Meeting Basic Needs:

NUTRITION

NOEL M. LAXAMANA, MD, FPAFP, DPCOM

Fellow in Family Medicine
Green, G.B. et al. The Washington Manual of Medical
Therapeutics. 31st Ed. Philadelphia: Lippincott Williams &
Wilkins. 2004.

McGuire, M. Nutritional Sciences: From Fundamentals to Food.

2nd Ed. California: Wadsworth Cengage Learning. 2011.

Wallace, R. Maxcy-Rosenau-Last Public Health & Preventive

Medicine. 15th Ed. New York: McGraw Hill Medical. 2008.

Barker, L.R. et al. Principles of Ambulatory Medicine. 6th Ed.

Philadelphia: Lippincott Williams and Wilkins. 2003.

References
 Let thy food be thy
medicine and thy
medicine be thy food.

Hippocrates (460-364 B.C.)

 Nutrition as a public health concern
 Nutritional requirements & recommended intakes
 Nutritional status assessment
 Review on basic food pathway
 Selected macro- and micronutrient deficiency states

LECTURE OUTLINE
Nutrition
 The science which deals with food and how the body uses it.
 It is influenced by various disciplines.

Dietetics

Economics Clinical Nutrition

Behavioral NUTRITION Metabolism

Sciences

Food Biochemistry
Technology
Agriculture
 Basic Concepts
 Nutrition refers to the science of how living organisms obtain
and use food to support all the processes required for their
existence.

 Food is made up of different nutrients needed for growth and

health.

 All persons, throughout life, have need for the same nutrients,
but in varying amounts.

 The way food is handled influences the amount of nutrients in

it, as well as its safety, appearance, and taste.
 Basic Concepts
 Nutrients are substances in foods required or used by the
body for at least one of the following: energy, structure or
regulation of chemical reactions.

 Essential nutrients must be obtained from the diet, because

the body needs them & either can’t make them at all or can’t
make them in adequate amounts.

 Nonessential nutrients are food components that, if

necessary, the body can make in amounts needed to satisfy its
physiological requirements.
 Basic Concepts
 Macronutrients include water, carbohydrates, proteins and
lipids because they are needed in large amounts.

 Micronutrients include vitamins and minerals because they

are needed on only very small amounts.
Major Classification of Foods

 Sources of energy
 Sources of proteins
 Sources of vitamins and minerals
Major Classification of Nutrients in Foods
MACRONUTRIENTS

 Carbohydrates (4 kcal/gm) - 50% to 60% T.E.R.

 Proteins (4 kcal/gm) – 10% to 15% T.E.R.

 Fats (9 kcal/gm) – 30% to 35% T.E.R.

* Total Energy Requirements

** A kilocalorie is the amount of heat required to raise the temperature of
1 kilogram of water 1 degree Celsius
Major Classification of Nutrients in Foods
MICRONUTRIENTS

Vitamins
 Water soluble vitamins : B complexes & ascorbic acid
 Fat soluble vitamins: A, D, E, and K

Minerals
 Major: Ca, P, Mg, Na, Cl, K
 Trace: Fe, Cu, I, Se, Cr, Mn, Mo, Zn
Nutrient Requirement and Recommended
Intakes
Nutrient Requirement
 the minimum amount of nutrients needed to maintain
optimum health and growth
 determined by age, sex, physiologic states, body weight and
activity

Recommended Intake or RDAs

 it is equal to nutrient requirement plus a safety margin to allow
for individual variations and other factors
 used as nutrient-intake goals for individuals
Nutritional Status
 It is the outcome of food as to its –

Availability Consumption Utilization

Production Socio-cultural factors Health Aspects

Economics Health Aspects
Storage Food Technology
Distribution
Marketing
 Classification of Nutritional Status
UNDERNOURISHED
◦ Mild: 80% to 89% of standard weight for age
◦ Moderate: 70% to 79% of standard weight for age
◦ Severe: < 70% of standard weight for age

ADEQUATELY NOURISHED
◦ 90% to 110% of standard weight for age

OVERNOURISHED
◦ Overweight: 111% to 120 % of standard weight for age
◦ Obese: > 120% of standard weight for age
OBESITY
Methods Used in Nutritional Status Assessment
COMMUNITY LEVEL

 Nutrition Surveys
◦ aimed to provide the data needed for planning or improvement
of nutrition intervention programs
◦ uses:
a. Nutritional surveillance
b. Provide baseline and progress data to evaluate specific
programs
c. Provide data for nutrition education programs

 Vital Statistics
◦ Morbidity rates
◦ Mortality rates
Methods Used in Nutritional Status Assessment
INDIVIDUAL LEVEL / DIRECT METHOD

 Clinical examinations
 Anthropometric measurements
 Biochemical determinations
 Physiologic studies
Methods Used in Nutritional Status Assessment
HOUSEHOLD LEVEL / INDIRECT METHOD
 Studies on food availability
 Studies on dietary practices and habits
 Measurement of food and nutrient intake
 Socio-cultural and economic conditions studies
 Studies on health conditions
 Determination of pertinent characteristics of the physical
environment
 Indicators of Nutritional Status
Weight-for-age
 indicator of current, acute malnutrition/nutritional depletion
Height/Length-for-age
 indicator of past or chronic malnutrition
Upper Midarm Circumference for Age
 for preliminary screening of malnourished individuals during
emergency situations; good gauge of nutrition for the under-six child
Triceps Skinfold Thickness
 for obesity assessment; rough estimate of body composition
Weight-for-Height
 a good indicator of current, acute malnutrition
 more accurately assesses body build
 useful in identifying a child who is acutely malnourished
 Community Nutritional Status

Educational Economic Food Health Preventive

level level availability aspects sources
CNS:___________________________________________________

Population Size
Food Consumption Surveys

 an important adjunct to the more direct methods of nutritional

status assessment

 purposes:
a. to assess the diets of populations
b. to provide bases for economic, agricultural and educational
measures aimed at improving dietary practices
Basic Tools in Food Consumption Surveys
1. Dietary Methods
a. Qualitative data vs. Quantitative data
b. Detailed data vs. Generalized data

2. Food Composition Tables

 most commonly used tool in evaluating nutrient contents of diets
 contains analysis of foods and the average nutrient content

3. Recommended Dietary Allowance

 a list of recommended intakes for specific nutrients for a particular
age, sex, or physiological state
 gives information on the nutrient adequacy of dietary intakes
 Dietary Methods at Different Levels

1. Population Level
 Food Balance Sheet / Apparent Food Consumption Data

2. Household Level
 Food inventory and food list

3. Individual Level
 Recording or recall of present intake
 Retrospective: 24-hour food recall, food frequency questionnaire
 Prospective: diet record, food record
Food Pathway and Points of Disruption

I. Ingestion
II. Digestion
III. Absorption / Utilization
IV. Metabolism
V. Excretion
VI. Others
I. Ingestion
Point of disruption is present when there is a failure to take in the
proper quantity and quality of foods to meet the individual
requirements.

Affected by:
a. Economic
b. Psychologic: anorexia nervosa, psychiatric disorders
c. Psychosocial: dietary foods, crash diets, reliance on
snack foods
d. Cultural: regional or national food habits
e. Educational: ignorance of essentials
I. Ingestion
Affected by: (cont’d)

f. Inability to obtain, prepare and serve foods to self:

elderly as physically handicapped persons
g. Chronic alcoholism and chronic drug addiction
h. Iatrogenic: protracted use of unbalanced or restrictive
therapeutics diets
i. Anorexiant drugs: amphetamines
j. Loss of teeth or presence of ill-fitting dentures
II. Digestion

Inadequate intake of food because of GIT disorders

Affected by:
a. Anorexia following major surgery, especially GIT surgery
b. Loss of sense of taste or smell
c. Difficulty or inability to swallow food (neurologic or
obstructive lesions)
d. Pain on ingestion of food (oral, esophageal, or gastric
lesions)
e. Chronic nausea and vomiting
III. Absorption / Utilization
Defective absorption or utilization of food because of GIT
diseases

Affected by:

a. Interference with the absorption of fat in any disease such

as diarrhea, ulcerative colitis, dysentery, intestinal
obstruction, celiac disease, congenital atresia of bile
ducts, etc.
b. Reduced absorbing surfaces, altered secretions,
hypermotility, taking in of alkalis, absorbents, etc.
IV. Metabolism

Impaired metabolism of nutrients

a. Hereditary biochemical disorders

b. Acquired biochemical disorders (liver damage, drugs)

V. Excretion
Factors increasing excretions

Affected by:
a. Increase fluid output (as in forcing of fluids, excessive
perspiration, polyuria, lactation may accentuate existing
deficiencies)
b. Various drugs used as therapeutic agents may increase
excretion of Vitamin C
c. Excess protein loss may occur from hemorrhage, operations,
injuries, GIT obstructions, burns, proteinuria
VI. Others
Increased need for food

Affected by:

a. Increase physical activity (heavy labor and exercise)

b. Chronic febrile states
c. Increase metabolism (hyperthyroidism, fever)
d. Abnormal excretion
e. Pregnancy / Lactation
 Important Malnutrition Types

I. Protein Energy Malnutrition

II. Nutritional Anemias
III. Vitamin A Deficiency Disorder
IV. Iodine Deficiency Disorder
I. Protein Energy Malnutrition
 Results when the body’s need for protein, energy or both
cannot be satisfied by diet

 Affects primarily infants and preschool children

 W.H.O. estimates 800 M to 1 billion people involved

 Philippines
◦ 8 out of 100 are moderate to severely malnourished
◦ 30 out of 100 are mildly malnourished
 Severe Types of Protein Energy Malnutrition
MARASMUS
 energy deficient malnutrition

Causes:
a. Early weaning from breast feeding
b. Diluted milk formula / inadequate lactation

Characteristic appearance:
a. Generalized muscle wasting, absence of subcutaneous fats,
skin and bone appearance
b. Apathetic and anxious; “wizened old man” appearance
c. Marked growth retardation and <60% weight-for-age
d. Non-elastic and wrinkled skin
 Severe Types of Protein Energy Malnutrition
KWASHIORKOR
 protein deficient malnutrition
Causes:
a. Late weaning
b. Supplementary foods given are starchy
Characteristic appearance:
a. Soft, painless, pitting edema
b. “Flaky paint” or “crazy pavement” dermatitis
c. “Flag sign” of the hair

Both or Marasmic-Kwashiorkor
 deficient in both energy and protein
II. Nutritional Anemias
 Conditions which result from the inability of erythropoietic
tissue to maintain a normal hemoglobin concentration due to
inadequate supply of one or more essential nutrients

 Types:

a. Iron Deficiency Anemia

b. Folate Deficiency Anemia
c. B12 Deficiency Anemia
Hemoglobin Levels Indicative of Anemia for People
Living at Sea Level
(W.H.O., 1968)

Hemoglobin (g/dL)

Children 6 months – 6 years < 11

Children 6 years – 14 years < 12
Adult male < 13
Adult female, non-pregnant < 12
Adult female, pregnant < 11
A. Iron Deficiency Anemia
 Microcytic, hypochromic RBC, high TIBC, low serum ferritin level
Causes:
1. Decreased Iron Absorption
a. Decreased iron intake
b. Poor bioavailability;
i. Heme iron: 20% - 30%
ii. Non-heme iron: 1% - 6%

2. Increased Blood Loss

a. Parasitic infection
b. Excessive menstrual flow
c. Bleeding from GIT

3. Increased utilization associated with increased requirements

A. Iron Deficiency Anemia
Treatment:

Adults and adolescents: Iron (60 mg to 120 mg/day)

Infants and Children: Iron (3 mg/kg BW/day)

Pregnant women: Iron (120 mg/day)

B. Folate Deficiency Anemia
 Megaloblastic, macrocytic, hypochromic RBC

Causes:
1. Decreased Folic acid intake
2. Defective Folic acid absorption
3. Increased requirements
4. Drug use

Treatment:
Usual dosage: Folic acid 200-400 μg/day
Pregnant women: Folic acid 600 μg/day
C. B12 Deficiency Anemia
 Megaloblastic, macrocytic, hypochromic RBC

Causes:
1. Strict vegetarian diet
2. Absence of Intrinsic factor
3. Parasitic infections
4. Drug intake

Treatment:
Vitamin B12 at 1 μg/day
Clinical Features of Anemia
1. Pallor
2. Respiratory distress
3. Sleepiness and fatigability
4. Reduced power of concentration
5. Systemic disturbances as condition worsens
Effects of Anemia
1. Poor work performance
2. Adversely affects pregnancy
3. Increased susceptibility to infections
4. Poor mental performance
Diagnosis of Nutritional Anemias

1. Measurement of Hemoglobin
2. Estimation of Hematocrit
3. Thin Blood Smear
4. Specific tests
Prevention of Nutritional Anemias
1. Supplementation with medicinal drugs
2. Education and associated measures to increase
dietary intake
3. Control of infections
4. Food fortification
III. Vitamin A Deficiency Disorder
 Most common cause of preventable blindness among children

 Extremely rare among developed countries, but it is a major

health problem in developing and underdeveloped countries

 In the Philippines, 11 out of 15 regions have Vitamin A

deficiency
◦ Still a major health problem among 6 month-old to 6 year-old
children
Vitamin A Status
1. Acceptable
 Liver stores are enough to maintain normal levels of circulating
Vitamin A
2. Marginal
 Low levels of circulating Vitamin A, but liver stores are not yet
fully exhausted
3. Deficient
 Liver stores and circulating levels of Vitamin A have been
depleted
4. Excessive
 Excessive Vitamin A stored in the liver
Functions of Vitamin A
1. Proper vision
2. Maintenance of the integrity of the epithelial lining
3. Growth
4. Reproduction
5. Immune system
Vitamin A Deficiency Disorder Risk Factors
1. HOST
a. Age
b. Sex
c. Protein Energy Malnutrition
d. Diarrhea, RTI, Measles, and other infections
2. AGENT / DIET
a. Inadequate intake of Vitamin A rich food
b. Withholding of breast feeding
c. Low fat, low protein and low Vitamin E diet
3. ENVIRONMENT
a. Seasonality of vitamin A rich foods
b. Infections and parasitic infections
Xerophthalmia
 Visual disorder caused by vitamin A deficiency

Clinical Features
1. Night blindness
2. Conjunctival xerosis
3. Bitot’s spot
4. Corneal xerosis, ulceration and softening
Treatment and Prevention
Vitamin A Treatment of Xerophthalmia
Infant/children <8 kg Preschoolers
Upon diagnosis 100, 000 IU 200, 000 IU
2nd day 100, 000 IU 200, 000 IU
4th week 100, 000 IU 200, 000 IU

Vitamin A Prevention Schedule of Xerophthalmia

Infant/children <8 kg Preschoolers
1st contact 100, 000 IU 200, 000 IU
6th month 100, 000 IU 200, 000 IU

**Post partum mothers: 200,000 IU within the 1st month

IV. Iodine Deficiency Disorder
 Associated with inadequate intake or absorption of iodine

Consequences include –
1. Physical retardation
2. Mental retardation
3. Fetal wastage
4. Poor socio-economic productivity
Predisposing Factors of Iodine Deficiency Disorder
1. Genetics
2. Goitrogens
3. Malnutrition
4. Poverty
5. Strictly farming areas
6. Susceptibility of the host
 Spectrum of Iodine Deficiency Disorder
1. FETAL STAGE
a. Abortion, stillbirth, perinatal death or LBW
b. Cretinism
c. Psychomotor defects
d. Subnormal mental/cognitive functions
2. INFANT STAGE:
a. Neuromuscular disorders
b. Deaf-mutes
3. CHILDHOOD STAGE:
a. Goiter
4. ADULT STAGE
a. Goiter
Prevention and Control of Iodine Deficiency Disorder
1. Iodination of salt
◦ 20 mg to 50 mg/Kg salt
2. Iodination of drinking water
◦ 4 to 6 drops of Lugol’s solution (0. 03g KIO3/20 ml H2O ) in a glass
of water
3. Iodized oil
◦ Injectible iodized oil: Lipiodol 0.5 to 1 ml deep IM
◦ Oral iodized oil capsule
4. Education and Communication
◦ Politicians/Leaders
◦ Health workers
◦ Community and Citizen groups
Thank you for listening!