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NUTRITION
DR FARHANA JABEEN SHAH
COMMUNITY MEDICINE
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illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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DIET :

 Diet differs according to the nature of occupation ,physical labour ,body surface ,sex ,age ,climate
,availabilities ,taste and desires ,religious prejudices ,social customs.

 Balanced diet : is defined as a diet that contains the optimum requirement of food calories or alkalosis
.though the body is capable of enormous chemical adjustment ,its safety lies in a generous and varied
ration(PORTION). Children especially , should have a wide margin as to quantity and quality .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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CONT…

 A balanced diet should also be such that it favors prompt digestion and absorption .such a diet can only be
obtained but supplementing cereal products ,tubers (roots) meat ,milk ,eggs fruits and leafy vegetables .the
following points should be considered .
 Extra allowance of 10-15% made for those doing hard work.
 10% for waste .
 Age and sex should be kept in view ,male over 14 years old should be given full diet .
 On an average in Pakistan, a baby at birth weighs six pounds.by the age of five months the infants usually
doubles its birth weight .by one year triples it .and by two and a half year ,is four times its birth weight .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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CONT…

 During first few years of life ,eight increases at a rapid but generally ,decelerating(SLOWING) rate .gain in
weight is related to age ,sex ,race ,climate ,and other environmental factors .

 Calorie needs per pounds of body weight keep on decreasing with age ,during infancy caloric needs are about
fifty calories per pounds ,at the age of four years ,the caloric requirements comes down to forty calories per
pound .at 12 years and over that age caloric needs are reduced to twenty calories per pound of body weight .

 Not less than 10 % of proteins should be from animal source ,a variety of cereals is preferable to one. Pulses
and dals should not be more than 4 oz. Half the fat should be from animal source .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
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 Caloric chart : 6
AGE CALORIES AGE CALORIES REQUIRED
REQUIRED
1 WEEK 300 CAL WOMEN over 14 2100 cal
2 MONTHS 350 CAL Men over 14 2600 cal
3 MONTHS 450 CAL Nursing mother 3100 cal
4 MONTHS 500 CAL Pregnant women 2500 cal
5 MONTHS 600 CAL Extra calorie light work 75 cal .extra
6 MONTHS 700 CAL Moderate work (ploughing ) 75 – 150 cal .extra
12 MONTHS 800 CAL Hard work (sawing ) 150 – 300 cal .extra
4-5 YEARS 1000 CAL
6-7 YEARS 1300 CAL
8-9 YEARS 1600 CAL
10 -11 YEARS 1800 CAL
12- 13 YEARS 2100 CAL

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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BASAL METABOLISM :

 It is energy requirement of an individuals at complete rest ,in a comfortable and relaxed position both
physically and mentally .
 It depends on such factors as age ,sex ,race ,state of nutrition ,surface area ,external temperature and
pathological conditions .these factors have to be considered in deciding whether the basal metabolic rate
(BMR)of an individuals is within the normal range of variation from the average 10 %.
 Calories comes from proteins ,carbohydrates and fats .most food contains calories for more than one source .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
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 Each gram of proteins contain ……………4gms

 Each gram of carbohydrates contain ……………4gms
 Each gram of fats contain ……………9gms

illyas shah ansari ,public health and community medicine ,8th

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 It has been estimated that BMR of an adult male is 40 calories per hour per square meter of the body
surface.
 It is 37 for women ,44 for boys above 15 years and 50 calories for boys between 12 and 13.
 For example: taking the area of an adult male as 1.75 sq. meter ,his caloric requirement in 24 hours will be:
40(Weight) x 1.75 x 24 =1680 or 1700 calories .
 To calculate the basal caloric requirement for a individual ,one has to undertake a two step process.
 First ,calculate the ideal weight of an individual on the basis of the body frame and height .
 Second ,on the basis of the calculated ideal weight ,calculate the requirement for a 24 hour period ,based on
the person's activity .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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Calculation of ideal weight of an individuals :
Gender Small frame Medium frame Large frame

Male Minus 10% of 106 pounds for Plus 10 % of calculated weight for
calculated weight for 5 feet height + 6 height .
height pound per inch

Female Minus 10% of 100 pounds for Plus 10 % of calculated weight for
calculated weight for 5 feet height + 5 height .
height pound per inch

illyas shah ansari ,public health and community medicine ,8th

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Calculate the basal calorie requirement of an individual
for a 24 hour period:

For basal metabolism Ideal weight x 10

For sedentary person ideal weight (I.W In Ibs) x 3

For moderately heavy work Ideal weight x 5

For heavy work ideal weight x 10

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
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Nutritional requirements in physiological states :

Infancy and childhood :

there is rapid growth and development of the body during the early phases of life .
For normal growth and development ,food must be provided in such a way that it meet the
quantitative and qualitative standards of life .
 Energy requirement per unit of body weight are greatest in infancy and decline through
later years of childhood .
 In the first month of life the need is around 110 cal per kg body weight as against 40 cal
per kg for an adult .side wise ,the requirement of proteins , vitamins ,minerals and
water are greater in infancy proportionate to the body size .
illyas shah ansari ,public health and community medicine ,8th
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 The infant diet is composed of largely milk and may deficient in ascorbic acids ,A,D vitamins.it is important
to supplement these essential nutrient s.
 Modern technology has made available several substitutes for breast milk and mothers who are socially over
occupied have a tendency for early weaning .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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Nutrients and energy requirements for infants and children:

Group Particulars Body Net Protein Fat gm/d Calcium Iron Retinol B-
weight energy gm /d mg /d mg /d micro g/d carotene
in kg kcal /d micro g/d

Infant 0-6 months 5.4 108 /kg 2.05 /kg 500 350 1200

6 -12 8.6 98 /kg 1.65 /kg

months
Children 1-3 years 12.2 1240 22 12 400

4-6 years 19.0 1690 30 25 400 18 400 1600

7-9 years 26.9 1950 41 26 600 2400

illyas shah ansari ,public health and community medicine ,8th

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Adolescence:

 There is marked acceleration of growth prior to sexual maturity and puberty . This phase of growth occurs
earlier in females than in males .the need pertaining to caloric and other requirement should appropriately
should be met with .the recommendation are given in table :

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
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Nutrients and energy requirement for boys &girls 10 to 18
years age group :
Group Particular Body Net Proteins Fat g/d Calcium Iron Retinol B-
s weight /kg energy g/d mg /d mg /d carotene(pi
kcal /d gment)

Boys 10 -12 35.4 2190 54 22 600 34 600 2400

years
Girls 10-12 31.5 1970 57 22 600 19 600 2400
years
Boys 13-15 47.8 2450 70 22 600 41 600 2400
years
Girls 13-15 46.7 2060 65 22 600 28 600 2400
years
Boys 16-18 57.1 2640 78 22 500 50 500 2400
years
Girls 16-18 49.9 2060 63 22 500 30 500 2400
years
illyas shah ansari ,public health and community medicine ,8th
07/05/2021
edition ,2016
 ADULTS :
They are based on the activity undertaken by them during the course of 24 hours .table 27.10.
Adults :
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Grou Particulars Body Thiamine Riboflavi Nicotinic Pyridoxin Ascorbic Folic acid Vit B-12
p weight mg /d n mg /d acid g/d e mg/d acid mg/d Mg/d
(kg) mg /d
Man Sedentary work 60 1.2 60 20 400 28 600 2400
Moderate work 60 1.4 60 20 400 28 600 2400
Heavy work 60 1.6 60 20 400 28 600 2400
Wom Sedentary work 50 0.9 50 20 400 30 600 2400
en
Moderate work 50 1.1 50 20 400 30 600 2400
Heavy work 50 1.2 50 20 400 30 600 2400
Pregnant women 50 +0.2 +15 30 1000 38 600 2400
Lactation 50 +0.2 +15 30 1000 38 600 2400

0-6 months 50 +0.3 +25 45 1000 30 950 3800

0-12ansari
illyas shah months 50 medicine ,8th
,public health and community +0.2 +18 45 1000 30 950 3800
07/05/2021
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Pregnancy and lactation :

 It has been demonstrated that complications of pregnancy are fewer and the infants
conditions at birth is better in women of adequate diets as compared to those on poor
diets .the pregnancy and period of lactation required planned diets to meet the
additional requirements of essential nutrients particularly the proteins ,vitamins and
minerals .the recommendations are given in previous table i.e. 27.10.

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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Old age :

 The dietary requirements during old age is less than those of adults as the basal metabolic requirement of
the former are reduced
 The consideration of diet should be to maintain satisfactory and healthful years and should be of standard
quantitively and contain adequate amount of proteins ,calcium and vitamins .
 Accompanying the normal aging process are several physiologic changes that have an impact on the older
adults nutritional requirements:

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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Needs for elderly :

 Proteins needs : 0.8 -1.0 g /kg body weight for an healthy elderly ,providing about 12
-1 4 % of total calories .
 Fat needs :no more than 30 % of total calories .only 10 % of calories should come
from saturated fats .dietary cholesterol should be limited to 300 mg or less per day.
 Carbohydrates needs :minimum recommended daily intake is 50 -100 g/day.at least
50 % of the total calories should come from complex carbohydrates sources .daily
recommended fiber intake is 20 -35 grams .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
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Calories :

 Energy needed decrease with age because lean body mass decreases and because overall level of activity is also
reduced .
 Calorie needs are dependent on activity level as well as on body compositions. Caloric requirement for a
person who is bedridden are less than those for one who is mobile and active.
 Exercise helps active older people maintain lean body mass decreases some what even in those who exercise
extensively. The higher the LBM,the more a person can eat without gaining weight and more likely he or she
will obtain an adequate supply of all nutrients .the body needs about 1.5 times the basal energy expenditure .

illyas shah ansari ,public health and community medicine ,8th

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 There is 10 % reduction of caloric needs between ages 51 -75 with an additional 10 – 15% reduction after
age 75 depending on individual activity .
 Although older adults needs fewer calories ,they have an increase needs for certain vitamins and minerals
.this increased needs must be satisfied with lower overall intake of food .thus it is important for elderly to eat
food rich in nutrients e.g. fruits ,vegetables ,whole grains ,lean meat ,fish poultry ,low fat milk and dairy
products .nutrients poor food like sweets ,and alcohol should be limited .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
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Recommended dietary standards :

 The recommended dietary allowances for Pakistanis population obtained from planning and development
division ,govt of Pakistan Islamabad, have been indicated against individual nutrients .
 The individual daily food guide is shown in table :is to be used as a guide to determine ,if the family
members ar eating enough calories and right type of food this table does not includes infant under one year
of age .

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
 Daily food guide for Pakistan:
Food type women Pregnant Lactating Man Female Male 10 Child 7-9 Child Child 1-3
women women 10-19 -19 4-6 24
Rice or 5 roti 6 roti 7 roti 8 roti 5 roti 7 roti 6 roti 5 roti 2 roti
chapatti
Vit& min 3 3 3 2 3 3 2 2 2
vegetables ½ cup 1cup 1 cup 1 cup ½ cup 1 cup ½ cup ½ cup ½ cup
Protein ½ cup ½ cup 1 cup 1 1/2 cup 1 cup 1 cup 1 cup 1 cup ¼ cup
,legumes
Meat ,egg ¼ cup ¼ cup ¼ cup ¼ cup ¼ cup ¼ cup ¼ cup ¼ cup ¼ cup

Milk or 2 cups 3 cups 4 cups 2 cups 3 cups 3 cups 2 cups 2 cups 3 cups
yogurt
Breast milk --- ------ ---- ----- ------- ------ ------- ======= On demand
until 2 years
Oil or fats 8tsp 8tsp 8 tsp 8 tsp 6 tsp 6 tsp 4 tsp 4 tsp 2tsp

Total 2113 2606 3050 2956 2342 2917 2201 1898 1328
calories

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
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 Diet is broken into four groups of food : the staple ,vitamins ,minerals rich ,proteins rich and energy rich.
 All four groups are important each day. Within the group ,many different foods can be eaten .if the amount
required to eat is different ,substitutions or equivalents can be made .e.g. some people eat rice or corn instead of
chappati.For the two or three servings of fruits , one small piece of fruits or ½ cup OF JUICE ARE EQUAL.
 THE RECOMMENDED SERVINGS FOR vegetables are cooked, if uncooked vegetables are eaten then 2 times
the amount should be eaten .in the protein group ,legumes, meat and milk products should be eaten in the amounts
specified each day .an egg can substitute for meat .if neither egg or meat is eaten that day then additional legumes
(dal) should be consumed.
 Oil or fat should be added to the food during cooking.it is an important source of calories for family members .it is
difficult to determine the amount of oil one person eats ,the procedure to determine the amount that the entire
family used is as under :

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
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Meeting nutritional needs :
Steps in determining the nutritional needs :

Approach This can be given in table : Activities

1. Nutritional education After considering the above 8 factors, assess the family
actual nutritional needs ,provide appropriate counselling,
and demonstrate handling, preparation and storage of
food.

2. Supplementary feeding Provide iron and folic acid to pregnant women .refer them
to world food programme if available and if the family is
eligible.

3.Personal hygiene After assessing their practices ,identify areas of need and
instruct them on the washing of hands before serving and
eating food .
illyas shah ansari ,public health and community medicine ,8th
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 First determine which family members are at risk of nutritional problems .physician should consider all
pregnant and lactating women at risk as well as ,all infant and children to age 5,others ,the elderly , the sick
or the very thin are also at risk .
 Conduct a diet recall on the past two days (2 day diet – recall ),use a separate recall sheet for each at risk
person, for each day, write down exactly what the individual has eaten ,including all food and drinks
during meal and in between meals .
 in assessing the nutritionals status and need of infant and children ,the best tool to use is growth chart .a
growth chart is a graph on which an infant and child expected weight is given up to five years of age
 As physician you should periodically record the weight of each child in your case load .instruction for the
filling out the growth chart are covered in the chapter on the health of children .

illyas shah ansari ,public health and community medicine ,8th

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Record of food intake :

 Start with the current day and work backwards .mention the day on the week and any other special events to
help them remember what they ate .try to interview the person who prepared and served the food .

illyas shah ansari ,public health and community medicine ,8th

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How to use the food recall form :

 Use one form for each person ,adult or child ,for each day . Write down the person ,name and gender ,the age
of the children is essential .in the section mark meal time ,amount and food /drink, write down the foods and
drinks ,including the amounts eaten by the family member at risk .remember ,put only one food per line .
 In the column labelled food group analysis in the food recall section ,for each food item that you wrote
,mark the amount each under the appropriate food group listing .for example ,if a pregnant women had 2
chapattis , ½ cup of yogurt , a banana and tea with milk in the morning you would mark a 2 under the
chapatti column, a 1 in the fruit column and in the milk column ½ for yogurt and ½ for milk (milk serving is
one cup ).see completed example food recall sheet on pregnant rushna in table 27-13 .

illyas shah ansari ,public health and community medicine ,8th

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Table :27-13
Food recall
illyas shah ansari ,public health and community medicine ,8th
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Name : pregnant RUSHNA AGE : ……………………….
PUT ONE FOOD ITEM PER LINE FOOD GROUP ANALYSIS
Meal time Amount Food :drink staple vit /min protein Rich Milk product
31Energy rich
rice chapatti Fruit veg Legu meat egg Oil Fats

Morning 2 Chapatti 2
½ cup yogurt ½ cup
banana 1
1 cup milk tea ½ cup

snack Tea with milk ½ cup

Apple 1
afternoon 2 Cup rice 20
½ Cup potato curry ½ cup
water

snack Tea with milk 1 ½ cup

Rusk
Evening 2 Chappatis 2
4 Pieces of meat ¼ cup
kabab.
½ Cup of lassi ½ cup

Snack 25
TOTAL ½ cup ¼ cup 2 ½ cup

illyas shah ansari ,public health and community medicine ,8th

07/05/2021
edition ,2016
 INDIVIDUAL FOOD NEED :
ADDITIONAL FOOD RECOMMENDED INTAKE ACTUAL INTAKE 32
ADDITIONAL
NEEDS
STAPLE
Rice 2 cups
Chapatti
Vitamins / minerals 6 5 None
Fruits 3 2 1
Vegetables 1 cup ½ cup ½ cup
Protein rich
Legumes ½ cup ½ cup
Meat ¼ cup ¼ cup none
Egg
Milk product 3 cups 2 ½ cups ½ cup
Breast milk
Energy rich
Oils 8 teaspoons More
illyas shah ansari ,public health and community medicine ,8th
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Oil recommendation :

 Do this for each group item except oil total each food group listing .
 Add together the total amount of oil recommended for each family member to determine the total of oil
needed for that day ,e.g. all adults need 8 tsps. Of oil each ,teen age children ,6 etc. ,for a family of 6:
 2 adults need …………………..16 tsps.
 Male teen ager …………………6 tsps.
 Child of 7 years needs …….. 4 tsps.
 2 year old child needs ……. 2 tsps.
 Total ………………………………. 32 tsps. Oil each day

illyas shah ansari ,public health and community medicine ,8th

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 Since one tsp is equal to 5 ml,and 3 tsps. are in a tablespoon with 16 table spoons per cup ,the correct
measure of oil for the family food preparation is 160 ml.or 2/3 of a ordinary tea cup .once you know the
recommended amount ,ask the food prepare to show you in a cup or jar how much oil she uses a day in food
preparation .
 Determine if all family members are eating the foods that the oil is in and counsel accordingly .if some
members of the family are particularly malnourished ,after other family members food is served ,a little
more oil can be added to the cooking pot for their serving .
 Transfer the totals to the individuals food needs section marked actual intake and subtract it from the
recommended intake .

illyas shah ansari ,public health and community medicine ,8th

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 Discuss with the family what foods need to be added and be sure to explain why the additional foods are
important ,help them figure out ways to provide the foods to the family .give them specific tasks to improve
their nutritional status ,teach them methods of new preparation ,plan a garden etc. . Discuss supplemental
nutrition programs and personal hygiene instructions .
 If the child is on breast –feeding ,on their food recall in the recommended amount section , write whether
the feeding should be exclusive (only breast milk and no other fluids ) and the frequency .in the actual
intake section ,write the frequency of feeding, and in the recommended need write the advice .for example
night feed to increase frequency ,stop bottle feeding ,feed two or more times during the day or feed longer
from each breast .

illyas shah ansari ,public health and community medicine ,8th

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Nutritional counselling :

 Once an individual ,s additional food needs are determined ,they must be discussed with them ,this is usually
carried out by the medical social worker.
 Assessment of nutritional status :
An ideal index or guide of nutritional status ,for any age group ,should meet the following requirements:
i. It must be correlated with body fat and protein stores .
ii. It must be correlated with health or functional outcomes .
iii. It must be simple to obtain and interpret in the field .it must also be accurate ,valid ,precise .
In addition to these requirement ,an adult height id determined by individual genotype and child hood nutritional
experience ,it follows that if an index is to reflect current nutritional status in adults it must be independent of height .

illyas shah ansari ,public health and community medicine ,8th

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Weight :

 The use of weight alone to assess nutritional status should be limited to monitoring purposes because it is
confounded by height .weight is appropriate for monitoring ,the progress of patients suffering from long
term morbidity ,recovering from disease or surgery ,or during nutritional rehabilitation within the
therapeutic feeding centres.

illyas shah ansari ,public health and community medicine ,8th

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Body mass index:

 The BMI is calculated from weight and height measurement using the formula :
 BMI = weight in kg / height in meter square .
 BMI was first introduced by QUETLET ,in order to eliminate the confounding effects of height on weight .in
normal adult ,the ratio of weight to the square of height is roughly constant ,and a person with low BMI is
underweight for their height .
 BMI reflects protein and fat reserves ,which in turn reflects the functional reserves including the ability to survive
nutritional deficit and diseases .BMI may be appropriate for the population level assessment of chronic under
nutrition.
 In 1988,the researchers proposed the use of BMI to define and diagnose chronic under nutrition .this classification
provides a useful frame work for the analysis of height and weight data from chronically under nourished adult
populations .

illyas shah ansari ,public health and community medicine ,8th

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Body shape :

 The ratio of leg length to trunk length some times called the sitting height to standing height ratio (SH /S)
or cormic index .this index varies both between populations and within populations .sitting height can be
measured by sitting the person on a straight – backed chair with a height board strapped to the back .this
measurement is then used to correct BMI by applying a correction factors based on a linear regression
model .

illyas shah ansari ,public health and community medicine ,8th

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Mid upper arm circumference (MUAC):

 This is the circumference of the left upper arm, measured at the mid –point between the tip pf the shoulder
and the tip of the elbow (olecranon process and the acromion).
 In children ,MUAC is useful for the assessment of nutritional status .it is good at predicting mortality and in
some studies .MUAC alone or MUAC for age 10,predicted death in children better than in any other
anthropometric indicators .this advantage of MUAC was greatest when the period of follow up was short .

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 Thank you

illyas shah ansari ,public health and community medicine ,8th

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