8.

1 INTRODUCTION

Nutritional Deficiency Syndrome

A nutritional deficiency occurs when the body doesn't absorb or get from food, the necessary amount
of a nutrition required to maintain a good health. Deficiencies can lead to a variety of health problems.
These include skin disorders, impaired immunity, metabolic disorders, stunted or defective bone
growth and even dementia.

DEFINITION

An inadequate supply of essential nutrients such as vitamins or minerals in the diet resulting in
malnutrition or various diseases. Nutritional Deficiency disorders are the diseases that occur when a
person's dietary intake does not contain the right amount of nutrients for healthy functioning or when
nutrients are not properly absorbed from food.

8.2 FORMS OF NUTRITIONAL DEFICIENCY DISORDERS

1. Under Nutrition: Pathological state resulting from the consumption of an inadequate quantity of
food over an extended period of time. For example: PEM.

2. Specific Deficiency: Absolute or relative lack of an individual nutrient or a particular nutrient. For
example: Deficiency of vitamin C causes Scurvy/vitamin A causes night blindness.

3. Over Nutrition: Consumption of an excessive quantity of food for an extended period of time. For
example: excess carbohydrates causes' obesity.

4. Imbalance: Disproportionate among essential nutrients.

 83 COMMON DEFICIENCY DISORDERS

➤Malnutrition

➤Protein Energy Malnutrition

➤Kwashiorkar

➤Marasmus

➤Marasmic-Kwashiorkar

➤Trace Element Deficiency

➤Vitamin Deficiency

➤Mineral Deficiency

➤Obesity

8.3.1 MALNUTRITION

The world health organization defines malnutrition as "the cellular imbalance between supply of
nutrients and energy and the body's demand for them to ensure growth maintenance and specific
functions.

Malnutrition refers to deficiencies or excesses in nutrient intake, imbalance of essential nutrients or

impaired nutrient utilization.

Causes

• Primary

➤Inadequate dietary intake

• Secondary

➤Nutrient malabsorption

➤Impaired nutrient utilization/storage

➤Excess nutrient losses

➤Increased need for nutrients

Magnitude of problem

• According to WHO, an estimated 50.6 million under 5 children are malnourished in developing
countries.

• 43% and 36% of under 5 children in India are underweight according to NFHS 3 and NFHS 4
respectively.

• Mortality rates in children with SAM were 9 times higher than ell nourished children ith infectious
diseases.

PROTEIN ENERGY MALNUTRITION

Protein energy malnutrition is the term used to describe clinical disorders, resulting from deficiency of
protein and energy.
 Definition
Protein energy malnutrition is a form of malnutrition that is defined as range of pathological
conditions arising from lack of dietary protein and/or energy (calories) in varying proportions.

Classification

 Kwashiorkor
 Marasmus
 Marasmic-Kwashiorkar

TABLE 8.3.1: CLASSIFICATION OF MALNUTRITION BY INDIAN ACADEMY OF

PEDIATRICS (IAP)

Grade of malnutrition Weight for age standard (mean)% Severity

Normal >80%

Grade 1 71-80% Mild

Grade 2 61-70% Moderate

Grade 3 51-60% Severe

Grade 4 <51% Very severe

TABLE 8.3.2: GOMEZ CLASSIFICATION

Weight for age (%) Malnutrition

91-100 Normal

75-90 1º degree

61-75 2º degree

<60 3º degree

TABLE 8.3.3: WHO/FAO CLASSIFICATION

Body weight as percentage of standard Oedema Deficit in weight for height

kwashiorkor 60-80 + +
Marasmic-Kwashiorkar <60 + ++

Marasmus <60 0 ++

Nutritional dwarfing <60 0 MinimalM

Underweight child 60-80 0 +

Causes

Following are the causes contributing to PEM.

Dietary Factors

 Diet deficient in protein and energy/calories

 Lack of proper food
 Dilute milk
 Faulty dietary habits

Socio-Economic Factors

 Poverty which can lead to low food availability.

 Improper food distribution among family members.
 Unsanitary living conditions.
 Misconceptions about certain foods
 Foods and fallacies
 Poor child rearing practice
 Lack of knowledge and education

Environmental Factors

 Overcrowding leads to various infections

 Unsanitary living conditions leads to digestive and
 Respiratory infections

Biological Factors

 Maternal malnutrition
 Infectious diseases such as diarrhea, measles, mumps
 Respiratory infections.
 Parasitic infections
 Impaired immunity

8.4 MARASMUS
Marasmus comes from a Greek word meaning "to waste". Marasmus is a severe form c PEM which
occurs in children due to inadequate intake of nutrients primarily carbohydrates. Marasmus usually
develops between ages of 6 month and 1 year who have been weaned from breast milk or suffering
from immune disorder like HIV.
Definition

Marasmus is a severe form of malnutrition which occurs due to inadequate intake of protein and
calories, primarily characterized by muscle wasting, stunted growth and severe weight loss.

Pathophysiology

Due to inadequate dietary intake of decreased

Carbohydrates(calories) in diet.

Increases activity and energy expenditure.

Decreased glucose in blood

Conversion of stored glycogen to glucose

Glycogen storage decreased

Glucose

Triglycerides

Fatty acids

Increase protein catabolism

Muscle wasting
 Marasmus

Sign and symptoms

Growth Retardation

 Weight is less than 60% of expected for age.

 Length, head, chest and abdominal circumference are also affected.

Loss of subcutaneous fat

 Loss of elasticity in abdominal wall.

 The limbs (thighs and buttocks) become wrinkled and hanging.
 Buccinators fat disappears leads to loss of hollowing cheeks and triangle face.
 Old man appearance

Muscle wasting

 Thinning of abdominal wall.

 Stick like appearance of limbs.

Bitot's spots

 Foamy spots on conjunctiva due to vitamin A Deficiency.

Diagnosis of marasmus

 Blood glucose value lower than 50mg/dl.

 Hemoglobin levels lower than 6.5 mg/dl.
 Examinations of blood smear-parasite detection.
 Urine examination and culture.
 Electrolytes test.
 Albumin lower than 35gm/1.

Treatment
Resuscitation-This step involves rehydration

1. Correct water and electrolytes balance.

2. Intra-venous rehydration.

3. OF feeding

4. Continuous breast feeding.

Stabilization - This step involves gradual feeding to improve levels of nutrients in the body.
1. Start with milk or formula mix.

2. Dietary support

3. Vitamin and mineral supplements.

4. 3-4 gms of protein and 200 cal/kg body wt/day

5. Small frequent feeds

6. Vitamin A and folic acid.

Nutritional Rehabilitation

 Stick to balance and nutrient rich diet

 8.4 KWASHIORKAR

Kwa is an African word meaning "the disease of the displaced child" who is deprived of adequate
nutrition. Kwashiorkor is a debilitating and life threatening condition caused b the deficiency of
protein in the diet.

Mortality and Morbidity

5 million children younger than 5 years die of malnutrition every year. 70 million present with wasting
and 230 present with some Stunting.

Definition

Kwashiorkor is a severe form of malnutrition caused by protein deficiency which characterized by

fluid retention leading to edema under the skin (swollen belly Kwashiorkor is a form of severe protein
malnutrition characterized by edema and an enlarged liver with Fatty infiltrates.

Pathophysiology

Low dietary intake of protein

Decreased ferritin Decreased protein

Decrease Hb + aneamia hypo albuminima

Impaired beta-dipoprotein Decrease oncotic pressure

Fatty liver edema

 Sign and symptoms

Hepatomegaly

Sign and symptoms

 Edema: putting edema of feet and ankles which eventually spreads to the rest of body due to

absence of plasma protein.

 Moon shaped face: children presents a moon shaped face due to edema.
 Changes in hair color and texture: protein is required for formation of hair.
 Lack of protein.

Hair is dry, thin and sparsely distributed brownish red and easily pulled out.
Skin changes
 Hyperpigmentation of skin with dark colored patches.
 Peeling of epidermis layer.
 Distended abdomen
 Lack of proteins
 Zero substantial pressure gradient
 Failure to draw fluids from tissues into bloodstream
 Pooling of fluid in abdomen
 Edema and belly disorder
 Weight loss
 Stunted growth
 Delayed puberty
 Impaired immunity
 Fatty liver
 Hepatomegaly
 Decreased muscle mass in arms and legs
 Anemia
 Diarrhea
 Loss of teeth

Laboratory findings/ diagnosis

 Physical examination: swelling, protruded belly, Hepatomegaly
 ABG analysis
 Total plasma protein: less than 4mg/dl
 Serum albumin: less than 2mg/dl
 BUN, serum creatinine
 CBC
 Serum potassium decrease
 Serum sodium increase

Treatment
Dietary management

 Diet with more calories and proteins.

 Carbohydrates in form of simple sugar and fats to be included in diet.
 Vitamins and minerals supplements.
Rehydration

 Treat dehydration with formulated rehydration solution.

Maintain body temperature

 Prevent and treat hypothermia.

Treatment of parasitic infections

 Metronidazole

Treatment of other infections

TABLE 8.5: DIFFERENCE BETWEEN KWASHIORKOR AND MARASMUS

Feature Kwashiorkor Marasmus

Aetiology  Due to protein deficiency  Due to protein and calorie deficiency

 Late weaning abrupti
 Acute illness. Trauma, infections Early and abrupyly stopped weaning
or sepsis  Prolonged periods starvation
 Repeated infection

Occurrence  Young children (6 months to 5  Infants are affected

years)
Appetite  High/feeder  Poor

Changes in physical  Presence of oedema of  Oedema is absent

appearance Extremities  Shrinked stomach
 Bulging protruding stomach  Ribs are prominent
 Ribs are not very prominent  Dry skin
 Flaky skin  Severe weight loss
 Mild eight loss
Muscle wasting  Mild  Severe

Liver  Enlarged due to fatty liver  Absence of fatty liver

Subcutaneous fat  Present  Absent

Prognosis  Poor  Good

Treatment  High protein diet  Diet rich in protein carbohydrates,

fat are other nutrients
Preventions of PEM

Health promotion

 Health education and nutritional supplements for pregnant and lactating mothers.
 Improvement of family diet
 Nutritional education.
 Lifestyle modification
 Promotion of breast feeding
 Family planning and birth spacing
 Development of low coat weaning food
 Exclusive breast feeding

Specific protection

 Dietary modification
 Diet rich in proteins and calories.
 Include dietary essentials such as milk, eggs, fruits to pregnant
 lactating mothers and children.
 Immunization against diseases
 Food fortification
 Early detection and treatment
 Growth monolog
 Periodic surveillance
 Early diagnosis with degree of malnutrition
 Mass screening
Treatment
 For PEM-3-4 gm/kg/day protein Calorie 100-120/kg/day
 ORS for children with diarrhea
 Deworming for parasitic infections
 Rehabilitation
 Rehab formula given by NIN Hyderabad Nutritious laddu

TABLE 86: METHOD TO PREPARE NUTRITIOUS LADDU

Ingredients Quantity

Green gram 100 gm

Bengal gram 100m

Whole wheat flour 100 grams

Jaggery 100 gm

Desi ghee 150 gm

Ground nuts 50 gm

Steps to prepare
i. Take roasted wheat, grams and ground nuts and grind them.
ii. Boil little water and Jaggery together.

iii. Add this solution to above ingredients and mix

iv. Add ghee
laddu 33kcal and 11.3 kg of protein.

Role of nurse
Assess the nutritional status of the client.
Assess skin,hair and musculoskeletal system.
Plot the measurements on the growth chart.

Administer supplements as prescribed.

Demonstrate proper feeding techniques and methods to parents.
Develop an individualized care plan to meet the needs of the client.
Develop an individualized teaching plan to instruct the parents aboutchild's diet needs.
Promote adequate child nutrition using different approaches.

 Advice the family about various Nutritional interventions to maintain appropriate weight-height
for age
 Maintain a high nutrient diet for example include protein and calories indiet
 Gradually increase nutrients an ise small frequent feedings with adequatefluids to ensure
dehydration.
 Monitoring and maintaining fluid and electrolytes level Le. calcium, magnesium and
phosphorus.
 Encourage nutrition, high calorie foods and Fortified foods to increase nutrient density.
 Encourage the diet containing dairy products, meat and meat products. For eg soyabean,
pulses, fruits and green leafy vegetables.
 Encourage the parents to participate in child care using appropriate feeding techniques and use
of balanced diet.
 Make regular home visits to access the nutritional status of community people.

8.7 CHILDHOOD OBESITY

Childhood obesity is a serious medical condition where excess body fat has accumulated to the extent
that it may negatively affect children and adolescents health or well being.

Overweight is defined as abnormal or excessive fat accumulation that may impair the health

-WHO

Obese children are above the normal weight for their age and height. Excess intake of energy is stored
in the body as fat, which over the time may result in an individual becoming overweight and obese.

Causes:
 Lifestyle factors:
 Increased consumption of high carbohydrate beverages, fast food.
 Increased snacking between meal
 Decline in levels of physical activity
 Increases in sedentary activities
 Environmental factors:
 High pressure for academic performance
 Maternal educational level
 Socio economic status
 Prenatal factors:
  Weight gain during pregnancy
 High birth weight
 Gestational diabetes

 Genetic factors:
 When both the parents are obese
 Down syndrome
 Gene mutation

 Hormonal factors:
 Linking adipose tissue, CNS and GI tract
 Chusing syndrome
 Growth hormone deficiency
 Hyperinsulinism
 Hypothyroidism

Sign and symptoms:

 Stretch mark on the hips and abdomen

 Dark, velvety skin around the neck
 Fatty tissue deposition in the breast area
 Poor self esteem
 Eating disorders
 Sleep apnea
 Constipation
 Delayed puberty in boys
 Dislocated hip

Consequences of obesity:

 Insulin resistance and type 2 diabetes

 Hypertension
 Hyperlipidemia Mood disorders
 Poor self esteem
 Reproductive dysfunction
 Liver diseases
Assessment:

i. Clinical assessment:

 To measure the skin fold thickness

 Calculate the body mass index.

BMI is computed by dividing the weight in Kg by the square of the height in meters and value
is compared to standard values with respect to child age and growth pattern.
𝑤𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)
BMI=
𝐻𝑒𝑖𝑔ℎ𝑡(𝑚)2

ii. Physical assessment:

 To conduct the anthropometric measurement

iii. Biochemical assessment:

 Serum HDL and LDL level

 Serum free fatty acids
 Cholesterol and triacylglycerol
 Fasting blood glucose
 Glucose tolerance

Management and prevention and role of nurse

 Improve the dietary habits by increasing the intake of fruits and vegetables
 Reduce intake of food containing high fat and high sugar
 Avoid watching TV during eating as commercial advertises attract the children to consume
junk food.
 Parents should encourage the children to perform outdoor physical activities.
 Family and school based approaches can reduce the obesity by collaborative efforts.

Role of nurse:

 Monitor the children for risk factors and family history ofobesity
 Assess the children for height, weight, waist and armcircumference and body mass index/
 Carefully keep a check on BMI percentiles.
 Monitor child's eating habits and activity levels.
 Educating the parents regarding the modification of lifestyle of children.
 Limit TV time
  Emphasize activity not only exercise.
 Encourage the child in activities he/she likes.
 Educate the parents regarding controlling calorie intake and modelling healthful behaviour.

8.8 VITAMIN DEFICIENCY DISORDERS

Vitamin is a micronutrient that is not prepared by the body in sufficient amounts. This is the reason
why it is necessary to take in from outside sources for the normal functioning of the body. Inadequate
intake of vitamins results in vitamin deficiency diseases. It is classified as

 Primary deficiency: it is caused by hen not enough vitamin intake.

 Secondary deficiency: it is caused by due to underlying disorder such as malabsorption

Vitamin A Deficiency
8.8.1 NIGHT BLINDNESS

It is one of the earliest signs of vitamin deficiency. Night blindness or nyctalopia is defined as Inability
to see well in dim light due to insufficient vitamin for the formation of rhodopsin.

Mechanism

Dietary insufficiency

Vitamin A Deficiency

↓ Inhibits the production of rhodopsin (the eye pigment responsible for sensing and adapting to low
light situation)

Impaired formation of retinal

Inadequate retinal to bind to opsin

Inability of eye to adjust to dim light

Night blindness

Symptoms
  Trouble adapting to dark
 Blurry vision
 Difficulty seeing in places with dim light
 Trouble adjusting from bright areas to darker ones
 Inability to see at night

8.8.2 BITOT'S SPOT

It is "usually appear in children aged 3-6 years" Bitot's spots are triangular pearly white or yellowish
Foamy spots on the bulbar conjunctiva on either sides of the cornea. Bitot's spots appear as grayish
white triangular plaques, firmly adherent to conjunctiva due to increased thickness of conjuctiva in
certain areas.

8.8.3 CORNEAL XEROSIS

Corneal xerosis is a disorder of eye caused by deficiency of vitamin A child by sdry, hazy appearance
of the cornea which may further develop into keratomalacia.

Due to deficiency of vitamin A:

 Glands in conjuctiva unable to function normally

 Cornea becomes dry
 Absence of tears and mucus

8.8.4 KERATOMALACIA
The most severe form of xeropathalmia is keratomalacia in which more thanone third of the cornea is
affected.

Keratomalacia is an eye emergency that involves drying, clouding and liquification of cornea due to
deficiency of vitamin A which may result in bursting the cornea open/eye collapse.

Treatment

 Administration of massive dose of 20000 IU of retinol palmitate orally on two successive days.
 Timing Vitamin A dose

< 6 months of age 50,000 IU

6-12 months of age 1lakh IU

>12 months of age 2 lakh IU

Next day same age specific dose

Atleast 2 weeks later same age specific dose

Prevention and Control

 Short Term Prevention
The strategy is to administer single massive dose of vitamin A in oil orally.

Age Group Dose Duration

Children <12 months 1 lakh TU once every 4-6 months

Children 12 months 2 lakh IU once every 4-6 months

Child bearing age 3 lakh IU within one month of deliver

Medium term action

Food Fortification

Fortification of certain foods such as milk/skimmed milk, vanaspati margarine with Vitamin A
Improvement of diet

 Consume diet rich in vitamin A such as green leafy vegetables

Breast feeding

 Exclusive breast feeding upto 6 months of age.

Environmental health

 Ensuring safe and adequate water supply

 Maintenance of sanitary latrines safeguard against diarrhea
Immunization

 Immunization against diseases such as MMR and other infections

Weaning

 Better feeding of infants

 Proper weaning practice
 Educating mothers regarding inclusion of weaning food
National programme for nutritional blindness focuses on
Promoting consumption of vitamin A rich food by pregnant lactating mothers and children upto 5
years of age.

 Administration of massive dose of vitamin A upto 5 years of age.

 All children with xerophthalmia to be treated at health facilities
 All cases of severe malnutrition to be given one additional dose ofvitamin A.


8.9 VITAMIN B DEFICIENCY

The B vitamins are a group of water soluble vitamins that plays an importantroles in cell metabolism.

List of B vitamins
Vitamin B1 Thiamine
Vitamin B2 Riboflavin
Vitamin B3 Niacin/Niacinamide
Vitamin B5 Pantothenic Acid
Vitamin B6 Pyridoxine

Vitamin B7 Biotin
Vitamin B9 Vitamin B12
Folic Acid Cobalmins/Cyanocobalamin

Table: Deficiency Disorders

Vitamin Name Deficiency

B1 Thiamine Beri beri

B2 Riboflavin Wernicke's Encephalopath

Ariboflauis, Chulosis, Glossisits,

B3 Niacin Dermatitis Pellagra, Dermatitis

B4 Pantothenic Acid Parasthesia

B5 Pyridoxine Microcytic Anemia

B7 Biotin Neurological Disorders

B9 Folic Acid Anemia

 B12 Cobalmins Pernicious Anemia
Peripheral Neuropathy

Vitamin B1 (Thiamine)
Thiamine plays a vital role in growth and function of various cells.
It plays a key role in normal functioning of heart and nervous system

Causes

 Diet deficient in B complex vitamins

 Improper cooking practices
 Diet rich in highly processed carbohydrates
 Conditions that increase body's need for thiamine
 Fever
 Hyperthyroidism
 Strenuous activity
 Pregnancy
 Lactation
 Impaired metabolism of thiamine
 Kidney disorders
 Liver disorders
 Impaired absorption
 Chronic diarrhea
 Parasitic infections
 Chronic Alcoholism in adults

Beri beri
Beri beri is a disease in which body doesn't have enough thiamine.
Types of Berries
1. Wet berries
2. Dry berries

Wet Berry:
 Shortness of breath during Physical activity
 Palpitations
 Tachycardia
Dry Berries:
 Muscular dystrophy
 Tingling Sensation
 Pain
 mental confusion
  Vomiting
 Involuntary eye movement
 Paralysis

Wernicke-korsakoff syndrome
Wernicke's and Werinick's encephalopathy are two different form of braindamage caused by thiamine
deficiency. Wernicke's encephalopathy is an Acute neurological condition characterized by clinical
traids of opthalmaparesis nystagmus caused by deficiency of thiamine.

Symptoms

 Confusion
 Memory loss
 Problem learning new information
 Inability to remember recent events
 Loss of muscle coordination
 Visual problems-rapid eye movement
 Double vision
 Hallucinations

nfantile Beri Beri

Occurs in infants aged 3-4 weeks who are breastfed by mother with thiaminedeficiency.

Symptoms

 Nystagmus
 Muscle twitching
 Bulging fontanelle
 Convulsions
  Loss of reflexes
 Aphasia

Management

 Thiamine supplements
 Multivitamin supplements
 Intra venous thiamine 50mg IV/IM
 Foods Fortified with thiamine like cereals, bread and milk

Vitamin B2 (Riboflavin)
The word riboflavin is derived from two sources Rubose-means rubose sugar found several vitamins
Flavin-means yellow coloured pigment
The vitamin B2 is essential for the metabolism of carbohydrates, fats and aminoacids.

Causes

 Malabsorption
 Long term infections
 Liver disorders
 Malignancy
 Alcoholism
 Inadequate diet
 Less consumption of meat, Fortified cereals and dairy products
 Phototherapy

Ariboflavinosis

 Angular Stomatits And Angular Cheilitis/Cheilosis

 Glossitis
 Red Swollen Patches At The Corners of the mouth
 Inflammatory Besion at the corners of the mouth
 Mouth Ulcers
 Inflammation of lining of mouth and tongue
 Cracked and red lips

Glossitis

 Swollen red inflamed tongue

 Hyperemia and swollen mouth cavity
Seborrheic dermatitis

 Dry and scaly skin

 Skin lesions
 Itchy skin
 Eczema
 Flaking

Bloodshot eye/inflammed eyelids

 Itching in eyes
 Watery eyes
 Photophobia

Management

 Riboflavin 5-30 mg orally OD in divided doses until recovery

 Parental riboflavin
 Multivitamin preparations

Vitamin B3 (Niacin) Deficiency

Niacin is used as a synonym for nicotinic acid and also includes nicotinamideand nicotine acid.
Niacin helps to convert nutrients to energy, create cholesterol and fat, repairDNA and exert
antioxidant effects.

Causes

 Impaired absorption of niacin and byptophan

 Hartnup disease
 Carcinoid syndrome
 Alcoholism
 Disorders of digestive system
 Diarrhea
 Cirrhosis
 Hepatomegaly
 Malabsorption
 Alcoholism
 Prolonged treatment with drug isoniazid.

Pellagra
Pellagra is a disease caused by deficiency of niacin characterised by 4 D's-Dermatitis, diarrhea,
dementia and if untreated death.

Symptoms
  Chronic disorder
 Abdominal pain and indigestion
 Loss of appetite

 Nausea
 Vomiting
 Skin rashes
 Mouth sores
 Fatigue
 Weakness
 Neurological symptoms such as tremor, Numbness and tingling in handand feet
 Delirium and dementia

Management

 Niacin supplements
 Niacin enriched foods
 Adequate nutrition
 Treatment of underlying disorder
 Other vitamin B supplements.

Vitamin B5 (Pantothenic Acid)

Pantothenic acid is referred to as "anti stress" vitamin can be produced in bodyby intestinal flora.
The coenzyme form of pantothenic acid called coenzyme A (CoASH) assist in metabolic reactions to
synthesize and metabolize proteins, carbohydrates and fats

Sign and symptoms

 Fatigue
 Insomnia
 Depression
 Irritability
 Vomiting
 Constipation
 Burning feet
 Tingling and Numbness of both hand and feet
Management

 Consuming Fortified foods

 Consuming animal products (milk/cheese)
 Vitamin B5 and B12 supplements.

Vitamin B9 (Folate)
Folic acid along with vitamin B12 is required for the formation of red blood cells and synthesis of
DNA thus leading to megaloblastic anemia. Folate is necessary for the development of nervous system
in foetus. Deficiency of folate in pregnant women increases the risk of neutral tube defects in infants.

Megaloblastic Anemia
Megaloblastic anemia is caused by the deficiency of vitamin B9 characterised by Impaired synthesis
of red blood cells resulting in macrocytic anemia.
Megaloblastic anemia encompasses a heterogeneous group of anemia characterised by presence of
large blood cells precursors called megaloblasts in the bone marrow caused by Impaired DNA
synthesis.

Causes

 Inadequate consumption of folate

 Dietary insufficiency
 Alcoholism
 PEM
 Increased need for folate
 Pregnancy
 Lactation
 Malabsorption syndrome
 Celiac disease
 IBD
 Liver disorder

Sign and symptoms

 Fatigue
 Pallor
 Dizziness
 Irritability
 Shortness of breath
  Muscle weakness
 Numbness and tingling in hand and feet
 Red and sore tongue

 Glossisits
 Diarrhea
 Weight loss

Management

 Oral supplements (vit B9 and vit B12)

 Dietary modification
 Include following foods in diet
 Eggs chicken
 Fortified cereals
 Beef Milk and milk products
 Green leafy vegetable
 Lenses
 Folate

Cyanocobalamin (Vitamin B12)

Cyanocobalamin is referred to as energy and vitamin. It helps to keep nerve cells healthy, factor in
DNA synthesis and helpful in Fatty acid and amino acid.

Pernicious anemia
Pernicious anemia is a decrease in red blood cells that occurs due to deficiency and Impaired
absorption of vitamin B12.

Causes

 Inadequate dietary intake

 Vegetarian diet
 Gastro intestinal disorders
 Gastric atrophy
 GERD
 Stomach cancer
 Malabsorption syndrome
 Inflammatory bowel disease
 Pancreatic disorders
 Acute/chronic Pancreatic
 Auto immune disorders
Sign and symptoms

 Fainting
 Fatigue
 Muscle pain

 Angina
 Opleeno megaly
 Hepatomegaly
 Glossitis pallor
 Parasthesia
 Mental disturbance
 Clumsy movement of fingers
 Red beefy tongue

Management

 Administration of vitamin b12

Initial dosage: 1000mg hydroxycobalamin daily for one week
Maintenance dosage: 1000 microgram once every three months

 Including meat and meat products in diet

 Consuming animal products
 Foods Fortified with vitamin b12
 Vitamin B Complex supplements

8.10 VITAMIN C DEFICIENCY

Vitamin C (absorbic acid) is essential for formation/growth and repair of bone, skin and connective
tissues. It helps to maintain healthy teeth and gums and is essential for normal functioning of blood
vessels.
Vitamin C is also essential for iron absorption thus plays an important role in formation of red blood
cells.
Acts as an antioxidant and supports immune function.

Causes

 Dietary insufficiency: diet deficient in vitamin C.

 Anorexia
 Increased metabolic demand for vitamin C.
a. Pregnancy b. Lactation
b. Lactation
c. Hyperthyroidism
d. Chronic diarrhea
 Smoking
  Alcoholism

General Signs of Vitamin C Deficiency

Organ System/Function Signs

Appetite decreased

Growth decreased

Immunity decreased

Heat resistance decreased

Muscular skeletal muscle atrophy

Vessels increased capillary fragility

Nervous tenderness

SCURVY
Classic scurvy is manifested in human adults after 40-80 days of stopping vitamin Consumption.

Sign and symptoms

 Impaired wound healing

 Edema
 Hemorrhage
 Bleeding under the skin, around the gums and in the joints
 Bleeding in mucus membranes and internal organs
 Weakening of collagen structure in bone, cartilage, teeth and connective tissues.
 Scorbutic adults may present with swollen gums and Bleeding gums with teeth loss.
 Lethargy
 Fatigue
 Muscular atrophy

MOEUER-BARLOW DISEASE
MBD is seen in non breastfed infants usually at about 6 months of age when maternally derived stores
of vitamin C have been exhausted.

Sign and symptoms

 Widening of bone cartilage boundaries particularly in rib cage.

 Joint pain
 Anemia
 Fever
 Inability to walk
 Gum Bleeding
 Petechial Hemorrhage

Management:

 Vitamin C supplements
Children - upto 300mg daily
Adults-500-1000 mg daily

 Induce citrus fruits and vegetable in diet like oranges, tomatoes, guava, strawberries
 Induce vegetable like broccoli, bell peppers and spinach in diet.

8.11 VITAMIN D DEFICIENCY

Vitamin D is a fat soluble vitamin. This vitamin is best absorbed when taken with foods ro h in fat.
Vitamin D is available in two forms

 Vitamin D2 (Ergocalciferol)
This form is synthesized from plants and yeast precursor.
Used in high dose supplements

 Vitamin D3 (cholecalciferol)
Most active form of vitamin D synthesized in skin under direct sunlight.

Causes

 Inadequate exposure to sunlight

 Darker skin people
 Excessive use of suscreen
 strict vegan diet
 obesity
 kidney disorders
 malabsorption disorders
 liver disorders
 decreased absorption
  crohn's disease
 celiac disease
 medications
 barbiturates
 steroids

Disorders Vitamin D deficiency

Vitamin D Deficiency

Rickets (children) Osteomalacia (Adults)

Rickets
Rickets is the disorder of mineralization of newly synthesized bone material osteoid

Definition
Rickets is defined as defects in the growth plate and in the mineralization of cartilage caused by
vitamin d deficiency leading to characteristic deformities

Incidence
Age 4months to 2 years

Clinical feature

Sign Symptoms

Craniotabes Irritability

Frontal bossing Redlesness

Bowed legs Sweating of forhead

Knocked knee Delayed dentation

Pigeon chest Pot belly

Harrison sulcus Hypocalcemia

Delayed closure of anterior fontandie Hypophosphalemia

Management/treatment
 Initial dosage: 6lakh IU of vitamin D orally or IM for 3-4 weeks
 Maintenance dose: 400 IU per day
 Calcium and phosphate supplements
 Exposure to sunlight

OSTEOMALACIA
Osteomalacia is a generalized bone condition in which there is inadequate mineralization of bone
which may lead to osteoporosis.
Definition
Osteomalacia is the softening of bones caused by defective bone mineralization secondary
dietary deficiency if vitamin D and calcium resulting in weak and fragile bones prone to fracture

Clinical Features

 Diffuse joint and bone pain -spine pelvis, legs

 muscle weakness
 waddling gait
 positive tail sign
 compressed vertebra
 pelvic flattening
 weak, soft bones
 prone to fracture
 bending of bones
 pathologic fracture

Treatment

 Administrate 10000 IU vitamin D weekly for 4-6 weeks

 Calcium and phosphorus supplement
 Treatment of underlying disorders
 hypothyroidism, metabolic disorder
 Exposure to sunlight
 Diet including vitamin D and calcium

Vitamin D deficiency
Vitamin D status
 Normal level of vitamin D 30 mg/ml

Vitamin D insufficiency 21-29 mg/ml

vitamin D deficiency <20 mg/ml

Severe deficiency <10ng/ml

Pathophysiology

Due to dietary inadequacy

Applied Nutrition and Dietetic

Deficiency of vitamin d

Hypocalcaemia

Increased parathyroid hormones

Increased osteoclast number and activity

Loss of bone mineral and matrix

Low bone mass

Bone mineralization

Leads to rickets in children and osteomalacia in adults

 TABLE 8.12: DEFICIENCY AND TOXICITY SYMPTOMS OF VITAMINS

Vitamin Deficiency symptoms Toxicity symptoms

Vitamin A Short-term: Night blindness, flaking skin Long- Toxic symptoms appear with chronic
term: Xerophthalmia (dry, hard cornea); intake of 10 times the RDA, usually
progresses to softening of cornea and blindness due to supplement abuse.
if untreated
Symptoms include lack of appetite, dry.
itchy skin; loss and coarsening of hair,
liver damage, fetal defects and
miscarriage.

Vitamin D Rickets (faulty bone formation) in children Toxic symptoms appear with regular
Osteomalacia (softening of bone) in adults intake of five times the RDA, usually
due to supplement abuse. Symptoms
include lack of appetite, high blood
pressure, excessive thirst and urination,
high blood calcium and calcium
deposits in tissues, kidney stones, and
kidney failure which can lead to death.

Vitamin E Damage to cell membranes, leading to Relatively nontoxic use of supplements

destruction of red blood cells (hemolytic with 80 times or more of the RDA may
anemia); rare in humans except in premature cause symptoms. Symptoms include
infants and those with certain diseases. muscular weakness fatigue, and nausea.

Vitamin K Poor blood clotting, possibly leading to Natural forms are nontoxic; excessive
hemorrhage (rare in humans except in newborn synthetic supplementation can cause
infants and people on long-term general toxic symptoms in infants. Symptoms
antibiotic therapy) include anemia and jaundice

Vitamin C Scurvy: Fatigue, bleeding gums, poor appetite, Relatively nontoode, supplement abuse
slow wound healing, muscle fatigue may couse diarrhea.
Seen occasionally in infants fed only cow's milk
and elderly people
 Vitamin Deficiency symptoms Toxicity symptoms

Thiamine Beriberi: Poor coordination, muscle weakness, Nontoxic except for high does
edema, Nontoxic except for high dose injections.
injections. Nontoxic except for high-dose
injections. heart changes

Riboflavin Ariboflavinosis: Inflammation of the mouth and Nontoxic

tongue, Nontoxic cracks at the corners of the
mouth and lips, anemia dermatitis, eye-related
problems

Niacin Pellagra: Diarrhea, dermatitis, dementia, and Nicotinic acid form is tooxde with
possibly death (the four Ds) high-dose supplements. Symptoms
include flushing (>100 ug), liver
damage, increased levels of uric acid
and glucose in blood (3g). increased
use of glycogen during exercise.

Pyridoxine Convulsions, dermatitis, inflamed tongue, and Toxic with long-term supplement abuse
anemia: symptoms often seen in alcoholics, the (>1 g/day).
elderly, and women taking birth control pills
Symptoms include nerve damage and
lack of muscular control (usually
reversible).

Folate Macrocytic megaloblastic anemia, diarrhea, Nontoxic

mental confusion, depression, fatigue

Cyanoco-balamin Pernicious anemia: A macrocytic megaloblastic Nontoxic

anemia accompanied by nerve damage, most
commonly results from poor absorption due to
the lack of intrinsic factor, not from low dietary
intakes of vitamin

Biotin Poor appetite, nausea, sore tongue, depression, Nontoxic

pallor, hair loss, dry skin, increased blood levels
of cholesterol and bile; rare in humans

Panlolhenic Deficiency symptoms are rare in severely Nontoxic

malnourished individuals, symptoms such
acid paresthesia in the toes and soles of feet, burning
sensations in the feet, fatigue, insomnia,
depression may be seen.
 8.13 ROLE OF NURSE
 Assess the patient for signs and symptoms of vitamin deficiency before beginning vitamin
therapy.
 Assess the patient for underlying disorders leading to vitamin Ddeficiency to initiate treatment.
 Assess the patient's diet to determine cause of deficiency.
 Administer vitamins with food to increase absorption.
 Store vitamins in a light resistant container.
 Educate patients about the nutritional value of food and how to makehealthy choices.
 Administer prescribed doses of vitamin to overcome deficiency.
 The community health nurses and school health nurses should periodically assess the children
for early signs of vitamin deficiency.
 Provide adequate supplementation at school and community level.
 Educate the parents about feeding techniques, food choices andimportance.

8.14 MINERAL, DEFICIENC ISEASES

The essential minerals are all inorganic micronutrients they are required for the normal functioning of
the body. The functions of the different minerals in the body vary widely, but overall, they are needed
to regulate the body processes.
A mineral deficiency occurs when the body does not receive or absorb the required amount of a
mineral. This can be due to increased need for minerals in the body, lack of minerals in the diet etc.

8.15 IODINE

The micro mineral iodine is a necessary component of two thyroid hormones produced by the thyroid
gland (thyroxine and triiodothyronine). Thyroid hormone influences metabolism and is essential to
regulating the body's metabolic rate.

Deficiency diseases:
Goiter
Mental retardation
Hpothyroidism
Cretinism

Causes:
  Low dietary iodine
 Selenium deficiency
 Pregnancy
 Exposure to radiation

Goiter:
occurs due to iodine Goiter is one of the major nutritional deficiencies in India. It some areas, this
disease mainly occur in subtropical regions and tribal areas.

Symptoms:

 Swelling of the neck (enlargement of the thyroid gland)

 Increased sensitivity to cold
 Difficulty in swallowing

Mental retardation:
Mental retardation refers to significantly sub average general intellectual functioning resis in or
associated with concurrent impairments in adaptive behavior and manifested during development
period

8.16 CLASSIFICATION OF MR
Classification IQ

Mild Retardation 50-70

Moderate Retardation 35-50

Severe Retardation 20-35

Profound Retardation. <20

Sign and symptoms:

 Failure to achieve developmental milestones

 Deficiency in cognitive functioning
 Reduced ability to learn
 Psychomotor skill deficits
 Difficult performing self esteem
 Irritability
  Depression

Hypothyroidism:
Hypothyroidism is a condition where there isn't enough thyroid hormones release in bloodstream and
slow down the metabolism.

Sign and symptoms

 Tiredness
 More sensitivity to cold
 Constipation
 Dry skin
 Weight gain
 Puff face Hoarse voice
 Muscle weakness.
 Muscle aches, tenderness and stiffness
 Irregular menstrual cycles
 Depression

Cretinism:
Cretinism is a disease caused by hypothyroidism. Iodine deficiency in diet during pregnancy is the
major cause of cretinism or cretinism refers to the congenital hypothyroidism or under activity of
thyroid glands during early childhood leading to stunted growth and mental retardation.

Sign and symptoms:

 Stunted growth and mental retardation

 Short stature (dwarfism)
 Hearing and speech defects Mild neurological impairment
 Myxoedema
 Thickened skin
 Enlargement of thyroid gland
 Protruded abdomen
 Decreased IQ
 Management and prevention

lodized salt add in diet at production level concentration of iodine is 30ppm and at consumer level
15ppm
Iodized oil injection (IM) -Iml gives protection for 4 years
Iodized oil capsule
Early diagnosis of serum level of T3, T4 and TSH.

Examine the urine iodine excretion.

Hell prick test in neonates for congenital hypothyroidism.
Government of India initiated National lodine deficiency disorders control programme (NIDDCP) in
1992 to reduce the prevalence of iodine deficiency disorder below 10% b 2012 b achieve universal
access to iodized salt.
lodine can be found in certain fish such as cod and tuna.
Shrimp, seaweed and other seafood are rich source of iodine.
Dairy products, yogurt and cheese also contain iodine.

817 IRON DEFICIENCY

Deficiency of dietary iron leads to a condition called anemia, also referred as iron deficiency anemia.
Iron is required by the body to form hemoglobin, which is present in the red blood cells in our body.
The main function of hemoglobin is to transport oxygen from lungs to the various parts of the body.
Anemia: Anemia is a condition in which there is a reduction in the number of red blood cells and a
deficiency of hemoglobin resulting in decreased oxygen carrying capacity.

818 TABLE CLASSIFICATION OF ANEMIA

Degree of anemia Hb (g%)

Mild anemia 10.0-10.9

Moderate anemia 7.0-10.0

Severe anemia <7.0

Causes:

 Inadequate intake of iron

 Poor iron malabsorption
  Excessive loss of iron during menstruation
 Hookworm infestation
 Gastrointestinal bleeding
 Injury, hemorrhage

Sign and symptoms:

 Extreme fatigue
 Eyes, tongue and nails become pale
 Breathlessness on exertion
 Headache, dizziness or light headedness
 Brittle nails
 Tingling sensation in fingers and toes
 Poor appetite
 Poor coordination of body functions

Management and prevention:

 Replace the blood cells by transfusion in severe cases of anemia (<8g/dl)

 Iron supplements can help to restore the level in the body.
 Take iron rich diet which include red meat, green leafy vegetables, dates, liver, iron fortified
cereals, pulses.
 Vitamin c supplementation to helps the body absorb the iron.
 Preventing iron deficiency anemia in infants:
 Encourage the mother to breastfeed the baby for 6 months.
 At the age of 6 months, start feeding iron fortified cereals or pureed meat at least twice
a day to boost iron intake.
 Iron folic acid supplementation to pregnant mother
 Fortification of salt with iron
 Food fortification with iron
 Deworming the child
 Nutrition education and awareness

8:19 CALCIUM DEFICIENCY

Calcium is the major element in the body and an adult man of 60 kg has nearly one kilogram of
calcium. Almost 99% of this calcium is found in the hard tissues of the body, namely the bones and
teeth. It is essential for the blood clotting, contraction of heart and muscles, regulate the nerve centre
and foetal growth.

Causes:

 Lack of vitamin D leads to disorders of calcium absorption.

 Renal disease can impair calcium excretion
 Pregnancy and breast feeding increased the demand for calcium can lead to the deficiency.
 Inadequate intake of calcium rich food.
  Some medication, such as corticosteroids and antacids can interfere with calcium absorption
and lead to deficiency.
 Pancreatitis

 Thyroid diseases
 Elevated phosphorus level
 Lactose intolerant people allergic to dairy products.

Sign and symptoms

 Muscle spasm and muscle cramps

 Numbness and tingling in the hands, feet and face
 Confusion or memory loss
 Depression
 Weak and brittle nails
 Bone mass is reduced
 Applied Nutrition and Dietetics
 Inadequate intake of calcium, as well as inadequate intake of vitamin D, can leads to
developing rickets in children.
 Hypocalcaemia may also lead to osteoporosis in old age.
 Calcium deficiency can lead to osteomalacia in adults.
 Hypocalcaemia may also result in tetany of skeletal muscle.

Management and prevention

 Recommended the calcium supplements include:

 Calcium carbonate, which has the most elemental calcium
 Calcium citrate, which is most easily absorbed
 Calcium phosphate, which is also easily absorbed
 To increase the calcium intake such as milk, cheese, other dairy products and add food rich in
vitamin D in diet. These includes:
 Fatty fish like salmon and tuna
 Fortified orange juice
 Fortified milk
 Eggs
 In addition, keep intact a healthy lifestyle, such as avoid excess alcohol consumption, smoking
and eating too much of junk food.
 Exercise regularly and maintain healthy body weight.

8.20 ROLE OF NURSE

 Proper nutritional screening

 Assess the client for symptoms of mineral deficiencies
1. Anemia-pallor, hypoxemia, Fatigue.
2. Hypocalcemia-ostomalacia, rickets
 3. Goitre-enlarged thyroid Glands protruding eyes

 Assess the patient for underlying disorders leading to deficiency diseases.

 Investigate the intake of iron especially among adolescent girls andpregnant women.
 Educate the community about healthy and balanced diet.
 Gives knowledge about recommendations required by different age and gender group.
 Educate about best and easy ways to achieve good nutritious diet.
 Encourage about diet planning and managing locally available foods.
 Monitor intake output, electrolytes monitoring.
 Maintaining parental nutrition for client.
 Maintenance of adequate hydration.
 Administer mineral supplementation e.g. ferrous sulphate,iodine,calcium. Food fortification
 Collaborates with government and non government agencies for nutritional betterment of
public sectors.
 Parents education