. The lipid-protein complex is called lipoprotein. Four main types of lipoproteins are formed differing in their size and density. These are known as chylomicrons (rich in triglycerides), high density Lipoproteins (H DL), low density lipoprotein (LDL) and very low density lipoprotein (VLDL). Lipoproteins with a higher percentage of lipids have a lower density i.e., LDL and VLDL; those with a higher percentage of proteins have a higher density (HDL). Composition of these lipoproteins is depicted in Table 5.3.

21. LIPIDS (CONTD�) High levels of chylornicrons and LDL are associated with a higher risk of cardiovascular diseases. HDL is a protective lipoprotein and high levels tend to protect agalnst the hem diseases. Cells all over the body remove fat from the passing by chylomicrons. Few remnants, that loiter for long, are removed by the liver. Liver is also an active site of iipid synthesis. The synthesized lipids are transported as VLDL to various organs that need them. The body cells remove triglycerides from the VLDL and convert them to LDL. Liver cells also have special receptors that remove LDL fro+ circulation.

22. CARBOHYDRATES Carbohydrates provide energy, contribute to taste and texture of foods, preserve foods and are essential for digestion and assimilation of other foods. They also protect the proteins from being used for energy. Monosaccharides (glucose, fructose, galactose, ribose, deoxyribose) and disaccharides (sucrose, lactose and maltose) are known as simple carbohydrates while polysaccharides (starch, glycogen, fiber) are referred to as complex carbohydrates. Grains are the richest food source of starch. A starch typically consists of thousands of glucose molecules linked together. Other important source of starch are legumes (beans and peas) and tubers (potato, cassava etc.). Glycogen is a more complex storage form of glucose an6 is not found in plants. Body converts all carbohydrates (except those coming from fiber) to glucose. Glucose is used as a fuel by brain and muscle tissue or convened tc glycogen and stored by liver and muscles. Excess carbohydrates are converted to fat.

23. CARBOHYDRATES Carbohydrates constitute 55-60% of total energy intake; and preferably obtained from grains, legumes, vegetables and fruits. Such a diet is lower in fat and energy and higher in fiber, vitamin and minerals. These diets also contribute to lower rates of under nutrition, obesity, tooth decay, cardiovascular disease and diabetes. Excessive carbohydrate consumption in form of concentrated sweets is associated with dental caries. obesity, ischemic heart diseases and cataract (glucose cataract ln diabetes, galactose cataract in galactosemia). Lack of carbohydrates may produce ketosis, loss of energy, depression and breakdown of body proteins.

24. FIBRE High fiber diet is advocated for chronic constipation, diabetes, obesity and hypercholesterolemia. Low fiber diet is particularly useful in irritable bowel syndrome, chronic colitis and partial chronic G1 obstruction.

25. FIBRE Fiber components include polysaccharides such as cellulose, hemicellulose, pectins, gums, mucilages and non polysaccharide lignins. Fibers are considered important because of their water-holding capacity, bile acid binding capacity and for the growth of the normal microflora of the intestines. Water soluble fiber e.g., gums and pectins help in lowering blood cholesterol and limit glucose absorption. Fibers insoluble in water result in softening of stools and acceleration of intestinal transit time.

26. MICRONUTRIENT(S) INTRODUCTION micronutrients are nutrients needed in tiny amounts, may, be a few mg or micrograms per day and include various minerals and vitamins. They do not contribute to the energy intake but normal healthy living is not possible without them.

27. MICRONUTRIENT(S) Micronutrient Deficiency: A Global Issue Micronutrient malnutrition continues to affect over 2000 millon people worldwide. There are several reasons for such deficiencies. The population may be deficient because have poor access to 111icronutrient rich food due to \ poverty, defective crop growing pattern, \i" deficient soil quality, inappropriate climate or geographical isolation. Traditional dietary fads may also hinder intake, absorption or utilization of micronutrient rich foods.

28. MICRONUTRIENT(S) Micronutrient deficiency is clinically evident only in the later stage of the disease and therefore may result in grave consequences. The end results of such deficiencies include learning disability, impaired work capacity, increased susceptibility to infections and greater risk of dying. For the nation it means increased investment on health services, inferior economic productivity and poor gains on educational ventures.

29. MICRONUTRIENT(S) Vitamins Vitamins are essential for life and maintenance of normal health. These act as cofactor in many enzyme systems and are therefore cardinal for various bodily functions such as energy production, hemopoiesis, reproduction, neurological functions, hydroxylation and synthesis of fats,

30. VITAMINS Any aberrations in these critica l mechanisms cause profound changes in the nervous system and integrity of skin, mucous membrane, synthesis and repair of connective tissues and drug metabolism.

31. VITAMINS Vitamins are required in very minute quantities in the diet. The fetus and the infant get adequate vitamins from the mother during pregnancy and lactation. Dietary intake of vitamins may be low or marginal during infancy and early childhood. There is increased requirement of vitamins in preterm babies, during post-operative stress, infections and in some genetic metabolic disorders. Intestinal absorption of vitamins is impaired in chronic diarrhea, malabsorption, and bacterial overgrowth in intestines. Certain drugs may have an adverse effect on the enzyme systems, which require the vitamin. Thus, these may inactivate the vitamin and its effects.

32. VITAMINS \/itamins are classified into two broad groups viz., fatsoluble and the water-soluble vitamins. Fat-soluble vitamins include vitamin A, vitamin D, vitamin E, and vitamin K. Vitamin B complex and vitamin C are the water-soluble

33. MINERALS These are small inorganic elements and are indestructible unlike other major nutrients and vitamins Calcium, phosphorus, potassium, sodium, chloride. magnesium and sulfur are known as macrominerals and are usually required in amounts more than 100 mg per day. as they are present in relatively higher amounts in body tissues.

34. TRACE ELEMENTS The tern trace is applied to concentrations of element not excceding 250 micro g per g of matrix. The definitive feature of a nutritionally significant trace element is either its essential intervention in physiological processes or its potential toxicity when present at low concentrations in tissues, food or drinking water. A WHO expert consultation has divided nutritionally significant trace elements into three groups: (i) essential elements such as Iron, Iodine, Zinc, Selenium, Copper, Molybdenum and Chromium; (ii) elements which are probably essential, i e . , Manganese, Silicon, Nickel, Boron and Vanadium; and potentially toxic elements that have essential functions at low levels. F, Pb, Cd, Hg, As, Al, Li, Sb.

35. VITAMIN A DEFICIENCY Vitainin A deficiency (VAD) results in blinding several hundred thousand children a year. It is now recognized not only to harm the eyes but also to increase childhood and maternal mortality. Globally. 21% ol children have vitamin A deficiency and suffer increased rates of death from diarrhea, measles and malaria. About 800,000 deaths In chldren and women of reproductive age are attributable to vitamin A deficiency which, along with the direct effects on eye disease, account for 1.8% of global DALYs. (disability adjusted life yeas). This appears to be lower than previous estimates, possibly because of vitamin A supplementation or food fortification programs during the last decade.

36. VITAMIN A DEFICIENCY Vitamin A is a subgroup of retinoids exhibiting the biological activity of retinol. Naturally occuring retinoids include retinol (vitamin A alcohol), retinyl ester (vitamin A ester), retinal (vitamin A aldehyde) and retinoic acid (vitamin A acid). Retinoic acid is the most active form of the vitamin.

37. VITAMIN A DEFICIENCY Physiology. Vitamin A is essential for normal maintenance and function of body tissues, for vision, Cellular integrity, immune competence andgmwth. Vitamin A deficiency is therefore a systemic disease, most specific effects involving the eye. Vitamin A is also termed as an anti-infective vitamin. This is attributed to its role in maintaining integrity of epi thelial tissue for resisting invasion by pathogens and for functional immune response.

38. VITAMIN A SOURCES Sources. Rich sources of pre-formed vitamin A or retinol are cod liver oil, shark liver oil and liver Moderate sources are butter, ghee (butter oil). and egg yolk. Best source of carotene is red palm oil. Provitamin A carolenoids are present in good amounts in carrots, green leafy and yellow red vegetables and ripe mangoes.

39. VITAMIN A DEFICIENCY: SUBCLINICAL Subclinical deficiency. Respiratory system, urinary tract, intestinal epithelium and immune system are affected before the deficiency manifests clinically. Subclinical vitamin A deficiency contributes to an increased severity of certain infections and an increased risk of dying from these.

40. VITAMIN A DEFICIENCY: Early FEATURES EARLY features. Defective dark adaptation is the most characteristic early clinical feature. resulting in night blindness.

41. VITAMIN A DEFICIENCY: XEROPHTHALMAI Prolonged deficiency of VIT A in dlet results in a syndrome of xerophthalmia, especially prevalent in 6-36 month olds. It is often combined with general malnutrition. There is pigmentation of the caruncle with loss of normal lustre and moist appearance of palpebral conjunctiva, which appears dry and wrinkled. Bitot spots appear as chalky grey spots on the temporal side of cornea-scleral junction. Cornea is softened and ulcerated (keratomalacia). Eventually it is infected and perforation of cornea occurs, resulting in opacification and blindness. On fundoscopy, pale yellow spots can be visualised near the course of retina1 vessels and also in the periphery.

42. VITAMIN A DEFICIENCY: OTHER FEATURES OTHER FEATURES: Skin becomes scay and toad like. Toad skin is now believed to be due to essential fatty acids deficiency. Squamous metaplasia of respiratory mucosa makes these children more prone to respiratory infections. Alterations in mucosa of renal pelvis urinary bladder predispose to formation of renal and , vesical calculi. Atrophy of the germinal epithelium may . interfere with the reproductive functions. Vitamin A : deficiency may rarely lead to hydrocephalus.

43. VITAMIN A DEFICIENCY: Factors influencing vitamin A status. lntake of < 180 micro g of retinol per day places a person at risk of vitamin A deficiency. Diarrhea. worms an'd other intestinal orders impair vitamin A absorption, while measles, resi r a t o r y tract infections and other febrile illnesses, increase the metabolic demands. PEM interferes with : absorption, storage and utilization of vitamin A. In protein deficiency, RBP is not synthesized in adequate amounts.

44. VITAMIN A DEFICIENCY: Retinol is actively accumulated in the last trimester of pregnancy. Levels of retinal in the breast milk are almost equal to the concentration of vitamin A in the maternal serum. Preterm infants have lower retinal levels and are at high risk for developing vitamin A deficiency specially at a time when epithelia1 cell function is of greatest significance.

45. TREATING VAD Specific. Immediately on diagnosis, oral vitamin A is administered in a dose of 50,000, 1 lakh, and 2 lakh international units in children aped < 6 months, 6-12 months, and > 1 year, respectively. The same dose is repeated next day and 4 weeks later. Parenteral, watersoluble vitamin A administration is recommended (in half >doses suggested above for 6-12 months and Uth in <6 months of age) in cases with impaired oral intake, persistent vomiting and severe malabsorption. Oil based injections should not be used to treat xerophthalmia.

46. PREVENTING VAD Infants who are not breasrfed should receive a 50,000 IU supplem e n t of vitamin A by 2 months of age (or two doses of 25,000 IU each with I month interval in between) in areas of endemic vitamin A deficiency. Every infant should be administered one dose of I lac units of vitamin A along with measles vaccine at 9 months followed by four more doses of 2 lakh 1U each at 18, 24. 30 and 36 months.

47. IRON DEFICIENCY: ANAEMIA Iron deficiency affects about two billion people globally. Recent estimates find that Iron deficiency anemia (IDA) is responsible for a fifth of early neonatal mortality and a tenth of maternal mortality. It also affects growth and development, limits the leaming capacity, reduces cognitive development and reduces work capacity of the affected.

48. IRON: SOURCES Av in liver, kidney, egg yolk, green vegetables, and fruits.

49. IDA: TREATMENT The optimal dose of elemental iron is 3 -6 mg per kg of body weight given orally in three divided does. With this hemoglobin level should rise by about 0.4 g!dL per day. Iron absorption improves in presence of vitamin C, when given on empty stomach or in between the meals. The phytates in cereals and phosphates in the milk diminish iron absorption. Therefore, iron should not be given just after the milk-feeds or after food.

50. IDA: TREATMENT With iron therapy, the activity of iron containing enzymes in the cells improves. The child becomes less irritable and his appetite improves within 24 hours. Initial bone marrow response is observed within 48 hours. Rise ret i c u l o c y t e count occurs by the second to third day. This is followed by elevation of hemoglobin level. It may take up to two months depending on the severity of anemia. Body iron stores are repleted after correction of the hemoglobin levels.

51. IDA: Prevention and Control In childhood, 10 mg of elemental iron is required every day. Children fed purely on milk diet are prone to develop anemia. To prevent anemia, supplementary foods, especially rich in iron should be administered to the child from 4 months of age. Pulses, beans, peas, green leafy vegetables are fairly good sources of iron. Iron in the egg. however is not easily absorbed. Preterm and low birth weight infants with low iron stores should receive 10-1 5 mg of elemental iron daily.

52. IDA: Prevention and Control Iron needs are increased during puberty because of pubertal growth spurt and excessive bleeding during menarche in the girls. Therein, iron supplements are necessary during adolescence for preventing anemia of puberty. Several studies have shown that fortified salt has been able to prevent anaemia.

53. IODINE DEFICIENCY DISORDERS (IDD) Iodine deficiency disorders (IDD) refers to the wide spectrum of effects of iodine deficiency on growth and development. It includes endemic goiter, endemic cretinism, impaired mental function in chilben and adults with goiter and increased stillbirths and perinatal and infant mortality. Evidence is now available that these conditions can be prevented by correction of iodine deficiency.

54. IODINE DEFICIENCY DISORDERS (IDD) Iodine: Essential Trace Element Iodine is an essential component of thyroid hormones. Sea foods and vegetables grown on iodine rich soil are good sources of iodine. Soil in Himalayan regions has low iodine content due to leaching caused by deforestation. Low lying areas subject to flooding or high rainfall, such as Ganges valley in India and Bangladesh are also severely iodine deficient.

55. IODINE DEFICIENCY DISORDERS (IDD) Requirement. A daily iodine intake of 50 micro g (1-12 mo), 90 micro g ( 1-4 yr), 120 micro g (7-12 yr) and 150 micro g From 12 yr onwards is is recommended. The requirement should be doubled in case of presence of goiterogens in the diet. Cassava, maize, bamboo shoots, sweet potatoes and millets are important sources of IODINE.

56. IODINE DEFICIENCY DISORDERS (IDD) ENDEMIC CRETINISM: occurs with an iodine intake is <25 micro g /day in contrast to a normal intake of 80-150 micro g/day affecting up to 10% of populations living in severely iodine deficient areas is associated with endemic goiter and characteristic clinical features, which include deaf-mutism, squint, mental retardation, characteristic spastic or rigid neuromotor disorder (spastic diplegia) and dwarfism

57. IODINE DEFICIENCY DISORDERS (IDD) Two types of endemic cretinism are described : The neurological cretinism: characterized by deaf-mutism, squint, proximal spasticity and rigidity more in the lower extremities, disorders of stance and gait with preservation of vegetative functions, occasional signs of cerebellar or Oculomotor disturbance and severe mental deficiency. Myxedemarous cretinism is characterized by retarded psychomotor development, severe short stature, coarse facial features and myxedema without deaf-mutism

58. ZINC DEFICIENCY Zinc is present in all organs of the body , tissues, fluids and secretions of the body. The element is necessary for the RNA, DNA and ribosome stabilization. Zinc is critical for the functioning of the bio membranes. Animal foods such as red meat and pork are rich in zinc. Cheese, whole wheat, nuts and legumes also provide zinc.

59. ZINC DEFICIENCY Preadolescent children must receive 10 mg of zinc per day. Deficiency States. Severe zinc deficiency leads to growth retardation, hypogonadism, anorexia. alopecia, acral dermatitis, acrodermatitis enteropathica, behavioral changes and increased susceptibility to infections secondary to defective cell mediated immunity. Mild zinc deficiency is associated with a reduced growth rate and impaired resistance to infections. Zinc deficiency in pregnant women has been linked with premature delivery.

60. FOLIC ACID Folic acid is a B group vitamin, first isolated from spinach leaf in 1941. It occurs naturally as folates, which are temperature and storage sensitive and cooking causes significant fall in their concentration. Recommended daily allowance is 100 micro g. Sources rich in folates are liver. green leafy vegetables.

61. FOLIC ACID Foiic acid deficiency is also associated with increased thrombotic events, which may be related to increased homocysteine levels. A recent meta-analysis showed that 500-5000 micro g/d of folic acid intake reduces Homocysteine levels by 25%. Folic acid seems to be protective against development of atherosclerosis and other vascular disease by virtue of its homocysteine lowering effect.

62. FOLIC ACID FOR PREVENTING NEURAL TUBE DEFECT (NTD) all women should receive folic acid before or immediately after conception to have the desired effret, The ultimate goal of achieving better folate status in women of reproductive age group may be achieved by increasing the folate rich food intake, supplementation or food fortification. Folic acid also prevents pre term delivery, placental abruptions, infarctions and helps in increasing birth weight.

63. FOLIC ACID FOR PREVENTING NEURAL TUBE DEFECT (NTD) In 1992, the US Public Health Services recommended that all women capable of being pregnant should consume 400 micro g of folic acid through childbearing age to reduce the risk of having pregnancy affected with NTD. Society of Obstetrics and Gynecology of Canada Expert Advisory Group on Folic Acid in prevention of NTD recommended that all women of child bearing age should consume 400 micro g of folic acid to prevent the first occurance starting before conception and continued till the end of 12th week of gestation. A daily intake of 4000 micro g of folic acid was recommended in previously affected pregnancies starting from one month before to 3 months

64. VITAMIN B COMPLEX: B1 Thiamine exists in tissues mostly in the form of thiamine pyrophosphate (TPP), also known as carboxylase. It is , required for the synthesis of acetylcholine; deficiency results in impaired nerve conduction. It is a cofactor in carbohydrate and protein metabolism. In thiamine deficiency, utilization of pyruvic acid is decreased. Therefore pyruvic acid and lactic acid accumulate in the tissues and their blood levels are increased.

65. VITAMIN B COMPLEX: B1 Sources. Dried yeast, whole grain cereals, pulses, oil and groundnuts are good sources. Meat, fish And green vegetables are relatively poor sources.

66. OVER TO HANDOUTS VITAMIN B COMPLEX, C, D, E, and trace elements.

67. PROTEIN ENRGY MALNUTRITION (PEM) Undernutrition is widely recognized as a major health problem in the developing countries of the world. Severe PEM, often associated with infection contributes to high child mortality in underprivileged communities. Further, early malnutrition can have lasting effects on growth and functional status. The frequency of undenutrition cannot be easily estimated from the prevalence of commonly recognized clinical syndromes of malnutrition such a marasmus and kwashiorkor because these constitute only proverbial tip of the iceberg. Cases with mild to moderate undenutrition are likely to remain unrecognized because clinical criteria for their diagnosis are imprecise and difficult to interpret accurately.

68. PROTEIN ENRGY MALNUTRITION (PEM) Assessment of nutritional status by anthropometry is the simplest and most useful tool for assessing the nutritional status of children. Anthropometric measurements like weight, height and mid-arm circumference should be compared to the anthropometric norms for the corresponding age in the well nourished and healthy children of the community.

69. PROTEIN ENRGY MALNUTRITION (PEM) Protein-energy malnutrition (PEM) is the most widely prevalent form of malnutrition among children. Nutritional status of children is an indicator of nutritional profile of the entire community. PEM affects every fourth child world-wide. 150 million (26.7%) are underweight while 182 million (32.5%) are stunted. Geographically. more than 70% of PEM children live in Asia, 26% in Africa and 4% in Latin America and the Caribbean.

70. PEM : Etiliology Poverty Low Birth Weight Infections Population growth Feeding habits High Pressure Ad for Baby Foods Social Factors

71. CLINICAL MANIFESTATIONS OF PEM Nutritional marasmus and kwashiorkor are two extreme forms of malnutrition. Such extreme forms account for a small proportion of cases of malnutrition. A much larger number of subjects suffer from mild to moderate nutritional deficit.

72. PREVENTION OF PEM Prevention at family level Exclusive breast feeding for first 6 months. Nutrition supplements after the age of 6 months. Complementary foods should be a judicious mixture of cereals and legumes; Food should be energy dense; thick consistency and given hygienecally. As much milk, meat, eggs should be offered with the complementary food to enhance the net dietary protein value.

73. PREVENTION OF PEM Vaccine preventable diseases should be prevented by immunizations. Proper birth spacings between two pregnancies.

74. PREVENTION AT COMMUNITY LEVEL Early detection of malnutrition and intervention Growth monitoring Integrated health packages (immunization; kemoprophylaxix; periodic devermin) Nutrition education. Technological measures: iodizing the common salt, prevention of night blindness through vit A supplementation and distribution of folic acid and tron tablets.

75. OBESITY It is form of development driven malnutrition. CAUSES EXOGENEOUS or ENDOGENEOUS ENDOGENEOUS CAUSES: less than 10 % of the total

76. EXOGENEOUS OBESITY Dietary factors; large infrequent meals; high calorie density junk foods; Habits; psychogenic causes; more indoor games; watching TV; Decreased energy expenditure. Genetic factors; 1 �ob� gene which affects the appetite set point and metabolic rate;

77. MANAGEMENT OF OBESITY Diet; calorie intake; in between snacks; junk foods should be curtailed; high fibre : low calorie encouraged; Greater physical activity; Behaviour modification; constant encouragement; help of a psychologist; Drugs and surgical methods are NOT encouraged.

78. PREVENTION OF OBESITY: UNIVERSAL APPROACH SOCIAL CULTURAL POLITICAL PHYSICAL AND STRUCTURAL ENVIRONMENT to focus on prevention of rise in BMI. Issue of obesity should be addressed during every well child examination. Parents are asked NOT to overfeed the child. Food should NOT be used for comfort or reward. Sugared food should be avoided completely.