FOT 339

PRINCIPLES OF FOOD SCIENCE

AND NUTRITION
 LAST LECTURE
DISCUSSION

• MODIFICATION IN DIET
MALNUTRITION
PROTEIN-ENERGY
MALNUTRITION
 Definitions

 MALNUTRITION
WHO defines Malnutrition as "the cellular imbalance
between the supply of nutrients and energy and the
body's demand for them to ensure growth,
maintenance, and specific functions.“
Malnutrition is the condition that develops when the body
does not get the right amount of the vitamins, minerals, and
other nutrients it needs to maintain healthy tissues and
organ function.
  PROTEIN ENERGY MALNUTRITION
It is a group of body depletion disorders which include
kwashiorkor, marasmus and the intermediate stages

 MARASMUS
Represents simple starvation . The body adapts to a
chronic state of insufficient caloric intake
 KWASHIORKOR
It is the body’s response to insufficient protein intake
but usually sufficient calories for energy
DESCRIPTION

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 Protein-Energy Malnutrition
 PEM is also referred to as 
protein-calorie malnutrition.
 It is considered as the primary
nutritional problem in India.
Also called the 1st National
Nutritional Disorder.
 The term protein-energy
malnutrition (PEM) applies to
a group of related disorders
that
include marasmus, kwashiork
or, and intermediate states of
marasmus-kwashiorkor.
 PEM is due to “food gap”
between the intake and
requirement.
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AETIOLOGY
 AETIOLOGY:
Different combinations of many aetiological
factors can lead to PEM in children. They are:
Social and Economic Factors
Biological factors
Environmental factors
Role of Free Radicals & Aflatoxin
Age of the Host

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 Amongst the Social, Economic, Biological and
Environmental Factors the common causes are:
 Lack of breast feeding and giving diluted formula
 Improper complementary feeding
 Over crowding in family
 Ignorance
 Illiteracy
 Lack of health education
 Poverty
 Infection
 Familial disharmony

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  Role of Free Radicals & Aflatoxin: Two new
theories have been postulated recently to explain the
pathogenesis of kwashiorkor. These include Free
Radical Damage & Aflatoxin Poisoning . These may
damage liver cells giving rise to kwashiorkor.
 Age Of Host :
Frequent in Infants & young children whose rapid
growth increases nutritional requirement.
PEM in pregnant and lactating women can affect the
growth, nutritional status & survival rates of their
fetuses, new born and infants.
Elderly can also suffer from PEM due to alteration of
GI System
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CLINICAL FEATURES
 The clinical presentation depends upon the type
, severity and duration of the dietary deficiencies. The
five forms of PEM are :

1. Kwashiorkor
2. Marasmic-kwashiorkor
3. Marasmus
4. Nutritional dwarfing
5. Underweight child
 Classification of PEM
(FAO/WHO)
Body weight
as percentage Oedema Deficit in
weight for
of standard height
Kwashiorkor 60 – 80 + +

Marasmic < 60 + ++
kwashiorkor
Marasmus < 60 0 ++

Nutritional < 60 0 Minimal

dwarfing
Underweight 60 – 80 0 +
child
Source: FAO / WHO 1971 Expert
Committee on Nutrition 8th Report.
WHO Technical Report Series 477
 KWASHIORKOR

 The term kwashiorkor is taken from the Ga language of
Ghana and means "the sickness of the weaning”.
 Williams first used the term in 1933, and it refers to
an inadequate protein intake with reasonable caloric
(energy) intake.
 Kwashiorkor, also called wet protein-energy
malnutrition, is a form of PEM characterized primarily by
protein deficiency.
 This condition usually appears at the age of about 12
months when breastfeeding is discontinued, but it can
develop at any time during a child's formative years.
 It causes fluid retention (edema); dry, peeling skin;
and hair discoloration.
 Kwashiorkor was thought to be caused by
insufficient protein consumption but with
sufficient calorie intake, distinguishing it from
marasmus.
 More recently, micronutrient and antioxidant
deficiencies have come to be recognized as
contributory.
 Victims of kwashiorkor fail to produce Antibodies
following vaccination against diseases, including
diphtheria and typhoid.
 Generally, the disease can be treated by adding food
energy and protein to the diet; however, it can have a
long-term impact on a child's physical and mental
development, and in severe cases may lead to death.
 SYMPTOMS
 Changes in skin pigment.
 Decreased muscle mass
 Diarrhea
 Failure to gain weight and grow

 Fatigue
 Hair changes (change in color or
texture)
 Increased and more severe
infections due to damaged immune
system
 Irritability
 Large belly that sticks out
(protrudes)
 Lethargy or apathy
 Loss of muscle mass
 Rash (dermatitis)
 Shock (late stage)

 Swelling (edema)
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 MARASMUS

 The term marasmus is derived from the Greek word
marasmos, which means withering or wasting.
 Marasmus is a form of severe protein-energy malnutrition
characterized by energy deficiency and emaciation.
 Primarily caused by energy deficiency, marasmus is
characterized by stunted growth and wasting of muscle and
tissue.
 Marasmus usually develops between the ages of six
months and one year in children who have been weaned
from breast milk or who suffer from weakening conditions
like chronic diarrhea.
SYMPTOMS
 Severe growth retardation
 Loss of subcutaneous fat
 Severe muscle wasting



limbs appear as skin and bone
Shriveled body

The child looks appallingly thin and

 Wrinkled skin
 Bony prominence
 Associated vitamin deficiencies
 Failure to thrive
 Irritability, fretfulness and apathy
 Frequent watery diarrhoea and acid
stools
 Mostly hungry but some are
anoretic
 Dehydration
 Temperature is subnormal
 Muscles are weak
 Oedema and fatty infiltration are
absent
DIFFERENCE IN CLINICAL FEATURES
BETWEEN MARASMUS AND
KWASHIORKOR
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DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

CLINICAL MARASMUS KWASHIORKOR

FEATURES
-MUSCLE WASTING
Obvious Sometimes
hidden by edema and
fat
-FAT WASTING Severe loss of Fat often retained but
subcutaneous fat not firm

-EDEMA None Present in lower legs,

and usually in face and
lower arms

May be masked by
-WEIGHT FOR Very low edema
HEIGHT
Irritable, moaning,
-MENTAL CHANGES Sometimes quite and apathetic
apathetic
DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

CLINICAL FEATURES MARASMUS KWASHIORKOR

-APPETITE Usually good Poor

-DIARRHOEA Often Often

-SKIN CHANGES Usually none Diffuse pigmentation,

sometimes „flaky paint
dermatitis‟

-HAIR CHANGES Seldom Sparse, silky, easily

pulled out

-HEPATIC None Sometimes due to

ENLARGEMENT accumulation of fat
MARASMIC-KWASHIORKOR
A severely malnourished child
with features of both
marasmus and Kwashiorkor.
 The features of
Kwashiorkor are severe
oedema of feet and legs and
also hands, lower arms,
abdomen and face. Also there
is pale skin and hair, and the
child is unhappy.
 There are also
signs of marasmus, wasting
of the muscles of the upper
arms, shoulders and chest so
that you can see the ribs.
 NUTRITIONAL DWARFING
OR STUNTING

 Some children adapt to prolonged insufficiency of

food-energy and protein by a marked retardation of
growth.
 Weight and height are both reduced and in the
same proportion, so they appear superficially
normal.
 UNDERWEIGHT CHILD

 Children with sub-

clinical PEM can be
detected by their weight
for age or weight for
height, which are
significantly below
normal. They may have
reduced plasma albumin.
They are at risk for
respiratory and gastric
infections
BIOCHEMICAL & METABOLIC
CHANGES
BIOCHEMICAL & METABOLIC CHANGES
 Significant findings in kwashiorkor include hypoalbuminemia
(10-25 g/L), hypoproteinemia (transferrin, essential amino
acids, lipoprotein), and hypoglycemia.
 Plasma cortisol and growth hormone levels are high, but
insulin secretion and insulinlike growth factor levels are
decreased.
 The percentage of body water and extracellular water is
increased.
 Electrolytes, especially potassium and magnesium, are
depleted.
 Levels of some enzymes (including lactase) are decreased, and
circulating lipid levels (especially cholesterol) are low.
 Ketonuria occurs, and protein-energy malnutrition may
cause a decrease in the urinary excretion of urea because of
decreased protein intake.
 In both kwashiorkor and marasmus, iron deficiency anemia and
metabolic acidosis are present.
 Urinary excretion of hydroxyproline is diminished, reflecting
impaired growth and wound healing.
TREATMENT
 TREATMENT

Treatment strategy can be divided into three stages.
 Resolving life threatening conditions
 Restoring nutritional status
 Ensuring nutritional rehabilitation.

There are three stages of treatment.

1.Hospital Treatment
The following conditions should be corrected.
Hypothermia, hypoglycemia, infection, dehydration, electrolyte imbalance,
anaemia and other vitamin and mineral deficiencies.
2.Dietary Management
The diet should be from locally available staple foods - inexpensive, easily
digestible, evenly distributed throughout the day and increased number of
feedings to increase the quantity of food.
3.Rehabilitation
The concept of nutritional rehabilitation is based on practical nutritional training
for mothers in which they learn by feeding their children back to health under
supervision and using local foods.
PREVENTION
 PREVENTION

 Promotion of breast feeding

 Development of low cost weaning
 Nutrition education and promotion of
correct feeding practices
 Family planning and spacing of births
 Immunization
 Food fortification
 Early diagnosis and treatment
OBESITY
 OBESITY
• Excessive amount of body fat

–Women with > 20% body fat

–Men with > 20% body fat
• Increased risk for health problems
• Are usually overweight, but can have healthy BMI and high % fat
• Measurements using calipers
 Body Fat Distribution: Gynecoid

• Lower-body obesity--Pear shape

• Encouraged by estrogen and progesterone
• Less health risk than upper-body obesity
• After menopause, upper-body obesity appears
 Body Fat Distribution: Android

 Upper-body obesity--apple shape

 Associated with more heart disease, HTN, Type II
Diabetes
 Abdominal fat is released right into the liver
 Encouraged by testosterone and excessive alcohol
intake
 Defined as waist measurement of > 40” for men and
>35” for women
Body Fat Distribution
Facilitators
Change in eating behaviour
Increase in physical activity
Attitude and motivation
Monitoring food records, weighing
oneself
Social support
Awareness of the calorie content of the Eat everything on plate attitude, eat
food balanced diet
Barriers
No self control
Special occations
Not excersizing enough
Attitude and motivation
Stress, eating habits
fast foods, eating quickly, having lot of
food around, liking for fatty food, liking
for sweets
 Causes of Excessive Energy Intake

• Active: large portion sizes, frequent meals and snacks

• Passive: excessive intake of energy-dense foods
containing hidden calories
• Variety of options: the greater the variety of foods
offered, the greater the intake
–Sensory-specific satiety: as foods are consumed they
become less appealing
Assessment of obesity
 Body weight

• In adults, weight of 10% or more is said to be overweight

while 20% and above is said to be obese.

% body fat in excess Degree of obesity

25 Mild
50 Moderate
75 Severe
100 Very severe
 BMI
• Is accepted as a better estimate of body fatness and
health risk other than weight. It is also known as quetlet
index.
BMI= weight/height 2 (m)
Grades Status
>35 Grade III
30-34.9 Grade II
25-29.9 Grade I
<25 Obese
Proposed reclassification of overweight for asian adults is >23 kg/m2
and for obesity is >25 kg/m2
•It does not distinguish between overweight due to obesity and muscular hypertrophy
and it happens in athletes.
•No information about distribution of fat in the body
 Waist circumference
• For children
• Measures abdominal fat
level male Female
I > 94 cm > 80 cm
II > 102 cm > 88 cm

•Level I is the maximum acceptable waist circumference irrespective of the adult age and
their should be no further weight gain
•Level II denoted obesity and requires weight management to reduce the risk of type II
diabetes and cardiovascular complications
 Measurement of body fat
• Males - >25%
• Females- >30%
• Sub-cutaneous fat is less likely to cause insulin resistance
• Sumo wrestlers have more sub-cutaneous fat and less
visceral fat
category males females
Normal 12-20 20-30
Borderline 21-25 31-33
obesity >25 >33
 Ponderal Index
• Ratio of height in inches to cube root of weight
• Less than 13 is associated with obesity

Broka’s Index

• Height (cm)-100=ideal weight (kg)

Waist/Hip ratio
 Waist circumference is measured at the level of the
umbilicus to the nearest 0.5 cm
 The subject stands erect with relaxed abdominal muscles,
arms at the side, and feet together
 The measurement should be taken at the end of a normal
expiration
Discussion of Today’s
lecture

?
Dr. Mukul Kumar
Assistant Professor
Department of Food Technology and Nutrition
School of Agriculture
Lovely Professional University Jalandhar-Delhi G.T.Road (NH-1),
Phagwara, Punjab
7018952941
mukul.25090@lpu.co.in