NUTRITION

1. NUTRITION

2. Nutrition is the science of dealing with the utilization of food by the body processes which transforms food into body tissues and energy. • Nutrients are the constituents of food which are necessary to sustain the normal functions of the body. • The energy is provided by three classes of nutrients: fats, carbohydrates, proteins. The intake of these nutrients is larger than that of the other dietary nutrients. Therefore, they are called the macronutrients

3. . Those nutrients needed in lesser amounts, such as vitamins and minerals, are called the micronutrients Both macronutrients and micronutrients in optimal amounts are needed to maintain health and prevent disease in adults.

5. Biomedical importance Nutritional disorders may be due to deficiency or excess of nutrients. Common nutritional disorders are: • Obesity • Malnutrition • Vitamin deficiency disorders Obesity is a disorder of chronic calorie excess characterized by an accumulation of excess body fat . Malnutrion is the most wide spread nutritional problem in developing country affecting children. At one end of spectrum of malnutrition is marasmus and at the other end of the spectrum is kwashiorkor

6. Balance diet • A balance diet is defined as a diet , which contains variety of foods in such quantities and proportions that the need for energy , amino acids, minerals , fats , carbohydrates and other nutrients is adequately met for maintaining health, vitality, and general well being. • A balanced diet is a diet that provides all the 6 nutrients : carbohydrates, proteins, fats, minerals , vitamins , water in proper amounts and proportions to maintain good health.

7. Dietary goals ( recommendations for a balanced diet ) • BD must be low in saturated and trans fats , cholesterol, added sugars , salt. • Water : up to 1.5 lit to 2 liter day • Adequate Fibers and antioxidants • Energy : total supply should be +50 of RDA • Protein to be 10 to 15 % • Junk foods much be reduced • Main food :75% energy from cereals • 1:4 to 1:5 cereals to pulse ratio • Milk : 100ml in a day • 1 medium sized fruit and green leafy vegetables • Reduce alcohol consumption.

8. Construction of a balanced diet: 1. Selection of foods : The food selected should be economic, locally available, palatable and easily digestible. Foods should be selected from the basic food groups (cereal group, Protein/Meat group, Fruits & Vegetable group, Milk group, Sugar, Fats and Oil Group). Balanced diet should contain calories from carbohydrate, proteins and fats in the ratio 60:20:20 and obtained from the basic food groups. 2.Calories: Calorie requirement depends on the height, weight and physical activity of the individual . On an average calorie requirement for a person is taken as 30-35 kcal per kg of ideal body weight. 3. Protein requirement: 1g per kg body weight for adults and 2g per kg body weight for children. During pregnancy and lactation protein requirement is about 2.5 g per kg body weight

9. ICMR recommended Balanced Diet

10. Role of proteins in diet (nutritional role of proteins) • Required for : 1. provision of essential amino acids . 2. provision of energy (10% total energy requirement of body ) 3. provision of nitrogen , phosphorous and sulfur. Quality of dietary proteins: Is determined by their some of the indices … 1) Essential amino acid content and digestibility . 2) Biological value of proteins (BVP) 3) Net Protein utilization(NPU) 4) Chemical score 5) Digestibility coefficient

11. 1) Biological value of protein (BPV) Definition : it is the ratio between the amounts of nitrogen retained to the amount of nitrogen absorbed BVP= Nitrogen retained X 100 Nitrogen absorbed • It reflects the essential amino acid content of the proteins but not digestibility 2) Net protein utilization (NPU) Definition : ration between the amounts of nitrogen retained to the amount of nitrogen intake . NPU= Nitrogen retained X 100 Nitrogen intake • It accounts for both essential amino acid content and digestibility of proteins .

12. Foods Net Protein Utilization Egg - 100 % Milk - 100 Meat - 92 Fruits - 76 Vegetables - 73 Legumes - 70 Cereals - 59

13. 3) Digestible coefficient (DC): It is the percentage of food nitrogen which is absorbed from elementary canal. DC= Food nitrogen –(fecal nitrogen – metabolic fecal nitrogen )X 100 Food nitrogen Importance : legumes and seeds have lower DC than milk and egg proteins. Cooking improves DC of plant proteins. • Chemical score : Ratio between the content of most limiting amino acid in a test protein to the content of the same limiting amino acid in egg protein.(reference protein ) Chemical score = mg of limiting amino acid /g of protein X 100 mg of the same amino acid /g of egg protein

14. Dietary sources of proteins : There are two main dietary sources of proteins : A) Animal sources : contains all essential amino acids in sufficient amounts and have good digestibility . Called as complete proteins/ first class proteins. E.g. egg, milk ,meat , fish etc. B) vegetable sources : lack some essential amino acids. Incomplete proteins/ class II proteins. E.g. cereals and pulses Soy proteins is only complete plant protein.

15. Nutritional classification of proteins 1) complete proteins: contains all essential amino acids in sufficient amounts and good digestibility. E g. Egg, milk ,meat. 2) partially complete proteins :they partially lack one or more essential amino acids. They promote moderate growth. E.g. vegetable proteins . 3) Incomplete proteins: They completely lack one or more essential amino acids. They do not promote growth at all. E.g Zein of corn and gelatin of animal source.

16. Limiting amino acids : Some vegetable proteins lack one or more essential amino acids. E.g. pulses are deficient in methionine and cereals are deficient in lysine. Complementary action of proteins (complementary proteins) : Consuming mixed diet will solve problem of limiting amino acids. i.e combination of foods. This combination of different vegetables will form first class protein. This is called Mutual supplementation of proteins.

17. Food exchange system :foods with similar nutrient composition can be grouped together and they can be exchanged to provide dietary variety • E.g various legumes-pulses like bengal gram, red gram , black gram, green gram can be exchanged.

19. Nitrogen balance or Nitrogen equillibrium : Nitrogen intake should be equal to nitrogen output (in urine and feces ) N intake= N= output. Negative nitrogen balance: Nitrogen intake < Nitrogen output. Seen in starvation, protein energy malnutrition , wasting diseases like tuberculosis and illness . Positive nitrogen balance: Nitrogen intake > Nitrogen output

20. Protein Deficiencies • Adults : Protein deficiency in adults leads to loss of body weight, anemia, susceptibility to infection , general lethargy, edema , and delay in wound healing. • Children : Deficiencies of proteins mainly cause Protein Energy Malnutrition.

21. Spectrum of PEM in different age groups:

22. Protein Energy Malnutrition • Most common nutritional disorder of the developing countries including INDIA. • KWASHIORKOR and MARASMUS are two extreme forms of PEM.

23. Kwashiorkor • Definition : the word kwashiorkor is derived from(tribe ) Ghana , which means “ the sickness the older one gets when the next child is born “ • Kwashiorkor is caused due to protein deficiency in the presence of adequate calorie /energy. • Causes: Children between 1-5 years ,child weaned from mothers breast milk to carbohydrate rich food deficient in proteins.

24. Kwashiorkor • Edema • Pot (swollen ) belly • Fatty liver (enlarged liver due to fat accumulation) • Skin lesions • Discoloured hair ( due to lack of melanin formation ) • Anorexia • Hypoalbuminemia ( decreased serum levels of albumin )

25. Edema due to hypoalbuminemia Flaky paint dermatosis Flag sign in hair

26. Neurological changes: • slowing or regression of milestones, kwashi shakes • GIT: • Anorexia, Diarrhoea, abdominal distension, anemia • CVS: • Cold, pale extremities due to circulatory insufficiency. • Prolonged circulation time, bradycardia, hypotension, decreased cardiac output. • Impaired renal functions • Frequent hypoglycemic episodes

27. Changes in body composition: • Total body water • Increased. Increase in ECF seen in edema. • Total body protein • Reduced to approx 55-60% normal baby. • Mainly non-collagen proteins are reduced. • Muscle mass is greatly reduced as amino acids from myofibrils are translocated to liver & other tissues for their needs.

28. Total body fat • Normal or increased • Fatty liver is commonly seen. • Total body carbohydrates • Normal or reduced. • Due to fatty liver, glycogen storing capacity of hepatocytes is reduced. So hypoglycemia is common & frequent in such babies.

29. Changes in Hematopoietic system: Anemia is an invariable feature. Causes are: • Dietary deficiency of iron, folic acid or vit B12. • Reduction in Hb synthesis & red cell mass as an adaptation to reduced metabolic activity & decreased O2 requirement by tissue. • Erythropoietin secretion is reduced. • Malaria, hookworm infestation & other infections.

30. Changes in Immunological system: Cellular immunity is more affected. It is evidenced by presence of thymic & other lymphoid organ atrophy in kwashiorkor. Though concentration of γ-globulin in serum remains unaffected, Humoral immunity is deranged due to defective processing of antigen by antigen presenting cells. SecretoryIgA concentration are low in mucosal secretion  increased frequency of respiratory & GIT infection.

31. MARASMUS Definition : Marasmus ( means wasting ) is characterized by predominant energy deficiency and a lesser protein deficiency . ( primary calorie deficiency and secondary protein deficiency ) Causes: Seen in children less than 1 year when mother’s milk is weaned and replaced by a low cost native cereal diet, which is poor in both calorie and protein . ( so marasmus is also called protein calorie malnutrition )

32. MARASMUS Symptoms • Extreme muscle wasting ( emaciation ) • Weakness • Anemia • Diarrhea • Face of the patient shows apathy( no interest) • Marasmic patients do not show edema and decreased serum albumin in kwashiorkor .

33. Chest to head circumference ratio is reduced Generalized Emaciation of fat but prominently seen at buttocks, buccal pad etc. Irritable

34. Changes in body composition: Total body water: • Increased due to disappearance of fat stores & muscle wasting. Total body protein: • Reduced due to diversion of body protein to gluconeogenesis. • Muscle mass is severely reduced. • Here, contractile myofibril proteins are lost more than interstitial collagen  weakening of contractile power.

35. Total body fat • Markedly reduced. • Here, body fat may drop to as low as 5% of body weight. (Normal = 19% of body wt) • Total body carbohydrates • Liver glycogen stores are markedly reduced due to unavailability in diet. • Hypoglycemia is frequently seen.

36. Changes in Metabolism: • Deficient calorie intake  limited glycogen & fat stores. • When liver glycogen starts depleting, body starts using fats for energy purpose  increased mobilization of fat from adipose tissue to liver & then to peripheral tissues for energy purpose. • On the other side, glucose is spared for the organ like brain.

37. Overall changes in metabolism in marasmus GIT

38. Changes in Hematopoietic system: • Anemia: due to dietary deficiency of iron, folate, vit B12, worm infestation etc. • Leucocytes & Platelets appears normal. Changes in Immunological system: • Cellular immunity is slightly depressed but humoral immunity remains normal except in severe cases.

39. Difference b/w kwashiorkor & marasmus: Kwashiorkor Marasmus

40. Kwashiorkor • S. Protein: low (↓ albumin & β-globulin) • A:G ratio: reversed • Edema • Total Body Lipid: high • Fatty liver in characteristic feature. • Anorexia, less glycogen store in fatty liver  Hypoglycemia Marasmus • S. Protein: reduced but not so low as kwashiorkor • A:G ratio: maintained • Muscle wasting • Total Body Lipid: low • Fatty liver not common • Reduced intake, less glycogen & fat reserve  Hypoglycemia

41. Management of PEM: • Resuscitation. • Routine Treatment. • Diet management.

42. Resuscitation Prevent & Correct… • Hypothermia: warm atmosphere • Hypoglycemia: IV glucose, frequent feeding • Dehydration: IV fluids, ReSoMal, ORS • Electrolyte disturbances: • Micronutrient deficiency: multivitamin & mineral supplements. Treat infection if present

43. Initiate feeding: • Start with 100 kcal/kg/day with protein 1-1.5gm/kg/day & fluid130ml/kg/day. • In c/o edema give 100ml fluid/kg/day. • Increase upto 150-200 kcal/kg/day with 3-4gm protein/kg/day. • Look for improvement of edema & general conditions.

44. Diet management • Started initially as stated in resuscitation. • Addition of ghee, jaggery, oils can make food energy dense. Regular diet: • For Kwashiorkor  150kcal/kg/day • For Marasmus  200kcal/kg/day • Proteins  4gm/kg/day • Use of seasonal fruits & vegetables should be encouraged.

45. obesity • Most prevalent nutritional disorder. Obesity index : or modern expression Body Mass Index : W/H2 height in meters square. Disease related to obesity : Syndrome X: metabolic syndrome ( insulin resistance, hyperglycemia, hyperlipidemia) • Obesity leads to Diabetes Mellitus, CAD, hypertension. Treatment : • Lifestyle modification, Atkins diet : low carbohydrate ketogenic high protein diet for losing weight.

46. Other nutritional disorder include : • Rickets • Osteomalacia, • Iron Deficiency anemia • Night blindness • Beriberi, • Pellagra, • Pernicious Anemia , • Scurvy etc.

47. To summarize

48. Thank you