Community pharmacy Chapter 6: Nutrition

1. Community pharmacy Chapter 6:Nutrition

2. Is defined as a function of the living plants and animals, consisting of the taking in and assimilation of material through chemical changes ( metabolism) where by tissue is build up and energy liberated. • The successive stages of the metabolism are digestion, absorption, assimilation and excretion. Digestion is preceded by mastication and deglutition in man. • excretion is effected by expiration, perspiration, urination, and defection. Not all the materials involve in human metabolism can be synthesized by the body. Therefore, these essential material-nutrients must be provided by the diet.

3. Food is a composite mixture of substances including proteins, carbohydrates, fats, vitamins and minerals. Where as nutrition signifies a dynamic process in which the food that is digested absorbed and assimilated, is used for nourishing the body. • The word nutrition comes from the Latin “ nutrire ” which means to breast feed or nurse. No clear distinction has yet been made between the food and nutrients.

4. Classification of foods • The dietary constituents of food include proteins, fats, carbohydrates, vitamins, minerals and water. A complete food should contain all these factors. Proteins, fats, and carbohydrates are considered as proximate principles and a long with water they form the main bulk of food.

5. Food have been classified on the basis of their predominant functions: • Energy yielding foods: these foods are rich in carbohydrates and fats. Ex : sugar, honey, jellies. • Body building (anabolic food). Ex: meat, liver, fish, milk, eggs. • Protective foods: these items are rich in proteins, vitamins, and minerals. Ex : milk, egg, green vegetables. • The important functions of food are: provision of energy, body building and repair, and the maintenance and regulation of tissue functions

6. Proteins • Proteins are complex organic nitrogenous compounds. They are composed of carbon, hydrogen, oxygen, nitrogen and sulphur in varying amounts. • Some of the also contain phosphorus, iron and other elements. Proteins provide about 24 amino acids of which eight are essential fro human for normal synthesis of different proteins in the body and for maintaining nitrogen balance in the adults.

7. As the human body cant synthesize them in sufficient quantity they must be supplied from the dietary proteins. The quality of dietary protein is closely related to its pattern of amino acids. • Protein from milk and eggs have pattern of amino acids which are considered most suitable for human consumption. • Proteins have an important role in the consumption of all tissues including body fluids such as blood.

8. They are required for building ,repair, and maintenance of the body tissues, and for the biosynthesis of plasma proteins, hemoglobin, antibodies, enzymes, and hormones. • They are also responsible for the cell mediated immune response and the bactericidal activity of leucocytes. • Proteins can also serve as source of energy but under normal condition human body doesn’t utilize them for this purpose.

9. Proteins in our diet are generally obtained from 2 important sources: • Animal source: egg, meat, fish, beef, milk • Vegetable source: cereal, nuts, fruits • The proteins obtained from milk, eggs, and meat generally of higher biological value than the proteins from vegetable source.

10. Growing children need more proteins in the term of body Wight since new tissues laid during growth. Proteins needs of women during pregnancy and lactation are also greater. • Deficiency of proteins: proteins calorie malnutrition ( PMC) is the most prominent form of the protein deficiency. It occurs frequently among infants and adults children among 1-3 years of age. it is not only responsible for childhood morbidity and mortality but it may also lead to permanent impairment of physical and mental growth of surviving children

11. The two terms used to describe PCM: • Marasmus: it is chronic condition resulting from the deficiency of total energy intake. Consequently, the individual reserves of protein end energy are depleted. • Kwashiorkor: it is common in patients who have adequate caloric intake but relative protein deficiency and who are catabolic usually with trauma, infection of burns.

12. Treatment of PCM: essentially comprises of adequate diet, treatment of infections and measures to prevent relapse. • In most cases 3-5 gm of food quality protein/kg/day will suffice the child's needs. After deworming and treating other infections it may take about 3 months to obtain a complete cure of PCM. • Prevention of PCM: a number of measures are essential for prevention on PCM in the developing countries .these include

13. health education: measures directed to pregnant and lactating women, their education toward health consciousness, breast feeding, family planning, nutrition, and food requirements of the family and growing children. • Specific protection of infants and children: this can be achieved by timely immunization and provision of protein and calorie rich food like milk, eggs, and fresh foods where ever possible

14. Early diagnosis, treatment, and rehabilitation: these can be achieved by periodic surveillance, proper treatment of diarrhea and worm infections, development of supplementary feeding programs and follow up care in case of hospitalized children.

15. Fat • Are concentrated source of energy and thus form an essential part of out diet. They improve the palatability of food and are required for the absorption of vitamins A,D,E,K. • Dietary fats are derived from both animals source like milk, vegetable oils, and nuts. • Animal fats are in general poor source of essential fatty acids abut they are good source of retinol and cholecalciferol, where as the vegetable oils except coconuts oil are rich sources of essential fatty acids

16. Essential fatty acids include linoleic, linolenic and arachidonic acids. They are active in promotion of growth as well as in the maintenance of the dermal integrity. • Their deficiency may lead to some abnormal skin conditions. Diet rich in EFAs also reduce blood cholesterol. • The nutritional significance of fats has increased due to its influence on cholesterol levels in the blood.

17. A high blood level of cholesterol is one of the predisposing factors for the development of atherosclerosis leading to CHD. • Fatty acids are classified into saturated and unsaturated fatty acids. Fatty acid of animal origin is saturated where as those present in groundnut oil, sesame oil, safflower oil and sunflower oil are mostly ply unsaturated fatty acids. • Hydrogenated vegetables fats contain high proportion of saturated fatty acid.

18. The consumption of unsaturated fatty acids in diet can control the rise in blood cholesterol. Its now considered that the daily of fats should not account for more than 15-20% of the total calories in the diet and these should include some amount of vegetable fats which contain unsaturated fatty acids.

19. % of fatty acids contain of commonly used vegetable oils

20. Blood fats are found in various forms but only two of these cholesterol and triglycerides are important from the point of view of health. In general plasma cholesterol higher than 200 mg/ 100 ml +the age of person in years and plasma triglycerides level exceeding 150/100 ml required medical attention. An excessively high quantity of the fat in the blood vessel likely to get deposit on the wall of the blood vessels and make them narrow.

21. This narrowing of blood is called atherosclerosis . The narrowing of coronary arties may lead to decreased like angina and MI which may be fatal unless treated immediately and cared for life time. • Hydrogenation: converts the liquid oils into semi solid and solid fat which are commonly known as “ vanaspti” and are popular cooking medium in our country. • Helps in maintaining the quality of the vegetable oils even in hot and humid climates, but in drastically reduces the contents of EFAs

22. Refined oils: refining of vegetables oils is done by treatment with steam and alkalies. It renders them free from unpleasant odor and color and improve the taste. However, refining reduce the EFAs content of vegetable oils. • Invisible fats: fats like butter, ghee, vegetable oil “ visible fats” As their daily intake can be estimates. On the other hand, fat present in various foods items like cereals, pulses, nuts, meat, eggs, vegetables, milk cant be quantities and hence they are called “invisible fats”

23. Obesity • Represent an imbalance between energy intake and out put resulting in a surplus of energy which is converted to fat and stored as adipose tissue. • Individuals whose weight is 10-20% above the desirable weight for their age, gender and frame are defined as over weight. When the weight exceeded 20 %more than the desirable weight, a person is regard as above

24. The association of obesity with increased morbidity and mortality is well known. Hypertension, diabetes, gall bladder disease, gout, osteoarthritis, flat feet, coronary arteriosclerosis are frequently associated with obesity. • There is unexplained increase in the incidence in certain types of cancer ( breast, gall bladder, colon…) in obese individuals. • Obesity also presents special hazards in pregnancy and surgical patients.

25. Balancing one's weight • Gaining or losing weight is simply a question of balancing food calories with the body's need for calories. One kg of fat is equal to about 7500 kcal. Thus, if you have 500 kcal every day above what your body needs, you will gain 0.5 kg in a week. On other hand, if you intake 500 kcal below your needs, you will lose about 0.5 kg in a week.

26. Fat deposition occurs when caloric intake exceeds caloric output. ,modern living conditions contribute to the obesity problems because of several factors: • Family pattern of rich, high caloric foods • Good appetite , likes to eat may dislike fruits and vegetables. • Ignorance of caloric value of foods • Skipping breakfast, coffee break with high calorie intake • Pattern of living: secondary occupation, riding to work, little exercise, tend to watch more than participating

27. 6. Emotional outlet: eats to overcome worry, boredom 7. Many social events with rich foods, frequent eating in restaurants. 8. Lower metabolism with increasing age , but failure to reduce intake. 9. Influence by pressure of advertising for many high calorie food.

28. Treatment • Specific weight reducing agent and hormones (ex: thyroid) singly or in combination are either ineffective or hazardous and have no place in the treatment of obesity. • drug like fenfluramine have limited value a s anorexigenic. Juvenile onset obesity is often very difficult to treat, possibly because of unknown metabolic disorder and it is important to institute a therapeutic programme as early as possible.

29. Any programmed of weight loss of more than a few pounds should be directed by a physician. If a weight losing programmed is to be successful, the individual must be convinced of the rewards that will come better health, slimmer figure, more energy. • Although a low calorie diet is used only so long as the weight to be lost. Each obese person must be convinced that he needs to modify his life time eating habits. If he fails to do this, he will gain back all pounds he has lost.

30. Diet • Is the most important factor in the management of the obesity. Preventive education about diet should be started during the early, at the time when eating habits are being established. The motivation to reduce the caloric intake to normal level is difficult to achieve in patients with long standing overeating patterns. Diets that claim to offer was weight reduce by reliance on certain special food or unusual combinations of food not only are invalid but may actually be harmful

31. There are a number of basic points to be considered in planning a diet for an obese patient: 1. calories: in order to loss weight, it is necessary to decrease the intake below the caloric requirements. An intake of 500 kcal/day less than the required calories should lead to an average weight loss of approximately 0.5 kg/week. The number of calories/ day to prescribe for a patient varies with age occupation, any urgency to loss weight.

32. A daily caloric intake of 800-1200 kcal is satisfactory for the modest reducing diet.\ complications of rapid weight reducing are largely associated with severs or prolonged caloric restriction and occur most commonly in patients who were obese as children. • Weakness, postural hypotension, metabolic acidosis, hyperuricemia, ulcerative colitis, mental depression, and some times even suicidal thoughts also occur.

33. 2. protein: a protein intake of about 1 g/kg should be maintained. 3.Carbohydrates and fat: to keep the calories, fat must be decreased. After the proteins requirements have been met. The remaining calories may be supplied as half carbohydrates and half fat. 4. Vitamins and minerals: can be used to supply the average daily maintenance requirements during the time of weight reduction

34. Low calories diets: foods to be distributed into regular meals during the day

35. Carbohydrates • Are the main source of energy to the human body. • They consist of starch, sugars, and cellulose. Cereals and roots and tubers used as vegetables are rich in starch and account for the most of dietary carbohydrates. • Cane sugar and glucose are pure carbohydrates. Cellulose is the fibrous substance lining fruits, vegetables and in fibers. • Should provide 50-70% of total caloric intakein diet

36. Dietary fiber has not been considered an important component of human diet probably because it has no nutritional value. Most of the fiber is removed from the cereals by milling, while peelings, boiling reduce the same in vegetables and fruit. • Of the late there has been a reawakening of interest about useful role in dietary fiber. a wide range of diseases like constipation, colonic cancer, CHD, appending and gall stone have been associated with the deficiency of the dietary fiber.

37. Energy metabolism • Energy is required for: • Basal metabolism ( maintaining life) • Voluntary exercise and activity • Additional need such as growth. • Energy is derived from the oxidation of carbohydrates, fats, and proteins in the diet. We measure the energy value of the food or the energy needs of the body in unit called calories or joules. The calorie or the joule is measure of heat

38. Calorie: one large calorie ( kcal) is the amount of heat required to raise the temperature of 100 g of the water by 1C. In nutrition the large calorie is always used. It is 1000 times as great as the small calorie unit used in chemistry or physics. • Joule: the international unit of energy is joule. It is defined as the amount of heat needed to raise the temperature of 240 g of water by 1 C

39. 1 kcal = 4.184 kilojoules • The energy value of food is measured in the laboratory by an instrument called a bomb calorimeter. • Ex: carbohydrates: 4 kcal/gram, Fat: 9 kcal/gram, Protein: 4 kcal/gram. • Thus if we know the carbohydrate, fat and protein contents of food or diet, we can calculate the calorie value. • Energy needs of the body: the body used glycogen, sugars, fatty acids, glycerol and amino acids to supply energy.

40. The breakdown of these substances required numerous steps and is a very complex process. • The rate of breakdown depends upon the total daily energy requirement: the basel metabolism, the amount of voluntary activity, the influence of food and the need of growth. • Basel metabolism: account for more than ½ the energy requirement for most people. Its include the involuntary activity of the body while at rest but awake

41. The basal metabolism can be measured as basel metabolism rate(BMR). The following conditions are observed: • The individual is a wake but laying quietly in comfortable room. • He is in the post absorptive state( he has had no food for 12-16 hours). • The body temperature is normal • He is not tense or emotionally upset.

42. The BMR is then measured by indirect calorimeter, which is the measurement of oxygen consumption and carbon dioxide production arising from the combustion of specific nutrients. It is based on the fact that the amount of energy expended is always in direct relationship to the amount of oxygen utilized in the combustion of various food componants

43. In clinical practice, BMR can be estimated accurately by measuring O2 consumption of the patient for two 6 min periods under basel condition thus: • O2 consumption/hour= average O2 consumptionx10 • 1L of O2 = 4.825 kcal/hour • Convert O2 consumption/hour into kcal/hour • BMR=( Kcal/hour)/surface area = Kcal/m2/h • Surface area =obtained from the nanogram

44. Several factors affect the BMR: these include body size, muscle tissue, growth, age, thyroid state and climate.. • Voluntary activity: increases the energy requirement considerably. When calculating the person's energy needs the BMR may have to be doubled for a very active person. Under most normal life includes mainly light exercise ( office workers, teachers), moderate exercise ( nurses) of heavy exercise ( manual laborers

45. Useful table based on the type f activity, age and weight are available to help one determine quickly the needs of the individuals.

46. Classification of overweight and obesity Disease risk: DM 2, hypertension, CVD for men >40 inches and women>35 inches

47. Medications that can cause weight gain

48. Pharmacological treatment options available in USA

49. Complementary and alternative medicine