Nutrition PPT (PC-II, Medicine)

Course title: Human Nutrition
Credit hours: 2
Instructor’s name:
Kiday H/silassie (MSc/Nutrition)
Kiday H.(MSc, in Nutrition) 1

Introduction
 What is nutrition?
 What does nutrition deal with?
 Food?
 Nutrients?
 Diet?
 Balanced diet?
 Food security/insecurity?
 Nutrition security/insecurity?

Introduction…
Definition:
 Nutrition: the science of foods and the nutrients and
other substances they contain, and their actions within
the body (including ingestion, digestion, absorption,
transport, metabolism, and excretion)

Introduction…
Nutrition deals with:
 Nutrients, their characteristics, function, body’s need for
them, and their food sources
 Effects of an inadequate intake, and for some nutrients

an excessive intake
 The digestion of food, absorption of end products, their

utilization in the body and their elimination as waste

Introduction…
 Foods: products derived from plants or animals that can
be taken into the body to yield energy and nutrients
 Nutrients: the chemicals in foods that are critical to

human growth and function.
 Diet: the foods and beverages a person eats and drinks.

It is concerned about the eating patterns of individuals or
a group.
 Balanced diet: contains all the essential nutrients in the
proportion that is optimal for longer-term health and
survival.
Introduction…
 Food security:
When all people, at all times, have physical, social
and economic access to sufficient, safe and
nutritious food which meets their dietary needs
and food preferences for an active and healthy life.
 Food insecurity:
 When people do not have adequate physical,
social or economic access to food as defined above

The Conceptual Framework of Food Security

Introduction…
• Nutrition security:
– Access of all people at all times to sufficient food,
including adequate utilization and absorption, in
order to be able to live a healthy and active life
– A household achieves nutrition security when it has
secure access to food coupled with a sanitary
environment, adequate health services and
knowledgeable care to ensure a healthy life for all
household members

Conceptual framework of food security and
nutritional status at household level

Nutrients
 Are used by the body to provide energy and to support
growth, maintenance and repair of body tissues.
 ~ 40 nutrients are identified at this time.
Classification of Nutrients
1) Carbohydrates
2) Lipids (fats) Macronutrients
3) Proteins
4) Vitamins
5) Minerals Micronutrients
6) Water
Classification of nutrients
 There are several ways to classify the classes of
nutrients:
– Organic or inorganic
– Essential or non-essential
– Macronutrient or micronutrient
– Energy yielding or not

Classification of Nutrients…
 Essential nutrients: nutrients the body either cannot
make or cannot make enough of them to meet its needs.
These nutrients must be obtained from foods
(ingested in some manner)
Examples:
• Vitamins
• Calcium, iron, and other minerals
• Some of the amino acids

Classification of Nutrients…
 Non-essential nutrients: body can make from other
nutrients ingested.
Examples: Cholesterol, some amino acids.
Classifying nutrients by composition
 Organic nutrients: contain carbon
• Carbohydrates, lipids
• Proteins, vitamins
 Inorganic nutrients: do not contain carbon
• Minerals
• Water

Classifying nutrients by the quantity needed
 Macronutrients: needed in relatively large amounts
 Carbohydrates, lipids, proteins
 Micronutrients: needed in relatively small amounts
 All other nutrients
Classifying nutrients…
Energy-yielding nutrients (3):
– Carbohydrates, fats (lipids) and proteins

Introduction…
Relationship between nutrition and health
 Many other lifestyle and environmental factors, in
addition to nutrition, influence health and well-being,
 But nutrition is a major, modifiable, and powerful factor

in promoting health, preventing and treating disease, and
improving quality of life.

Nutritional situation Health outcomes
Table: Relationship between nutrition and health. NCD,

non-communicable disease.
Public Health Importance (Why we study
nutrition?)
– Human beings eat to survive
– Well nourished child is able to reach his/her full
potential
• Physically
• Mentally and
• Intellectually
– Malnutrition remains one of the most common
causes of morbidity and mortality among children
through out the developing world

Public Health Importance…
– Malnutrition has been responsible, directly or
indirectly, for
• 60% of the 10.9 million deaths annually among
under five children
– EDHS, 2005 from Ethiopia showed that
• 47%, 38% and 11% of children are stunted,
underweight and wasted, respectively (44%, 29%
& 10% EDHS, 2011)
– Indicating that malnutrition is an important public
health problem in Ethiopia

Macronutrients
 Carbohydrates
 Proteins
 Lipids (fats and oils)

Introduction
CARBOHYDRATES
 What are carbohydrates?

Carbohydrates
 Carbohydrates: cpds composed of carbon, oxygen, and
hydrogen arranged as monosaccharides or multiples of
monosaccharides (carbo = carbon (C), hydrate = with
water (H2O)).
 They provide the largest single source of energy in the
diet.
 There needs to be at least 3 carbons for a molecule to be
carbohydrate.
 Most, but not all, carbohydrates have a ratio of one
carbon molecule to one water molecule: (CH20 )n .

Carbohydrates…
 Vary from simple sugars containing 3 carbon atoms to
very complex polymers.
Generic names Examples

 3 Carbons: trioses Glyceraldehyde
 4 Carbons: tetroses Erythrose
 5 Carbons: pentoses Ribose
 6 Carbons: hexoses Glucose
 7 Carbons: heptoses Sedoheptulose
 9 Carbons: nonoses Neuraminic acid

Carbohydrates…
 The hexoes (6 C sugars) and pentoses (5 C sugars) and
their polymers play an important role in nutrition.
 They are represented by the formula (CnH2nOn).
 The different elements of carbohydrates are brought

together by the machinery of plants called chlorophyll.
 The chlorophyll in plants uses the solar energy from the

sun, carbon dioxide from the atmosphere and water
from the soil.
Classification of carbohydrates
 Carbohydrates are classified in to different categories

based on the number of single carbohydrate unit and
their functions

Characteristics of mono & disaccharides
 Soluble in water, have crystalline structure,
 Sweet taste,
 Called sugars and all have the same suffix- ose.
 Monosaccharides have an empirical formula of C6H12O6,
but have different structural formula.
Characteristics of polysaccharides
 Are polymers of monosaccharides joined together by
glycosidic linkages. They are:
 Insoluble in water,
 Do not form crystals & do not taste sweet,
 No characteristic suffix.
Monosaccharides
1)Glucose:
 Sometimes called dextrose or grape sugar/blood sugar,
 Widely distributed in nature in animals and men,
 End product of digestion of starch, sucrose, maltose &
lactose,
 Found in fruits, vegetables, honey, corn syrup and
molasses.
 Major fuel source oxidized by cells for energy,

Glucose…
 After meal, glucose is converted to glycogen and excess
glucose will be converted to triacylglycerol and stored.
 Absorbed actively coupled with sodium (glucose-sodium

coupled or co-transport mechanism)
 Is used as intravenous fluids (e.g. Dextrose normal saline,

Dextrose in water…etc.)

2) Fructose:
 Has same chemical formula as glucose and only differ
in their chemical groups arrangement,
 Is the sweetest of all sugars,
 Also known as levulose or fruit sugar,
 Produced during digestion of sucrose,
 Found in nectar of flowers, honey, and molasses

Fructose…
 Other sources include products such as soft drinks,
ready-to-eat cereals, and desserts that have been
sweetened with high-fructose corn syrup,
 Is absorbed by diffusion without any consumption of

energy.

3) Galactose
 Is not found free in nature but is produced in the
body during the digestion of lactose,
 Also called milk sugar,
 During lactation, glucose is converted to galactose so

that milk can be produced by mammary glands.

Disaccharides
A) Sucrose:
 Is made up of 1 glucose unit & 1 fructose unit,
 White and brown sugars are almost 100% sucrose,
 Also found in maple syrup, molasses, sorghum and corn

syrups.
 Also called table sugar and used at home in daily diet.

Glucose Fructose

B) Maltose
 Is made up of 2 glucose units
 Not consumed in large amount in the average diet
 Maltose (malt sugar) is found in sprouting grains
 Is one of the commonly used sweetening agents
 Is formed in the body as an intermediate product of
starch digestion
 Is found in beer, infant formulas, malted breakfast
cereals

Maltose…
 Commercially produced by malting and fermentation of
grains and in the body during digestion of starch.
 Adding a malt powder called power flours (Amylase rich
flours, ARF) will prevent gelatinizing and increases
viscosity of starch-based infant foods and enables to
make these foods energy dense.
 This idea can be used very well in the preparation of
energy dense complementary foods to children less than
2 years.

Fig. Condensation of 2 monosaccharides to form a disaccharide

C) Lactose (milk sugar)
 Only found in milk
 The amount is 6.8 gram/100ml and 4.8 gram/100ml in

human and cow’s milk, respectively.
 When hydrolyzed, yields galactose and glucose.

Sugar alcohols
 Are not found free in nature, but are produced as
intermediate products during metabolism of
carbohydrates or are commercially prepared.
 Are Sorbitol, Mannitol and Xylitol
 Used as sweetening agent for food products
 Absorbed more slowly, so no increase in blood glucose
and no stimulation of insulin.
 No tooth decay because not used by dental flora.

Polysaccharides
 Are complex carbohydrates that contain as many as 60,
000 simple carbohydrate molecules.
 Three types of polysaccharides are important in

nutrition: glycogen, starches, and fibers.

1) Starch
 Storage form of glucose in plants
 Is the most abundant carbohydrate throughout the
world in man’s diet.
 Found in grains, tubers, and legumes
 The seeds of plants are richest storehouses of starch.
 Example: Corn, millet, rice, wheat are important cereal
grains, dried peas & beans also contain starch up to
40%.

Starch…
 It is not soluble in cold water but when boiled with
water, they form viscous solution (pastes).
 When temperature raises, starch granules swell &
mixture becomes viscous.
 This change is called “gelatinization”.
 Cooking makes starch-containing foods more palatable
& more easily digestible.

2) Glycogen
 A polysaccharide found in animals.
 Storage form of glucose in the body
 Provides a rapid release of energy when needed.
 Composed of thousands of glucose units and has highly
branched structure.
 Is found in liver and muscle of animals.
 Two third is in muscle for energy needs of muscle cells
and one third is in the liver, as source of energy for any
body cells.

3) Cellulose
 Contains as many as 12, 000 glucose units.
 Is the structural constituent of the plant cell wall.
 Humans and carnivores do not have the enzyme to
digest it.
 Man gets it from ruminant animals (cow, sheep).
 Is also called dietary fiber or roughage.

Digestion and Absorption
of Carbohydrates
 The ultimate goal of digestion and absorption of sugars
and starches is to break them into small molecules-
chiefly glucose-that the body can absorb and use.
 The large starch molecules require extensive breakdown;

the disaccharides need only be broken once and the
monosaccharides not at all.

Carbohydrate Digestion
 Digestion of CHOs begin in the mouth
 In the mouth, the salivary enzyme amylase begins to
hydrolyze starch into short polysaccharides and maltose.
 In the stomach, acid continues to hydrolyze starch while
fiber delays gastric emptying and provides a feeling of
fullness (satiety).

Carbohydrate Digestion…
 In the small intestine, pancreatic amylase among other
enzymes (maltase, sucrase, and lactase) hydrolyzes
starches to disaccharides and monosaccharides.
 In the large intestine, fibers remain and attract water,

soften stools and ferment.

 Dextrins: short chains of glucose units that result
from the breakdown of starch.
Lactose intolerance

 Inherited or acquired defect resulting in inadequate
secretion of lactase needed to break down lactose to its
simple sugars.
 The undigested lactose produces symptoms including

abdominal pain, diarrhea & flatulence.
 Begins early in life & becomes more prevalent with age.

Carbohydrate absorption
 Primarily takes place in the small intestine
 Glucose and galactose are absorbed by active

transport.
 Fructose is absorbed by facilitated diffusion.

Carbohydrate metabolism
 Carbohydrate and fats are main sources of energy (ATP)
for animal cells.
 Glucose is the principal sugar used by cells and tissues. It
is usually obtained from:
Digestion of food
Dietary fructose and galactose
Liver glycogen

Metabolic fate of monosaccharides
 Primarily controlled by body’s energy demands
 Carbohydrate pathways:
– Glycogenesis
– Glycogenolysis
– Glycolysis
– Hexose monophosphate shunt
– Krebs cycle
– Gluconeogenesis

Functions of carbohydrates
1) Energy supply:
 The main function of carbohydrates is to meet
immediate energy needs as glucose,
 Some is stored as glycogen in liver and muscles,
 Rest is converted to fat and stored as adipose
tissue.
 The central nervous system (CNS) is entirely
dependent on glucose for energy,
 Other tissues can utilize glycogen when blood
sugar is low.

Functions…
2) Protein-sparing action:
 When the CHO & fat content of diet is below the
desirable level, more protein is used for energy at
the expense of tissue building & maintenance.
3) Helping the body use fat efficiently:
 Prevents the occurrence of ketosis due to
mobilization of lipids when energy supply from
CHOs is limited.
4) Lactose enhances calcium absorption

Functions…
5) As component of body substances and compounds:
Heparin, nervous tissue, ribose in RNA & DNA
6) Encouraging growth of useful bacteria:

Some carbohydrates like oligosaccharides promote
the growth of important bacteria like lactobacillus &
bifido bacteria.

Functions…
7) Promoting normal functioning of the lower intestinal
tract:
Dietary fiber promote peristalsis and normal
movement of the food and waste products along the
GIT and prevent occurrence of diseases like
constipation, hemorrhoids, cancer and also coronary
heart disease.

Functions…
8) Improving the palatability of food/drink:
 In the form of sugar (sucrose), they are used as
sweetening agent and are added to many kinds of
foods like biscuits, soft drink, coffee, tea, etc.
9) Texturing and preservative:
 Sugars give textures to some foods,
 They are also endowed with the function of
preserving foodstuffs.
 Starch and soluble fiber are also used in food
industry to improve texture.

Recommended daily allowance
 Carbohydrates can be synthesized in the body from
glucogenic amino acids by the process called
gluconeogenesis.
 Their daily intake from food should not contribute
more than 50% of ones total daily energy requirement.
 To prevent ketosis, one should take 50-100 g of
carbohydrate.

Recommended daily allowance…
 Excessively consumed carbohydrates could be
converted to lipids and get stored leading to obesity
and related chronic diseases.
 Dental carries is the commonest problem that

encounters frequent sugar consumers.

Food sources of carbohydrates
 Free sugars (High CHO density): Syrups, cereal grains,
dried fruits, vegetables, processed foods (pasta), breads,
candies, fruits like banana, dates and sweet potato.
 Oligosaccharides (medium CHO density): Garlic, onions,

legumes (peas, beans), fruits, molasses and vegetables.
 Polysaccharides: fruits, vegetables, cereals and legumes,

whole grain cereals

PROTIENS

Session objectives
At the end of this session, you will be able to:
 Define proteins
 Identify the building blocks of proteins
 Classify proteins
 Discuss the digestion and absorption of proteins
 Discuss nitrogen balance
 List the functions of proteins

Introduction
 Protein was the 1st substance to be recognized
as a vital part of living tissue.
 Proteins are made from 20 different amino
acids, 8/9 of which are essential.
 Each amino acid has an amino group, an acid
group, a hydrogen atom, and a side group.
 It is the side group that makes each amino acid
unique.

Fig. Basic structure of amino acids
Introduction…
 The sequence of amino acids in each protein
determines its unique shape and function.
 About half of our body’s dry weight is
contributed by proteins.
One third of our body’s protein is found in
the muscles
One fifth (bones & cartilages)
One tenth (skin and the rest)

Proteins…
Composition
 Proteins are composed of C, H, O2 and N2 .
 16% of their weight is nitrogen.
 Could also contain other elements like sulphur,
phosphorus, iron and cobalt.
 Plants synthesize proteins from nitrates and
ammonia in the soil.

Proteins…
 Animals obtain the nitrogen they require from
protein foods of either plant or animal origin.
 Animal metabolism, excretion and death finally

return the nitrogen in to the soil.

Proteins…
 Not all amino acids need to be ingested from diet
on a daily basis.
 Some amino acids could be synthesized in the
body from other nitrogen sources.
 Those that can not be synthesized in the body are
called essential (indispensable) amino acids.
 Their absence from the diet leads to poor growth
performance by a growing humans and animals.

Proteins…
 Those amino acids that could be synthesized by
the body from nitrogen source available in the
body are called non-essential (dispensable).
 8 amino acids are essential for adults.
 Histidine has become essential specifically for
infants making the total number of essential
amino acids to be 9.
 Cystine replaces 30% of Methionine and Tyrosine
replaces 50% of Phenylalanine.

Proteins…
 A combination of 2 amino acids by a peptide
bond gives dipeptide.
 When 3 amino acids are combined it is called
tripeptide etc.
 10 to 100 amino acids joined by a peptide bond
is called polypeptide.
 Hundred to several thousand amino acids joined
together by a peptide bond is called protein.

Classification of proteins
 How are proteins classified?

Classification of proteins…
I) Based on their chemical composition
 Simple protein: yield amino acids upon complete
hydrolysis (e.g. albumin- in eggs).
 Compound/conjugated protein: yield protein + non
protein.
Examples:
 Hgb (protein + hem)-Blood
 Casein (protein + phosphoric acid)- Milk
 Mucin (protein + CHO)- saliva
 Lipoprotein (protein + lipid)- Blood
II) Based on their nutritional value
 Complete protein: contains sufficient amounts of
all the essential amino acids (e.g. proteins of
animal origin- egg & milk).
Considered as “high quality” protein.
 Incomplete protein: does not contain all
essential amino acids (e.g. proteins of plant
origin- legumes, cereals).
Not sufficient for growth and health
Considered a “low quality” protein
 Soya bean has the best quality protein from plant family.
 Most common food sources of proteins for the
developing countries are plants especially cereals and
legumes.
 Mixing of cereals and legumes will give a better quality
protein.
 A complementary protein is one, w/c can supply the
deficient essential amino acid in another protein.
Legumes (best in lysine but lack methionine) can
complement cereals (high in methionine but lack
lysine).
E.g. Bread + peanut butter.
III) Based on the conformation of the protein
 This refers to the 3 dimensional shape of the
protein in its natural state.
a)Globular proteins
 Tightly folded polypeptide chain- spherical or
globular shape
 Mostly soluble in water, salt solution & body
fluids.
 e.g. Enzymes, antibodies, and many
hormones, hemoglobin.
b) Fibrous proteins
 Polypeptide chains arranged in parallel manner
along an axis,
 Tough and insoluble in water and give strength
to body tissues.
 Examples:
Collagen of tendons & bone matrix
Keratin of hair, skin, nails and
Elastin of blood vessels
IV) Based on their chemical structure
a)Primary structure:
 Refers to the sequence of amino acids in the
polypeptide chain of proteins held by peptide
bond.
 The sequence of amino acids in the protein is
determined by the genetic material (DNA) and it
in turn determines whether the protein is
structural or functional.
E.g. Ala---gly---phenala---histd---tyr---trp
b) Secondary structure:
Refers to the folding of the polypeptide chain upon
itself resulting in alpha helix or beta-pleated sheet.
This structure is held strong by intra molecular
hydrogen bonding.

c) Tertiary structure:
 This refers to the 3 dimensional arrangement of
the protein structure.
Folded upon itself (globular proteins) or
Straight chain of polypeptides (fibrous
proteins).
 This structure is maintained by the sulfide bond.

d) Quaternary structure:
This refers to the aggregation of individual polypeptide
chains by electrostatic bonding.
Hemoglobin is a typical example.

Summary of protein structure

Digestion of proteins
 Do proteins in foods become body

proteins directly?

Digestion of proteins
 Proteins in foods do not become body proteins
directly.
 Instead, they supply the amino acids from w/c
the body makes its own proteins.
 When a person eats foods containing protein,
enzymes break the long polypeptides into
shorter strands,
 The short strands into tripeptides and
dipeptides, and,
 Finally, the tripeptides and dipeptides into
amino acids. Kiday H.(MSc, in Nutrition) 95
Digestion of proteins…
Mouth & esophagus – none
In the stomach:
 The major event in the stomach is the partial
breakdown (hydrolysis) of proteins.
 HCl denatures each protein so that digestive enzymes
can attack the peptide bonds.
 The HCl also converts the inactive form of the enzyme
pepsinogen to its active form, pepsin.
 Pepsin cleaves proteins-large polypeptides-into smaller
polypeptides and some amino acids.

Digestion of proteins…
In the small intestine:
 Several pancreatic and intestinal proteases
hydrolyze polypeptides further into short
peptide chains, tripeptides, dipeptides, and
amino acids.
 Then peptidase enzymes on the membrane
surfaces of the intestinal cells split most of the
dipeptides and tripeptides into single amino
acids.

Digestion of protein…
 Cooking increases the digestibility of proteins.
 Over heating can destroy some amino acids.
 Cooking with water makes proteins more

palatable.

Absorption of Amino Acids/proteins
 Proteins are absorbed by active transport
mechanism coupled with sodium.
 Most absorption in proximal small intestine.
 Less than 5% of ingested N2 to feces
 Several transport systems

Absorption of proteins…
Peptide absorption
 Peptides have different transport systems than
amino acids
 67% of a.a. are absorbed into mucosal cell in the

form of small peptides.
 Hydrolyzed by cytoplasmic peptidases in

mucosal cell.
Nitrogen balance
 What is nitrogen balance?

 Refers to the situation in w/c nitrogen intake
from food is equal to nitrogen excretion.
 This occurs in a healthy non-growing adult

person taking adequate amount of energy from
CHOs and fats.
 The sources of nitrogen for our body are foods

that we eat.
 Nitrogen is excreted via urine, feces, sweet etc.

Nitrogen balance…
 When the nitrogen excretion is greater than the
intake, it is called negative nitrogen balance.
 This occurs when a person is in a state of illness,
starvation, protein energy malnutrition and
other pathologic conditions.
 When the nitrogen excretion is less than
nitrogen intake from food, it is called positive
nitrogen balance.
Examples: pregnancy, lactation, growth
and recovery from illness.
Functions of proteins

Functions of proteins…

How much protein should we eat?
 Proper protein intake depends on:
Activity level, age, health status
 A sedentary adult requires 0.8 grams of protein
per kg of body weight.
 People who require more protein include:
Infants, children, adolescents
Pregnant or lactating women
Athletes

Risks of eating too much protein
 High cholesterol and heart disease
Diets high in protein from animal sources are
associated with high cholesterol.
 Possible bone loss
High protein diets may cause excess calcium
excretion leading to bone loss.
 Kidney disease
High protein diets are associated with an increased
risk of kidney disease
Especially for people who may be susceptible to
kidney disease
Recommended Daily Allowance
 For adults in general intake of 0.8 gram of protein/kg
of body wt is adequate.
 RDA calculations for proteins should consider:
Age, sex,
Body size,
Physiological and pathological conditions,
The quality of the protein,
Energy Intake – if energy is too low, protein will
be used for energy- not growth.

Recommended Daily Allowance…
 Exercise does not increase the demand for protein
provided the total energy intake is adequate.
 For exercise, the immediate source of energy is
glycogen, then lipid and then protein.
 However, in muscle building exercises some
recommend 2 g of protein/kg of body wt/day.

Protein metabolism
 Proteins are deaminated and the amino group goes to
urea cycle and the carbon skeleton will be involved in
the intermediary metabolic path way to liberate
energy.
 From the total of 9.2 kilocalorie that is available in
every gram of a protein, 5.2 kilocalorie/g will be lost as
metabolizable energy via the urea cycle.
 This make the total kilocalorie to be provided by a
gram of protein only 4.
 Therefore, proteins are not cost effective sources of
fuel to the body.

Amino acid metabolism
 Liver is the primary site for uptake after meal.
 ~20% for protein/N compound synthesis.
– 14% remains in liver
– 6% plasma proteins
 ~57% catabolized in liver
 ~23% released to systemic circulation—primarily
branched amino acids.

Food sources of proteins
A) Animal sources:
 High quality proteins
 Are complete proteins (e.g. meat, egg, poultry, milk,
fish, lamb, beef, etc. ).
 Have high biological value.
Brown meats (e.g. beef, lamb, etc…) have high level
of saturated fatty acids which increase the level of
low density lipoprotein (LDL) cholesterol.
White meats (e.g. fish & chicken) have more
polyunsaturated fatty acids, which increase the level
of high density lipoprotein (HDL) cholesterol.
Food sources of proteins…
B) Plant sources:
 Mostly incomplete (e.g. legumes, cereals)
 Contribute significant amount (e.g. soybean)
 Most legumes lack methionine but have high Lysine
 Cereals lack Lysine but have methionine
 Combining the two together gives quality protein
 The quantity of plant food that must be eaten to
provide the amino acid values of one egg is large.

FATS AND OTHER LIPIDS

FATS AND OTHER LIPIDS
Instructional objectives
At the end of this unit, you are expected to:
 Describe the different types of lipids and how they are
digested, absorbed and metabolized in the body,
 Describe the functions of lipids in the body,
 Enumerate the food sources of lipids,
 Discuss the link between consumption of different
lipids and health consequences,
 List the RDAs of lipids and health problems related to
over/under intake of lipids.

Fats and other lipids…
Definition:
 Are group of organic compounds that are insoluble in
water but soluble in alcohol, ether, chloroform and
other organic solvents.
 The majority (95%) of dietary lipids constitutes
triglycerides (fats and oils).
Generally, lipids:
 Are forms of stored energy in animals.
 Like carbohydrates, contain C, H and O2

 Some have phosphorus and nitrogen.
 Lipids and oils because of similar solubility, are
classified as lipids.
 Lipids that are liquid at room temperature are called
oils.
 Lipids that are solid at room temperature are called
fats.

Classification:
 Nutritionally important lipids are classified in to 3 main
groups on the basis of their chemical structure.
Simple lipids- include fats and oils.
Compound lipids- includes Phospholipids,
lipoproteins.
Derived lipids- includes fatty acids and sterols.
 Some authorities classify lipids as Structural
(Phospholipids), Metabolic (fatty acids, lipoproteins,
and sterols) and Storage lipids (triglycerides).

1) Fatty Acids (FA)
Are composed of straight chain of carbon atoms with
hydrogen atoms attached and an acid group at one end.

Fatty Acids (FA)…
 Most fatty acids have even number of carbon atoms,
which are 2-24.
 The two variables which determine the physical

property of lipids are the length of carbon chain and
the degree of saturation.
 Saturation affects the physical characteristics of the fat

and its storage properties.

Classification of fatty acids
a) On the basis of the number of C-chain as:
 Short chain: 2-4 carbon atoms (e.g. Butyric acid)
 Medium chain: 6-12 carbon atoms (e.g. Caprillic acid)
 Medium- and short-chain fatty acids are found in
dairy products.
 Long chain: 14-18 carbon atoms (e.g. Palmitic acid,
stearic acid)
 Are found primarily in meat, fish, and vegetable
oils.
 Extra long chain: more than 20 carbon atoms (e.g
Arachidic acid).
Classification of fatty acids…
b) Depending on the presence or absence of double
bond (degree of saturation)
I) Saturated FA:
 Are found mostly from animal foods.
 E.g. butter contains up to 60% saturated FAs while the
saturated FA content of animal meats varies from 28%
in beef to 46% in lamb.
 The only plant sources of saturated FAs are coconut oil
and palm oil/palm kernel.

Saturated FA…
 The degree of unsaturation refers to the number of
double bonds between carbon atoms.
 If all of the carbon atoms in FA are “saturated” with all
hydrogen atoms they can hold, no double bond can
exist.
 Such FAs are classified as saturated.
 All short or medium chain FAs are saturated.
 The major saturated FAs are palmitic and stearic acids.

Example of saturated fatty acid
Stearic acid, an 18-carbon saturated fatty acid

Classification of fatty acids…
II) Unsaturated FA
 Have one or more double bonds between carbon
atoms.
 Most unsaturated FAs are from plant origin.
 Vegetable oils like olive oil, sunflower oil, etc and fish
are rich in unsaturated FAs.
 Human breast milk is also rich in polyunsaturated FAs.
a) Monounsaturated FA:
 Contain only one double bond.
 The most prevalent MUFA in the diet is oleic acid.

Example of monounsaturated fatty acid
Oleic acid, an 18-carbon monounsaturated fatty acid

Unsaturated FA…
b) Polyunsaturated FA (PUFA):
 Have two or more double bonds
 Omega-3 and omega-6 are examples.
 In omega-3, the first double bond is found 3 carbon
atoms from the methyl carbon.
The most abundant omega-3 FAs are linolenic acid
(found in plants) and the fish oils eicosapentanoic
acid (EPA) & decosahexanoic acid (DHA).

Polyunsaturated FA (PUFA)…
 In omega-6, the first double bond occurs 6 carbon
atoms from the methyl carbon.
 Linoleic acid is one of the PUFAs commonly found in

both animal and plant foods.

Essential Fatty Acids
 These are fatty acids which can not be synthesized by
the body and must be consumed from outside sources.
 Linoleic (18:2 n-6)

– Arachidonic (20:4 n-6)
 Alpha-linolenic (18:3 n-3)
 Deficiency yields dermatitis
 Needed in cell membranes

Essential Fatty Acids…
 Linoleic acid (18:2) is an Omega-6 essential
polyunsaturated fatty acid.
 It is the shortest chain omega-6 FA, which is converted
in the body to Arachidonic acid (20:4).
 Arachidonic acid is a physiologically significant n-6 fatty
acid and is the precursor for prostaglandins and other
physiologically active molecules.
 Prostaglandin: controls smooth muscle contraction,
blood pressure, inflammation, and body temperature.

Triglycerides
 Concentrated form of energy
 95% of dietary fat
 Glycerol + 3 fatty acids (esters)
 Exist as fats or oils
Short-chain tend to be oils at room temperature.
Unsaturated tend to be oils at room temperature.
 If all the 3 fatty acids forming the triglyceride are the
same, it is called simple triglyceride and if they are
different, it is called mixed triglyceride.

Triglycerides…
 If a triglyceride contains more long chain and
saturated fatty acids, it will be solid (fat) at room
temperature otherwise it will be liquid (oil).
 Liquid vegetable oils can be converted in to solid fats
by addition of hydrogen to the oils.
 This process is called hydrogenation and the principle
is applied in the production of margarine from
vegetable oils.
 Fat from Junk foods (margarine and other
hydrogenated foods such as potato chips, cookies,
etc.) is very hard to digest and is strongly associated
with vascular disease.
Phospholipids, Sterols and Lipoproteins
I) Phospholipids:
 Are structural compounds found in cell membranes.
 They form the fluid mosaic model of cell membrane
(plasma membrane).
 Their chemical structure constitutes 2 fatty acids,
nitrogen base, an acid phosphate and glycerol
molecule.

II) Sterols and Steroids
 Four-ring core
 Cholesterol (animal tissue)
– Cell membrane – particularly nerve tissue
– Precursor for bile acids, estrogens, androgens,
corticosteroids, & vitamin D.
– Sterols with phospholipids make up only 5% of
dietary lipids.

Cholesterol
 Is the most studied sterol because of its
epidemiological linkage with atherosclerosis and
coronary heart disease.
 Atherosclerosis: a common arterial disease in which
raised areas of degeneration and cholesterol deposits
form on the inner surfaces of the arteries obstructing
blood flow.
 Excessive consumption of cholesterol increases the
serum cholesterol level that in turn facilitates
atheroma (fatty deposit in artery) formation in the
vascular structures.

Cholesterol…
 When the coronary blood vessels are involved, there
may be ischemia of the myocardium resulting in
ischemic heart disease.
 Ischemia: an inadequate supply of blood to a part of

the body, caused by partial or total blockage of an
artery.

Cholesterol…
 If the ischemia is excessive, it may result in violent
myocardial infarction and sudden death of the
subject.
 Limiting the consumption of foods rich in cholesterol

such as: egg yolk, butter, cream, cheese, animal fat is
very important besides regular exercise.

Lipoproteins
 Are compound lipids that contain both protein and
various types and amounts of lipids.
 They are 25-30% proteins and the remaining as lipids.
 They are made mostly in the liver and are used to

transport water insoluble lipids via out the blood
 Elevated levels of certain types of proteins

(hyperlipoproteinemias) mark a high risk for the
development of atherosclerosis.

Lipoproteins…
Based on their density, the lipoproteins are classified as:
a) High Density Lipoprotein (HDL):
 Primarily contain protein with small amounts of
triglycerides and cholesterol.
 HDL transports cholesterol from the tissues to the liver
to be metabolized.
 High serum levels of HDL are protective against
atherosclerosis.

Lipoproteins…
b) Low Density Lipoprotein (LDL):
 Composed mainly of cholesterol.
 LDL transports cholesterol from the liver to tissues.
 High serum level of LDL greatly increases the risk of
atherosclerosis.
 Diets that are high in saturated fatty acids are
associated with elevations in LDL cholesterol.

Lipoproteins…
C) Very Low Density Lipoproteins (VLDL):
 Contain primarily triglycerides with some protein and
cholesterol.
 VLDL transports endogenous triglycerides from the
liver to tissues.
 High serum level of VLDL increases the risk of
atherosclerosis.

Lipoproteins…
 Chylomicrons: composed mainly of triglycerides
encased in a protein and phospholipid coating.
 Transport absorbed triglycerides from the intestine to
the liver.
 High serum chylomicrons levels do not increase the risk
of atherosclerosis.

Digestion and absorption of fats/other lipids
 The most important problem in the digestion of lipids is
making them water-soluble.
 The hydrophilic parts of the lipids will remain facing the
outside water medium while the hydrophobic tails turn
inside making fat globules (micelles).
 Bile salts make lipids water-soluble and disperse them
increasing their surface area for the lipolytic enzymes to
act upon (emulsifying effect).

Digestion of lipids…
 Mechanical and chemical digestion of lipids begins in
the mouth.
 By the time the food reaches the stomach, gastric lipase
takes care of 30% of the digestion of lipids.
 Pancreatic lipase, which does have co-lipase, breaks
lipids into free fatty acids plus glycerol or diglyceride
plus fatty acid or monoglyceride plus two fatty acids.
 A minimal amount of chemical digestion of fat occurs in
the stomach via the action of gastric lipase.

Absorption of lipids
 Once the digestion of lipids is complete, they will be
absorbed via intestinal luminal cell membrane by
simple diffusion.
 The fate thereafter depends upon the size of fatty
acid.
 From the intestinal luminal cells, fatty acids with less
than or equal to 10 carbon atoms will be absorbed
directly in to the portal system as free fatty acids.

Absorption of lipids…
 However, fatty acids with larger chains of carbon, will
be re-esterified to form triglycerides, cholesterol will
be re-esterified in to cholesterol ester.
 This will be coated with phospholipids, proteins and
will form chylomicrons.
 Chylomicrons will be absorbed via the lacteals in to the
lymphatic system via which they join the systemic
circulation at the left subclavian vein.


 Once chylomicron joins the systemic circulation, it
circulates via the tissues and an enzyme called
lipoprotein lipase lyses contents of chylomicrons
resulting in their increased density and decreased
volume.

Metabolism of lipids
 Once the lipids/triglycerides are hydrolyzed in to fatty
acids and glycerol, they will join the pathways depicted
by the following figure for their metabolism.

Functions of fats and other lipids
1. Are concentrated sources of energy, i.e. 9 kcal/g of
fat.
 Thus, relatively small amounts of high fat foods
contribute large amount of calories.
 When wt gain is a problem, it indicates that fat
intake is too low.
 For thin or underweight subjects, increasing fat
intake might help to achieve desirable wt status.
2. When deposited under the skin, function as insulator
of heat.
3. Improve the palatability of food.
Functions of fats…
4. Vehicle for the absorption of fat-soluble vitamins.
5. Support the viscera or organs
6. Reserves (storage forms) of energy in animals and
man.
7. Phospholipids are important structural materials in
the formation of cell membranes.
8. Cholesterol is important in the synthesis of bile salts
in the liver.
9. Lipoproteins are important transporters for lipid
substances in the plasma.
10. They form myelin sheath of nerves.
Problems of excessive and inadequate intake of
lipids
 Excessive intakes of lipids results in a positive energy
balance and obesity which in turn results in a number of
complications like atherosclerosis, hypertension and
diabetes mellitus.
 Inadequate or no intake of fat in other words results in
essential fatty acid deficiency manifested by itching,
skin abnormality and other health problems.
 Linoleic acid is an essential fatty acid.

Problems of excessive and inadequate intakes…
 Once we have linoleic acid from food, arachidonic acid
can be synthesized in the body from linoleic acid.
 Different physiologically important chemicals like

prostaglandins, thromboxanes and leukotrienes are
synthesized from arachidonic acid.

Food sources of lipids
 Animal sources: Butter, meat (beef, pork and lamb), egg,
milk (these are mostly saturated) except those from fish
and chicken.
 Plant sources: Vegetables, fruits (Avocado), nuts,

margarine, soya bean, coconut, palm kernel, all
vegetable oils (these are mostly polyunsaturated).

Micronutrients:
1.Vitamins
2.Minerals

Vitamins
Instructional objectives
At the end of this topic, learners are expected to:
 Describe the different types of vitamins and how they are
digested, absorbed and metabolized in the body.
 Describe the functions of vitamins in the body.
 Enumerate the food sources of vitamins.
 Describe the clinical manifestations of specific vitamin
deficiency.
 List the RDAs of vitamins and health problems related to
over/under intake of vitamins.

Vitamins…
Definitions
 Vitamins: are organic compounds needed in small
amounts in the diet of higher animals for growth,
maintenance of health and reproduction.
 They are indispensable and non-caloric nutrients
needed in tiny amounts in the diet.
 Vitamins differ from CHO, fat and protein in structure,
function and food contents.
 Vitamins are similar to the energy-yielding nutrients in
that they are vital to life, organic and available from
foods.

Vitamins…
 Some vitamins like vitamin A and D are highly stored in
the liver and get released to their functional sites when
needed.
 Without vitamins, thousands of chemical reactions do
not occur.
 Most vitamins can not be synthesized in the body.
 Vitamin K and B-12 are synthesized by intestinal
microorganisms though not in adequate amounts.

Vitamins…
 Other vitamins like pyridoxine (B-6), vitamin D are
synthesized in the body.
 Facilitators – help body processes proceed; digestion,
absorption, metabolism, growth etc.
 Vitamins are not oxidized themselves (unlike energy
nutrients), but some help to liberate energy in a form
that the human body can use.
 Both deficiencies and excesses of the vitamins can
affect health.

Vitamins…
 Some appear in food as precursors or provitamins.
 These, once in the body, are chemically changed to one
or more active forms.
 Example: Vitamin A precursor- carotene
Active form- retinal

Classification of vitamins
 One method of classifying vitamins is based on the
basis of their solubility.
 Hence, existing vitamins are classified as lipid soluble
and water-soluble.
1) Water soluble vitamins
 Found in vegetables, fruit and grains, meat.
 Absorbed directly into the blood stream
 Not stored in the body and toxicity is rare.
 Alcohol can increase elimination, smoking, etc. cause
decreased absorption.

Classification of vitamins…
2) Fat soluble vitamins
 Found in the fats and oils of food.
 Absorbed into the lymph and carried in blood with
protein transporters (chylomicrons).
 Stored in liver and body fat.
 Can become toxic if large amounts are consumed.
 These are vitamins A, D, E and K.

Water soluble vitamins
A) Thiamin (vitamin B-1)
 The role of thiamine in disease first came to light in
Asia a few centuries ago.
 The Dutch physician Christian Eijkman linked Beriberi
to dietary factors in the early twentieth century.
 He speculated that the high consumption of white
rice/polished rice among Asian populations was one
reason why the disease was more common in Asia.
 It was later discovered that thiamine, a water-soluble
nutrient found in whole grains, was missing from
white rice.

Thiamin…
 Deficiency is the cause of Beriberi, a condition marked
by mental impairment, muscle wasting, high blood
pressure, and heart problems, w/c was common
among Asian sailors and prisoners before the
nineteenth century.
 Thiamine is primarily used to prevent and treat
impaired mental function and Beriberi, indicating the
impairment of the Nervous system and the
cardiovascular system.

Thiamin…
 Thiamin pyrophosphate (TPP) is the coenzyme form
 TPP is critical in several metabolic functions, including

the removal of carbon dioxide rxns, w/c in turn are
important in the conversion of amino acids, CHOs and
fats to energy
 It is also necessary for the conversion of CHOs to fat
 TPP is needed for the synthesis of acetylcholine, a lack

of w/c causes inflammation of the nerves and memory
loss
Thiamin…
 Thiamin is needed to metabolize alcohol, but the
absorption of the nutrient is hindered by excessive
alcohol intake.
 This puts alcoholics at risk for symptoms associated
with thiamine deficiency.
 Such a deficiency in alcoholics results in brain problems
known as Wernicke-Korsakoff syndrome.
 This can result in permanent memory impairment,
motor problems, and psychosis.

Thiamin…
Functions:
 Necessary for energy and CHO metabolism.
 Keeps mucous membranes healthy.
 Maintains normal function of nervous system, muscles,
and heart.
 Aids in treatment of herpes zoster.
 Promotes normal growth and development
 Treats Beriberi
 Replaces deficiency caused by alcoholism, cirrhosis,
infection, prolonged diarrhea, and burns.

Thiamin…
 To prevent the loss of the vitamin during food
processing:
Consume parboiled rice instead of polished or
white rice.
Cook foods in minimum amount of water or
steam.
Avoid high cooking temperatures and long heat
exposure.
Thiamine is stable when frozen and stored.

Deficiency
 First observed in the Far East among polished white
rice eaters.
 It is also a common problem in the refugees of Somalia
in Ethiopia.
Mild deficiency:
 Loss of appetite, fatigue
 Gastrointestinal disorders (n, v & constipation)
 Mental problems, such as rolling of eyeballs,
depression, memory loss, difficulty concentrating, rapid
heartbeat.
 Muscles become tender and atrophied.

Deficiency…
Gross deficiency:
Is common in severely ill alcoholics
Pain or tingling in arms or legs
Decreased reflex activity
Fluid accumulation in arms and legs
Heart enlargement
Gastrointestinal symptoms (constipation, n & v).

Recommended Daily Allowance
 Its intake depends on the amount of calorie intake
from CHOs.
 The requirement is therefore 0.5mg/1000 kcal.
 The therapeutic dose is b/n 3-8 g daily.
Age RDA
0-6 months 0.3mg
6-12 months 0.4mg
1-3 years 0.7mg
4-6 years 0.9mg
7-10 years 1.0mg

RDA…
Males Females
Age RDA Age RDA
11-14 yrs 1.3mg 11-50 yrs 1.1mg
15-50 yrs 1.5mg 51+ yrs 1.0mg
51+ yrs 1.2mg pregnant 1.5mg
Lactating 1.6mg

Food Sources
 The best dietary sources of thiamine are whole-grain
cereals and meat; however it is found in all of the ff
foods:
Plant Sources
Whole-grain products, rice bran, brewer’s yeast
Chickpeas, beans, soybeans

Sunflower seeds, wheat germ
 Flour, rye and whole-wheat.
Animal Sources
 Salmon steak, pork, beef kidney, beef liver

B) Riboflavin (vitamin B-2)
 Is important for energy production, enzyme function,
and normal fatty acid and amino acid synthesis
 Flavin mononucleotide (FMN) and flavin adenine

dinucleotide (FAD) are the coenzyme forms
– Easily destroyed by ultraviolet light and irradiation
– Not destroyed by cooking.

Riboflavin…
 Vitamin B-2 is not stored in ample amounts, with only
minute reserves in the liver, kidneys, and heart.
 Hence, a constant supply is needed.
 Deficiency in this vitamin does not occur in isolation,
but is part of a multiple-nutrient deficiency.

Functions:
Acts as component in 2 co-enzymes needed for
normal tissue respiration.
Aids in release of energy from food.

Functions…
 Maintains healthy mucous membranes lining
respiratory, digestive, circulatory and excretory tracts
when used in conjunction with vitamin A.
 Preserves integrity of nervous system, skin, eyes.
 Promotes normal growth and dev’t.
 Aids in treating infections, stomach problems, burns,
alcoholism, liver disease.

Functions…
 Necessary for the regeneration of glutathione (a

substance needed for antioxidant activity).
 Used as treatment for migraines, cataracts, and sickle
cell anemia.
 Activates pyridoxine.

Deficiency symptoms
Cracks and sores in corners of mouth
Inflammation of tongue and lips
Eyes too sensitive to light and easily tired.
Itching and scaling of skin around nose, mouth,
scrotum, forehead, ears, scalp.
Trembling, dizziness, insomnia, slow learning
Itching, burning and reddening of eyes
Damage to cornea of eye.

Angular Stomatitis

Recommended Daily Allowance (RDA)
 Intake of 0.6 mg/1000 kcal is sufficient.
Age RDA
0-6 months 0.4mg
6-12 months 0.5mg
1-3 years 0.8mg
4-6 years 1.1mg
7-10 years 1.2mg

RDA…
Males Females
Age RDA Age RDA
11-14 yrs 1.5mg 11-50 yrs 1.3mg
15-18 yrs 1.8mg 51+ yrs 1.2mg
19-50 yrs 1.7mg Pregnant 1.6mg
51+ yrs 1.4mg Lactating 1.8mg (1st 6 mons)
2nd 6 months (1.7mg)

Food sources
Plant:
 Wheat germ, green leafy vegetables
 Brewer’s yeast
Animal:
 Organ meats (beef, kidney)
 Chicken
 Cheese

C) Niacin (vitamin-B3 )
Niacin is the common name for two compounds:
Nicotinic acid, w/c is easily converted to the
biologically active form, and
Nicotinamide (or niacin amide).

Niacin…
 Niacin participates in more than 50 metabolic
functions, all of which are important in the release of
energy from CHOs.
 B/c of its pivotal role in so many metabolic functions,
niacin is vital in supplying energy to, and maintaining
the integrity of all body cells.
 Niacin also assists in antioxidant and detoxification
functions, and the production of sex and adrenal
hormones.

Niacin…
 Niacin deficiency, known as pellagra, affects every cell,
and is cxrized by dermatitis, diarrhea, and dementia.
 People entirely depend on maize diet are at risk of
developing niacin deficiency.
 Synthesized in liver from tryptophan—60 mg
tryptophan yields ~ 1 mg niacin.
Functions:
 Maintains normal function of skin, nerves, and
digestive system.
 Reduces cholesterol and triglycerides in blood.
 Corrects niacin deficiency.
Functions…
 Treats vertigo (dizziness)
 Prevents premenstrual headache
 Treats pellagra
 Niacin lowers total blood cholesterol and raises HDL
cholesterol
 Aids in release of energy from foods (carbohydrates,
lipids and proteins)
 Helps synthesis of DNA

Niacin…
Deficiency:
 A disease of 4 D’s (diarrhea, dermatitis, dementia &
death)
Early symptoms:
 Muscle weakness, general fatigue, loss of appetite
 Headaches, nausea and vomiting,
 Swollen, red tongue
 Skin lesions, including rashes, dry scaly skin, wrinkles,
coarse skin texture
 Dermatitis (affecting the sun exposed areas)
 Diarrhea, irritability, dizziness
Niacin…
 Late consequences of severe deficiency called
pellagra:
 Dementia (progressive deterioration of intellectual
functions such as memory).
 Death

Pellagra – Casal’s Necklace

Pellagra

Recommended daily allowance (RDA)
Age RDA Males
0-6 months 5mg Age RDA
6-12 months 6mg 11-14 yrs 17mg
1-3 years 9mg 15-18 yrs 20mg
4-6 years 12mg 19-50 yrs 19mg
7-10 years 13mg 51+ yrs 15mg

RDA…
Females
Age RDA
11-50 years 15mg
51+ years 13mg
Pregnant 17mg
Lactating 20mg

Niacin toxicity
 Naturally occurring niacin from foods causes no harm,
but large doses from supplements or drugs produce a
variety of adverse effects, most notably "niacin flush.“
 Niacin flush occurs when nicotinic acid is taken in
doses only 3 to 4 times the RDA.
 It dilates the capillaries and causes a tingling sensation
that can be painful.
 The nicotinamide form does not produce this effect-
nor does it lower blood cholesterol.

Niacin toxicity…
 Large doses of nicotinic acid have been used to help
lower blood cholesterol and prevent heart disease.
 Such therapy must be closely monitored.
 People with the ff conditions may be particularly
susceptible to the toxic effects of niacin:
Liver disease, diabetes, peptic ulcers, gout,
irregular heartbeats,
Inflammatory bowel disease, migraine
headaches, and alcoholism.

Niacin…
Food sources:
1) Plant sources:
 Brewer’s yeast
 Peanuts, sunflower seeds
2) Animal sources:
 Salmon, pork, chicken, white meat
 Beef liver, tuna, turkey, veal

D) Pantothenic acid (vitamin-B5)
 Found in a wide variety of food sources and exerts
influence in a number of body functions.
 Vitamin B-5 is converted in to coenzyme A, its only
known biological form.
 Coenzyme A is involved in the acetylation of
substances such as choline, the oxidation and synthesis
of fatty acids and other substances, and the
metabolism of carbohydrates, fats and proteins.
 It is also necessary for optimum adrenal function and
has anti-stress properties.

Pantothenic acid…
Functions:
 Decarboxylation of pyruvate to form acetyl CoA—
energy production from CHO, fat & protein.
 Condensation of acetyl CoA with activated CO2 to form
malonyl CoA as the first step in fatty acid synthesis.
 Prosthetic group for acyl carrier protein.
 Used for the support of adrenal function and in
rheumatoid arthritis.

Pantothenic acid…
Deficiency and toxicity:
 Deficiency is reported in severe malnutrition together
with the other B-vitamins.
 Vomiting, fatigue & weakness are symptoms
 Increased need:
– Alcoholism
– Diabetes mellitus
– Inflammatory bowel disease
 No toxicity to date

 Estimated safe intake is given below:
Age Estimated safe intake
0-6 months 2mg/day
6 months-3yrs 3mg/day
4-6 years 3-4mg/day
7-9 years 4-5mg/day
10+ years 4-7mg/day
 Pregnancy and lactation may increase the need by
one-third.

Pantothenic acid…
Food sources:
Brewer’s yeast Meats, all kinds
Corn Peanuts
Eggs Peas
Lentils Soybeans
Liver Wheat germ
Sunflower seeds
Whole grain products

E) Pyridoxine (vitamin-B6 )
 Occurs in three forms-pyridoxal, pyridoxine, and
pyridoxamine.
 All three can be converted to the coenzyme PLP
(pyridoxal phosphate).
 B/c PLP can transfer amino groups (NH2) from an
amino acid to a keto acid, the body can make non-
essential amino acids.
 The ability to add and remove amino groups makes PLP
valuable in protein and urea metabolism as well.

Pyridoxine…
 The conversions of the amino acid tryptophan to niacin
or to the neurotransmitters serotonin, dopamine,
melatonin, and norepinephrine also depend on PLP.
 PLP is also involved in the synthesis of heme (the non-
protein portion of hemoglobin), nucleic acids (such as
DNA and RNA), and lecithin.
 Unlike other water-soluble vitamins, vitamin B-6 is
stored extensively in muscle tissue.

Pyridoxine…
 Pts with carpal tunnel syndrome are often deficient in

vitamin B-6.
 This is a painful condition in w/c the median nerve b/n
the bone and ligament in the wrist is compressed.
 Vitamin B-6 may be a viable treatment for this
condition.

Pyridoxine…
 Alcohol destroys the vitamin.
 Some drugs like Isoniazid (INH) increase the renal
excretion of the vitamin; therefore, pts taking INH
should be supplemented with the vitamin to avoid
peripheral neuropathy that results.

Pyridoxine…
Food sources:
 Avocados, bananas, bran, brewer’s yeast, carrots,
 Flour (whole wheat), lentils, rice, salmon, soybeans,
 Sunflower seeds, tuna, wheat germ.
Functions:
 Participates actively in many chemical rxns of proteins
and amino acids,
 Helps normal function of brain,
 Promotes normal RBC formation,

Functions…
 Helps in energy production and resistance to stress,
 Treats some form of anemia,
 Treats isoniazid poisoning,
 Used in treatment of the ff conditions (asthma,
premenstrual syndrome, carpal tunnel syndrome,
depression, morning sickness, and kidney stones),
 Acts as co-enzyme for metabolic functions affecting
protein, CHOs and fat utilization,
 Promotes conversion of tryptophan to niacin or
serotonin.

To prevent reduction in the potency of the
vitamin:
 Avoid cooking foods that contain the vitamin in large
amounts of water,
 Freezing vegetables results in a 30 to 56% reduction of
the vitamin,
 Canning vegetables results in a 57 to 77% reduction of
vitamin B-6.

Deficiency
 Symptoms of vitamin B-6 deficiency are non-specific
and hard to reproduce experimentally.
Nervous system manifestations:
Weakness, mental confusion, irritability,
nervousness,
Insomnia, poor coordination walking, hyperactivity,
Depression, convulsions,
 Anemia, skin lesions, discoloration of tongue, kidney
stones, cracked lips, eczema.

Pyridoxine…
At risk groups:
 Breastfed infants born with low status
 Elderly
 Excessive alcohol consumers
 Renal pts w/dialysis losses
 Persons on drug therapies like isoniazid,
anticonvulsants, corticosteroids, etc.

 The therapeutic dose is b/n 50-100mg.
Age RDA
0-6 months 0.3mg
6-12 months 0.6mg
1-3 years 1.0mg
4-6 years 1.3mg
7-10 years 1.4mg

Recommended daily allowance…
Males
Age RDA
11-14 yrs 1.7mg
15+ yrs 2.0mg
Females
Age RDA
11-14 yrs 1.4mg
15-18 yrs 1.5mg
19+ yrs 1.6mg
 Pregnant (+2.2mg), lactating (+2.1mg)

Pyridoxine…
 Regular B-6 supplements are recommended if some
one is taking CAF, cycloserine, ethionamide,
hydralazine, immunosuppressants, isoniazid or
penicillamine.
 These decrease pyridoxine absorption and can cause
anaemia or tingling and numbness in hands and feet.
 Estrogen or oral contraceptives increase requirements
of pyridoxine.
 Tobacco decreases absorption. Smokers may require
supplemental Vitamin B-6.

F) Folic Acid (VitaminB9)
 Vitamin B-9, more commonly known as folic acid,
functions together with a group of related water-
soluble compounds, collectively called folacin, in many
body processes.
 Its primary coenzyme form, THF (tetrahydrofolate),
serves as part of an enzyme complex that transfers one
carbon compound that arise during metabolism.
 This action helps convert vitamin B-12 to one of its
coenzyme forms and helps synthesize the DNA
required for all rapidly growing cells.

Folic Acid…
 It is critical to cellular division because it is necessary in
DNA synthesis.
 Folic acid, also known as folacin or folate, maintains
the cell’s genetic code and transfer inherited traits
from one cell to another.
 It is vitally impt for the foetal dev’t of nerve cells, and a
folic acid deficiency during pregnancy has been linked
to several birth defects.
 Supplements of folic acid should be considered by all
women of childbearing age.

Folic Acid…
 Folic acid is a common vitamin deficiency.
 Vitamin B-12 should always be included in a folacin
supplement program because the folacin
supplementation can mask an underlying vitamin B-12
deficiency.
 Also, vitamin B-12 reactivates folic acid in the body and
a vitamin B-12 deficiency can cause a folic acid
deficiency.
 At greatest risk for a folate deficiency are the elderly,
women taking birth control pills, long-term antibiotic
pts, and alcoholics.

Folic Acid…
Folate and neural tube defects:
 Folate has proven to be critical in reducing the risks of
neural tube defects.
 Neural tube defects: malformations of the brain, spinal
cord, or both during embryonic dev’t that often result
in lifelong disability or death.
 The brain and spinal cord develop from the neural
tube, and defects in its orderly formation during the
early wks of pregnancy may result in various CNS
disorders and death.

Folate and neural tube defects…
 The two main types of neural tube defects are spinal
bifida (literally, "split spine") and anencephaly ("no
brain").
 Folate supplements taken one month before
conception and continued via out the 1st trimester of
pregnancy can help prevent neural tube defects.
 For this reason, all women of childbearing age who are
capable of becoming pregnant should consume 400
micrograms of folate daily.

Folate and neural tube defects…
 This recommendation can be met via a diet that
includes at least 5 servings of fruits and vegetables
daily.
 Furthermore, b/c of the enhanced bioavailability of
synthetic folate, supplementation or fortification
improves folate status significantly.
 Women who have given birth to infants with neural
tube defects previously should consume 4 milligrams
of folate daily before conception and via out the 1st
trimester of pregnancy.

Folic Acid…
Food sources:
 Barley, beans, brewer's yeast, calves' liver
 Fruits, chickpeas, lentils
 Green, leafy vegetables
 Peas, rice, soybeans, split peas, sprouts
 Wheat, wheat germ
 Orange juice, oranges.

Functions
 Promotes normal RBC formation.
 Maintains nervous system, intestinal tract, sex organs,
WBCs, normal patterns of growth.
 Regulates embryonic and foetal dev’t of nerve cells.
 Promotes normal growth and dev’t.
 Treats anaemia due to folic acid deficiency occurring
from alcoholism, liver disease, haemolytic anaemia,
pregnancy, breast-feeding, oral contraceptive use.
 Acts as co-enzyme for normal DNA synthesis.
 Functions as part of co-enzyme in amino acid and
nucleoprotein synthesis.
Deficiency symptoms
 Haemolytic and megaloblastic anaemia in w/c RBCs are
large and uneven in size, have a shorter life span or are
likely to have cell membranes rupture
 Irritability, weakness, lack of energy
 Sleeping difficulties, paleness, sore red tongue
 Neural tube defect in the foetus if deficient in pregnant
woman
 Mild mental symptoms, such as forgetfulness and
confusion
 Diarrhea

Folic acid…
 Haemolytic anemia: anemia that results from the
destruction of red blood cells and may be caused by
bacteria, genetic disorders, or toxic chemicals.
 Megaloblastic anemia: a form of anemia in w/c the
RBCs are unusually large because they have failed to
mature properly.

Recommended Daily Allowance (RDA):
Age RDA
0-6 months 25mcg
6-12 months 35mcg
1-3 years 50mcg
4-6 years 75mcg
7-10 years 100mcg

RDA…
Males Females
Age RDA Age RDA
11-14 yrs 150mcg 11-14 yrs 150mcg
15+ yrs 200mcg 15+ yrs 180mcg
Pregnant 400mcg
Lactating, 1st 6 mos 280mcg
2nd 6 mos 260mcg

Folic Acid…
 Pregnant women need to be supplemented with folic
acid at least 1 month before and 3 months after the
onset of pregnancy with the dose depending on the
level of risk they are in.
 High risk: a woman who had hx of a foetus with neural
tube defect or her relatives had the same hx,
 Low risk: women without such a hx.

G) Cobalamin (Vitamin B-12)
 Vitamin B-12 is found in animal foods.
 It is necessary for processing CHOs, protein, and fats in
the body.
 It affects the growth and repair of all the cells,
particularly nerve cells.
 The stomach parietal cells secrete a special digestive
hormone that increases the absorption of vitamin B-12
in the terminal ileum called intrinsic factor.

Vitamin B-12…
 Vitamin B-12 is called extrinsic factor.
 This vitamin is stored in the body tissues, so a
deficiency can take yrs to appear.
 It plays a role in the activation of amino acids during
protein formation.
 In combination with folic acid, it is necessary for the
synthesis of DNA and for maintaining the myelin
sheath that surrounds nerve cells.

Vitamin B-12…
A vitamin B-12 deficiency can result from:
 Inadequate diet as in the case of vegans (absolute
vegetarians)
 Disease like infection with fish tapeworm called
Diphyllobothyrium latum
 Lack of IF in the small intestine as in the case of surgical
removal of the parietal cells of the stomach
 Surgical removal of the terminal ileum
 There is some indication that 35% of people who are
HIV positive are also deficient in the vitamin.

Vitamin B-12…
 Whether this deficiency is the result of mal-absorption
or interactions with the drug AZT is not clear.
 Deficiency of vitamin B-12 and other nutrients will
facilitate and worsen the progression towards AIDS.
 In laboratory studies, vitamin B-12 has been shown to
halt the replication of HIV.
 Vitamin B-12 currently stands as assuring and
important addition to the treatment for this disease.

Vitamin B-12…
Food sources:
 Vitamin B-12 is found from foods of animal origin
which include:
Beef, beef liver,
Eggs,
Kidney
Milk, milk products
Sardines
Liver
 Note: Vitamin B-12 is not found in vegetables.

Vitamin B-12…
Functions:
 Promotes normal growth and dev’t
 Treats some types of nerve damage.
 Treats pernicious anemia (a severe form of anemia,
found mostly in older adults, that results from the
body's inability to absorb vitamin B-12).
 Treats and prevents vitamin B-12 deficiencies in people
who have had a portion of the GIT surgically removed.
 Prevents vitamin B-12 deficiency in vegan vegetarians
and persons with absorption diseases.

Functions…
 Acts as co-enzyme for normal DNA synthesis.
 Promotes normal fat and CHO metabolism and protein
syntheses.
 Promotes growth, cell dev’t, blood-cell dev’t, and
manufacture of covering to nerve cells, maintenance of
normal function of nervous system.

Vitamin B-12…
Deficiency:
 Impaired brain and nervous system function;
demylination of nerve fibers in CNS.
 Diarrhea
 Smooth, beefy red tongue
 Tingling and burning sensations
 Impaired mental functioning
 Inability to replicate cells lining mouth and GIT

Deficiency…
 False positive pap smear
 Pernicious anaemia (megaloblastic anaemia), with the
ff symptoms:
Fatigue, profound weakness, especially in arms and
legs,
Sore tongue, nausea, appetite loss, wt loss, bleeding
gums, numbness and tingling in hands and feet,
Difficulty maintaining balance, pale lips, pale tongue,
pale gums, yellow eyes and skin,
Shortness of breath, depression, confusion and
dementia, headache.

 Recommended dosage for detected deficiency states is
2000 mcg daily for 1 month, then 1000 mcg daily.
 Vegetarians are advised to obtain at least 100 mcg of
B-12 each day.
Age RDA Pregnant (+2.2mcg)
0-6 mons 0.3mcg Lactating (+2.6mcg)
6-12 mons 0.5mcg
1-3 yrs 0.7mcg
4-6 years 1.0mcg
7-10 yrs 1.4mcg
11+ years 2.0mcg
H) Vitamin C (Ascorbic Acid)
 Vitamin C has an antioxidant function.
 Antioxidant: a substance that inhibits the destructive
effects of oxidation, e.g. in the body or in foodstuffs.
 It helps to prevent many serious diseases such as heart
disease and cancers of the lung, throat, mouth,
stomach, pancreas, cervix, rectum and breast.
 It plays a major role in collagen formation, and in
amino acid metabolism and hormone synthesis.
 Humans cannot synthesize – most mammals
synthesize from glucose.

Vitamin C…
Food sources:
 Common sources of vitamin C are Citrus Fruits and
Green Leafy Vegetables:
Broccoli, cabbage, grapefruit, green peppers
Guava, kale, lemons
Oranges, papayas, potatoes, spinach, strawberries
Sweet and hot peppers, tomatoes, mangos

Vitamin C…
Functions:
 Promotes healthy capillaries, gums, and teeth.
 Helps heal wounds and broken bones.
 Prevents and treats scurvy.
 Treats anaemia, especially for iron-deficiency anaemia.
 Treats urinary-tract infections.
 Helps to form collagen in connective tissue and tissue
repair.
 Increases iron absorption from intestines.

Vitamin C…
Functions...
 Contributes to Hgb and RBC production in bone
marrow.
 Blocks production of nitrosamines.
 Participates in oxidation-reduction reactions.
 Needed for metabolism of phenylalanine, tyrosine,
folic acid, iron ( converts folic acid from inactive to
active).
 Helps utilization of carbohydrates, synthesis of fats and
proteins, preservation of integrity of blood vessel walls.

Food Preparation Tips to Conserve Vitamin C:
 Eat food raw or minimally cooked.
 Shorten cooking time by putting vegetables in very
small amounts of water.
 Avoid prolonged standing of food at room
temperature.
 Avoid overexposure of food to air and light.
 Avoid soaking vegetables.

Vitamin C…
Deficiency:
 Scurvy: muscle weakness, swollen gums, loss of teeth,
tiredness, depression, bleeding under skin, bleeding
gums
 Shortness of breath, digestive difficulties
 Easy bruising, swollen or painful joints
 Nosebleeds
 Anaemia: weakness, tiredness, paleness
 Frequent infections
 Slow healing of wound and reopening of surgical
wounds.
Vitamin C…
Recommended daily allowance (RDA):
Age RDA Age RDA
0-6 mons 30mg 4-6 yrs 45mg
6-12 mons 35mg 7-10 yrs 45mg
1-3 yrs 40 mg 11-14 yrs 50mg
15+ yrs 60mg
 Pregnant (70mg)
 Lactating (1st 6 months)- 95mg, 2nd 6 months- 90mg

Fat soluble vitamins
1)Vitamin A:
 Beta-carotene is a pro-vitamin A, found in plants.
 The body converts beta-carotene to vitamin A.
 Retinol is the precursor to active forms of vitamin A.
 These forms include retinal, w/c is used in vision and
reproduction, and retinoic acid, needed in growth and
genetic differentiation.
 Extreme deficiencies result in blindness, serious
damage to the immune system, and death.

Vitamin A…
 Vitamin A is used as an immune enhancer in viral
diseases.
 Supplements of this vitamin led to a 50% decrease in
mortality from measles in developing countries.
 High doses during pregnancy are dangerous, and can
result in birth defects.
 If a pregnant woman develops Xerophthalmia,
administration of low dose ( 5,000 IU ) twice in a day
for 2 wks be done.

Vitamin A…
 Carotenes are the pigments w/c provide colour in
plants and flowers.
 Some carotenes can be converted into vitamin A in the
body.
 While beta-carotene has the greatest pro-vitamin A
activity, there are other carotenes that are much more
powerful antioxidants.
 These include alpha-carotene and lycopene, w/c have
well-noted anti-cancer effects.

Vitamin A…
Food sources
A)Plant sources:
 Vitamin A is generally found in GLVs, yellow orange
fruits in the form of B-carotene.
 Apricots, fresh
 Papaya, mango, asparagus, broccoli
 Cantaloupe, carrots, kale
 Red palm oil, mustard greens, pumpkin, spinach,
 Sweet potatoes, watermelon

Vitamin A…
B) Animal sources: found in the form of retinol.
 Liver, fish liver oil
 Milk, egg
Functions:
 Aids in treatment of many eye disorders, including
prevention of night blindness,
 Promotes bone growth, teeth dev’t, and reproduction.
 Helps form and maintain healthy skin, hair, and
mucous membranes.
 Builds body's resistance to respiratory infections.

Vitamin A…
Functions...
 Helps treat acne, impetigo, boils, and carbuncles, open
ulcers when applied externally.
 Essential for normal function of retina.
 Combines with purple pigment of retina (opsin) to form
rhodopsin, w/c is necessary for sight in partial
darkness.
 Necessary for growth of bone, testicular function,
ovarian function, embryonic dev’t, regulation of
growth, differentiation of tissues.
 Has anti oxidant function

Vitamin A…
Deficiency:
 Night blindness
 Lack of tear secretion( due to destruction of goblet cell)
 Changes in eyes with eventual blindness if deficiency is
severe and untreated
 Susceptibility to respiratory infection
 Dry, rough skin
 Changes in mucous membranes
 Weight loss, poor bone growth
 Weak tooth enamel, diarrhea, slow growth

 RDA for vitamin A is expressed in retinol equivalents
(RE).
 One RE = 1 mcg retinol or 6 mcg beta-carotene.
Age Retinol Equivalents (IU)
0-6 months 375RE (2,100IU)
6-12 months 375RE (2,100IU)
1-3 years 400RE (2,000IU)
4-6 years 500RE (2,500IU)
7-10 years 700RE (3,300IU)

RDA…
Males Retinol Equivalents (IU)
11+ years 1,000RE (5,000IU)
Females
11+ years 800RE (4,000IU)
 Pregnant 800RE (4,000IU)
 Lactating (1st 6 months)- 500RE +2,500IU, 2nd 6
months 500RE +2,500IU

Vitamin A…
Overdose/toxicity:
 Bleeding from gums or sore mouth, bulging soft spot
on head in babies (infants), sometimes hydrocephaly
("water on brain"),
 Confusion or unusual excitement, diarrhea, dizziness,
double vision, headache, irritability, dry skin, hair loss,
 Peeling skin on lips, palms and in other areas, seizures,
vomiting, enlarged spleen and liver
The symptoms will be reversed when ingestion of
the vitamin is stopped.

2) Vitamin D (1,25, Dihydroxycholecalciferol)
 Also known as calciferol, 1,25-dihydroxy vitamin D
(calcitriol), vitamin D3 or cholecalciferol, vitamin D2 or
ergocalciferol
 Vitamin D is a non-essential nutrient that acts like a
hormone in the body.
 The body can make vitamin D with help from sunlight.

 The plant version of vitamin D is called vitamin D2 or
ergocalciferol.
 The animal version of vitamin D is called vitamin D3 or
cholecalciferol.
 Once the vitamin enters the body it must become
activated.
 Activation occurs via the action of the liver and the
kidneys.

Roles of vitamin D in the Body:
1) Vitamin D in bone growth
 Helps to maintain blood levels of calcium and
phosphorus
 Works in combination with other nutrients and
hormones
 Vitamin A, vitamin C, vitamin K
 Parathormone and calcitonin
 Collagen
 Calcium, phosphorus, magnesium, and fluoride

Roles of vitamin D…
2) Vitamin D in other roles
Immune system
Brain and nervous system
Pancreas, skin, muscles, cartilage, and reproductive
organs
Factors that contribute to deficiency
Dark skin
Breastfeeding without supplementation
Lack of sunlight
Use of non-fortified milk

Vitamin D Deficiency
a) Rickets
 Affects mainly children worldwide
 Deficiency symptoms:
Inadequate calcification of bones
Growth retardation
Misshapen bones including bowing of the legs
Enlargement of the ends of long bones
Deformities of ribs
Delayed closing of fontanel thus rapid
enlargement of the head

Vitamin D Deficiency…
b) Osteomalacia
 Affects adults
 Soft, flexible, brittle, and deformed bones
 Progressive weakness
 Pain in pelvis, lower back, and legs
C) Osteoporosis
Loss of calcium from the bones due to
inadequate synthesis of vitamin D
Results in a reduced bone density

The Elderly
Deficiency is likely due to inadequate production
and activation of vitamin D, a decreased
consumption of milk, and having little time in the
sun.
There is an increased risk for bone loss and
fractures.

Vitamin D Toxicity
 More likely to be toxic compared to other vitamins
 Vitamin D from sunlight and food is not likely to
cause toxicity.
 High-dose supplements may cause toxicity.
Toxicity symptoms
Elevated blood calcium
Calcification of soft tissues (blood vessels, kidneys,
heart, lungs, and tissues around joints)
Frequent urination

Vitamin D Toxicity…
 High blood calcium is called hypercalcemia and is often
associated with vitamin D excess
 Upper level for adults: 50 μg/day
 Toxicity disease is called hypervitaminosis D

Age RDA
0-6 months 7.5mcg
6months-10 yrs 10mcg
Males Females
11-18 yrs 10mcg 11-18 yrs 10mcg
19-24 yrs 10mcg 19-24 yrs 10mcg

25+ yrs 5mcg 25+ yrs 5mcg
Pregnant & lactating (10mcg)
Adults 51-70 yrs (10mcg)
Adults older than 70 yrs (15mcg)
Vitamin D in Foods (sources)
 Fortified milk, butter, and margarine
 Cereals
 Chocolate mixes
 Veal, beef, egg yolks, liver, fatty fish and their oils
 Sunlight plus subcutaneous fat
Vegans may need fortification or supplements if
they do not have adequate sun exposure.

3) Vitamin E
 There are 4 different tocopherol compounds (alpha,
beta, delta, and gamma), but only the alpha-
tocopherol has vitamin E activity in human beings.
 Vitamin E (also called alpha-tocopherol) shares top
billing with vitamin C as the most popular and most
often used vitamin.
 Vitamin E can boost the immune system so that it
fights off common old-age illnesses better.
 Experts believe that Vitamin E accomplished this by
inhibiting the oxidation of free radicals.
 Excessive amounts of these essential compounds tend
to oxidize and destroy human cells.

 Besides its role as an antioxidant, it is important in the
synthesis and maintenance of RBCs and their
constituents, and might have a direct effect on the
synthesis of Hgb.
 Vitamin E as an Antioxidant:
 Stops the chain rxn of free radicals
 Protects the lungs against damage from air pollutants;
 Prevents tumour growth; protects tissues of the skin,
eye, liver, breast
 Maintains the biological integrity of vitamin A and
increases the body’s stores of this vitamin.
 Protects the oxidation of LDLs

Food sources:
All vegetable oils(Apricot oil , Corn oil, Cottonseed
oil, Peanut oil)
Leafy green vegetables, wheat germ
Whole-wheat flour, margarine
Liver and egg yolks
Sunflower nuts and seeds
Walnuts
 Note: Easily destroyed by heat and oxygen

Functions of vitamin E
 Treats and prevents vitamin E deficiency in premature
or LBW infants.
 Prevents oxidation of free radicals
 Acts as anti-blood clotting agent.
 Protects tissue against oxidation.
 Promotes normal RBC formation.
 Involved in reproduction

Vitamin E deficiency
 Primary deficiency due to inadequate intake is rare
Deficiency symptoms:
I) Premature infants and children:
 Irritability, edema and haemolytic anemia
II) Adults
 Lack of vitality, lethargy, apathy
 Inability to concentrate, irritability
 Disinterest in physical activity
 Decreased sexual performance, muscle weakness
 Causes infertility

Vitamin E Toxicity
 Rare and the least toxic of the fat-soluble vitamins
 Upper level for adults: 1000 mg/day
 May augment the effects of anti clotting medication
Age RDA Males
0-12 months 3-4mg 11+ yrs 10mg
1-10 years 6-7mg
Females
11+ years 8mg

 Pregnant (10mg), lactating (1st 6 mos-12mg and 2nd 6 mos-
11mg).

4) Vitamin K
 Also known as phylloquinone, menaquinone,
menadione, and naphthoquinone
 Vitamin K is unique in that half of human needs are
met via the action of intestinal bacteria.
 Vitamin K deficiencies are uncommon but when they
do occur, it is usually the result of anti-coagulant
medication or the long term use of antibiotics.
These medications interfere with the function of the
vitamin.

 Deficiencies can occur in newborn infants
 Newborn infants receive a single dose of vitamin K
at birth b/c of a sterile intestinal tract.
 Vitamin K deficiency can cause uncontrolled bleeding.
Roles in the Body
 Synthesis of blood-clotting proteins
 Synthesis of bone proteins that regulate blood calcium
 Without vitamin K, a hemorrhagic disease may
develop.

Food sources:
Cabbage, spinach,
Turnip greens
Cauliflower
Green leafy vegetables
Green tea
Oats, soybeans
Milk, liver

Functions:
 Prevents hemorrhagic disease of the newborn.
 Prevents abnormal bleeding, particularly in those with
chronic intestinal disease or those taking anti-
coagulant medicines.
 Vitamin K is normally manufactured in the intestinal
tract by "friendly" bacteria.
 If bacteria are destroyed or damaged by disease or
antibiotics, vitamin K deficiency may develop.

Functions…
 Treats bleeding disorders due to vitamin K deficiency.
 Promotes production of active prothrombin (factor II),
proconvertin (factor VII), factor IX and factor X .
 These are all necessary for normal blood clotting.
Deficiency:
a) Infants
 Failure to grow and develop normally.
 Hemorrhagic disease of the newborn cxrized by:
Vomiting blood and bleeding from intestine,
umbilical cord, circumcision site.
Symptoms begin 2 or 3 days after birth.
Deficiency...
b) Adults:
 Abnormal blood clotting that can lead to nosebleeds,
blood in urine, stomach bleeding, bleeding from
capillaries or skin causing spontaneous black-and-blue
marks,
 Prolonged clotting time

 No RDA has been established.
 Adequate and safe range is 2mcg/kg body wt/day.
 Estimated Safe Intake/Day is given below:
Age Estimated safe intake
0-6 months 5mcg
6-12 months 10mcg
1-3 years 15mcg
4-6 years 20mcg
7-10 years 30mcg

RDA…
Males Females
Age RDA Age RDA
11-14 years 45mcg 11-14 yrs 45mcg
25+ years 80mcg 25+ yrs 65mcg
 Pregnant and lactating (65mcg)

Overdose/ toxicity:
Signs and symptoms:
 In infants: Brain damage.
 In all: Large doses may impair liver function and
decrease the effectiveness of anti clotting medications.

MINERALS

MINERALS
 Minerals are inorganic chemical elements
 They participate in many biochemical and
physiological processes necessary for optimum
growth, development and health.
 They constitute 4% of total body weight
 They are essential structural components of body
tissues and are vital for body processes

 For some functions the body needs balance between
some minerals:
Bone formation (Ca: P)
Muscular activity (Ca: K)
Osmotic control of water metabolism (K: Na)
 Other minerals may act as catalysts in enzyme
systems.

 Some form integral parts of organic compounds.
Examples:
Fe in haemoglobin
Iodine in thyroxin
Cobalt in vitamin B-12
Zinc in Insulation
Sulphur in thiamine and biotin

 Some minerals are excreted in urine and others in
faeces
 Some minerals are stored and reach toxic levels when
consumed in excess amounts
 Toxicities usually result from:
Mineral supplement
Environmental/industrial exposure
Human errors in commercial food processing
Alterations in metabolism e.g. genetic defect in
Fe absorption  hemochromatosis

Classification of Minerals

I) Major minerals (Principal elements)
 These are minerals that are required in relatively
larger amounts > 100 mg/d or are found in the body
in amounts > 5g.
A. Calcium
 Is the most abundant mineral in the human body
 The bones maintain over 99% of the body's calcium.
 This vital mineral is required for the formation and
maintenance of bones and teeth.
 Calcium also assists in enzyme actions involving
muscle contraction, neurotransmitter release, the
regulation of heartbeat, and blood clotting.

Calcium…
 In children, calcium deficiency is associated with
rickets, bone deformities, and growth retardation.
 Adult deficiency leads to osteomalacia (softening of
bones).
 Muscle spasms and cramps, high blood pressure,
osteoporosis, and colon and rectal cancers are also
attributed to low calcium levels.

Food sources:
Milk, cheese, yogurt, ice cream (?)
Tofu
Fish with bones (salmon, sardines)
Turnip greens, broccoli, kale
Legumes
Fortified juices & breads

Functions:
 Helps prevent osteoporosis in older people.
 Treats calcium depletion in people with
hypoparathyroidism, osteomalacia, rickets.
 Treats low-calcium levels in people taking
anticonvulsant medication.
 Treats tetany (severe muscle spasms) caused by insect
bites, sensitivity reactions, cardiac arrest, lead
poisoning.
 Prevents muscle cramps in some people.

Functions...
 Builds bones and teeth. It Maintains bone density and
strength.
 Buffers acid in stomach and acts as antacid.
 Helps regulate heartbeat, blood clotting, and muscle
contraction.
 Treats neonatal hypocalcaemia.
 Lowers phosphate concentrations in people with
chronic kidney disease.
 Participates in metabolic functions necessary for
normal activity of nervous, muscular, skeletal systems
(nerve transmission).

Deficiency:
 Osteoporosis (late symptoms): frequent fractures in
spine and other bones, deformed spinal column with
humps, loss of height
 Osteomalacia: frequent fractures
 Muscle contractions
 Convulsive seizures
 Muscle cramps
 Low backache

 It is recommend that women should take more calcium
than quoted by the RDA.
 The recommendation is 1,000 mg/day for pre-
menopausal women and 1,500 mg/day for post-
menopausal women and elderly men.
0-6 months 360mg

6-12 months 540mg
1-10 years 800mg
11-18 years 1000mg
18+ years 800mg
 Pregnant and lactating women (+400mg)
B. Phosphorus
 Is the 2nd most abundant mineral in the body.
 The majority of it is found as calcium phosphate.
 As phosphoric acid, it is fundamental to the growth,
maintenance, and repair of all body tissues.
Food sources:
Milk products (milk, cheese, yoghurt)
Eggs, fish, almonds, nuts
Meats, molasses, poultry,
Shrimp
Soft drinks, soybeans, tofu

Function:
 Fundamental to the growth, maintenance, and repair
of all body tissues.
 Necessary for protein synthesis.
 Critical for energy transfer and production.
 Plays a role in the phosphorylation of monosaccharides
for energy
 Necessary for oxidation of CHOs, protein and fats
leading to the formation of ATP.
 Phosphorous is a structural component of all cells.

It is part of the nucleic acids comprising the genetic code
in all cells.
Activates many enzymes, B vitamins, and ATP.

Deficiency Symptoms
Decreased appetite
Nervous system deterioration
Demineralization of bones and teeth
Cold hands and feet
Continuous diarrhea, constipation
Cramps, shooting pains, low fevers
Depression, sore breasts
Numbness, night sweats
Faint/rapid pulse

Age RDA
0-6 months 300mg
6-12 months 500mg
1-10 years 800mg
11-18 years 1,000mg
18+ years 1,000mg
 Pregnant and lactating women (1200mg)

C. Potassium
 Potassium is an intracellular cation which regulates
fluid and electrolyte balance in the body.
 A shortage of potassium results in lower levels of
stored glycogen, which can hinder exercise due to the
rapid depletion of energy.
 A potassium deficiency produces great fatigue and
muscle weakness, the first signs of potassium
deficiency.

Food sources:
 Unprocessed foods; some fruits & vegetables (banana,
pineapple), legumes, nuts, seeds
Functions:
 Promotes regular heartbeat.
 Promotes normal muscle contraction.
 Regulates transfer of nutrients to cells.
 Maintains water balance in body tissues and cells.
 Preserves or restores normal function of nerve cells, heart
cells, skeletal-muscle cells, kidneys, stomach juice secretion.
Unprocessed foods; some fruits & vegetables, legumes, nuts, seeds
Unprocessed foods; some fruits & vegetables, legumes, nuts, seeds

Functions...
 Treats potassium deficiency from illness or taking
diuretics (water pills), cortisone drugs or digitalis
preparations.
 Potassium is the predominant positive electrolyte in
body cells.
 An enzyme (adenosinetriphosphatase) controls flow of
potassium and sodium into and out of cells to maintain
normal function of heart, brain, skeletal muscles,
normal kidney function, acid-base balance.
 Cures alcoholism, heart disease, helps heal burns
 Prevents high blood pressures

Deficiency
Hypokalemia
Weakness, paralysis
High blood pressure
Life-threatening, irregular or rapid heartbeat that
can lead to cardiac arrest and death
Special Consideration
Potassium supplements for those who take diuretics

D. Sodium
 Sodium is an extra cellular cation necessary for
maintaining the proper blood PH and water balance
in the body.
 It is also needed for muscle, nerve and stomach
function.
 Carbon dioxide transport, and amino acid uptake
from the gut and transportation to all cells are all
dependent upon sodium.
 B/c it is found in virtually all foods and a deficiency in
sodium is rare, no recommended daily intake has
been established.

Food sources:
 Table salt (chief source of sodium)
 Tomatoes
 Beef, dried and fresh
 Bread, butter
 Green beans, margarine, milk, sardines
Note:
 In most commercially canned vegetables, frozen foods
and processed foods, salt is added to improve taste.
 "Highly processed" foods (also high in sodium) include
soups, pickles, potato chips, ham and snack foods.

Functions:
 Helps regulate water balance in body.
 Plays a crucial role in maintaining blood pressure.
 Aids muscle contraction and nerve transmission.
 Regulates body's acid-base balance.
As an electrolyte, sodium is present in all body cells.
Its most important function is to regulate the
balance of water inside and outside cells.
The two other most important electrolytes are
potassium and chloride.

Deficiency:
 Excessive sweating,
 Muscle and stomach cramps
 Nausea and vomiting
 Fatigue,
 Appetite loss
 Muscle twitching and cramping (usually in legs)

 Diets rarely lack sodium, and even when intakes are
low, the body adapts by reducing sodium losses in
urine and sweat, thus making deficiencies unlikely.
 Sodium recommendations are set low enough to
protect against high blood pressure
 The upper level for adults is set at 2300mg/day,
slightly lower than the daily value used on food labels
(2400 mg).

E. Chloride
 Chloride in an essential nutrient that plays a role in
fluid balance.
 It is associated with sodium and part of hydrochloric
acid in the stomach.
 Chloride Roles in the Body:
Maintains normal fluid and electrolyte balance
Part of hydrochloric acid found in the stomach
Necessary for proper digestion

Chloride Recommendations and Intakes
 Recommendations (Adequate Intake)
For those 19-50 yrs of age (2,300 mg/day)
For those 51-70 yrs of age (2,000 mg/day)
For those older than 70 yrs of age (1,800
mg/day)
Upper intake level is 3,600 mg/day
 Chloride Intakes
Abundant in foods (table salt, sea salt)
Abundant in processed foods

Chloride Deficiency and Toxicity
Deficiency is rare.
Losses can occur with vomiting, diarrhea or heavy
sweating.
Dehydration due to water deficiency can
concentrate chloride to high levels.
The toxicity symptom is vomiting.

II) Trace elements (micro-minerals)
1) Iodine
 Iodide is an essential component of the thyroid
hormone that helps to regulate metabolism.
 Iodine deficiency can cause simple goiter and
cretinism.
 The iodization of salt has greatly reduced iodine
deficiency.

Iodide roles in the body:
 Component of two thyroid hormones (T3 and T4)
 Regulates body temperature, growth, dev’t, metabolic
rate, nerve and muscle function, reproduction, and
blood cell production.
Iodine deficiency
 The hypothalamus regulates thyroid hormone
production by controlling the release of the pituitary's
thyroid-stimulating hormone (TSH).
 With iodine deficiency, thyroid hormone production
declines, and the body responds by secreting more TSH
in a futile attempt to accelerate iodide uptake by the
thyroid gland.
Iodine deficiency…
 If a deficiency persists, the cells of the thyroid gland
enlarge to trap as much iodide as possible.
 Sometimes the gland enlarges until it makes a visible
lump in the neck, a simple goiter.
 Goiter affects about 200 million people worldwide,
many of them in South America, Asia, and Africa.
 In all but 4 percent of these cases, the cause is iodine
deficiency.
 Goitrogen (antithyroid) overconsumption – naturally
occurring in cabbage, spinach, radishes, rutabaga,
soybeans, peanuts, peaches, and strawberries.

Iodine deficiency…
 Goiter may be the earliest and most obvious sign of
iodine deficiency, but the most tragic and prevalent
damage occurs in the brain.
 Children with even a mild iodine deficiency typically
have goiters and perform poorly in school.
 A severe iodine deficiency during pregnancy causes
the extreme and irreversible mental and physical
retardation known as cretinism.
 Cretinism affects approximately 6 million people
worldwide and can be averted by the early diagnosis
and treatment of maternal iodine deficiency.

 A worldwide effort to provide iodized salt to people
living in iodine-deficient areas has been dramatically
successful.
 B/c iron deficiency is common among people with
iodine deficiency and b/c iron deficiency reduces the
effectiveness of iodized salt, dual fortification with
both iron and iodine may be most beneficial.

Iodine Toxicity
 UL 1100 μg/day
 Symptoms include underactive thyroid gland, elevated
TSH, and goiter.
 Supplement use, medications, and excessive iodine
from foods
Iodine Recommendations
 Adults: 150 μg/day
 Pregnant (375mcg)
 Lactating (200mcg)

Sources:
Iodized salt,
Seafood,
Bread and dairy products
Plants grown in iodine-rich soils
Animals that feed on plants grown in iodine-rich
soils

2) Iron
 Iron deficiency is the most common nutrient deficiency
worldwide.
 The groups at highest risk are infants under 2 yrs of
age, teenage girls, pregnant women, and the elderly.
 Studies have found evidence of iron deficiency in 30 to
50% of the people in these groups.
 Iron deficiency is the most common cause of anemia.
 However, anemia is the last stage of iron deficiency
w/c is cxrized by RBCs that are small and pale.

 This condition is treated with supplemental iron,
usually in combination with vitamins A, C, E, and
copper.
 Iron is essential to periods of growth, such as infancy,
adolescence, pregnancy, and lactation.
 During these times, the amount of iron obtained via
the diet may not be enough.
 In addition to an inadequate dietary supply of iron,
deficiency may result from absorption problems,
chronic diarrhea, antacid use, and blood loss (such as
menstruation).

 Iron is found in functional forms, such as hgb and
enzymes, and in transport and storage forms such as
transferrin, ferrin, and hemosiderin.
 It is needed to transport oxygen from the lungs to body
tissue and to bring carbon dioxide from body tissues to
the lungs.
 It interacts with enzymes regulating the production of
energy, metabolism, and DNA synthesis.
 Functional iron exists in the form of hemeproteins.
 Heme iron binds to hgb in the blood and myoglobin in
the muscles.

 Iron that is involved in storage and transport functions
is of the nonheme variety.
 While a greater percentage of nonheme iron is
available via the diet, heme iron is more easily
absorbed.
 Heme iron is found in meat sources, poultry, and fish.
 Plant and dairy foods contain nonheme iron.
 Absorption of this form of the nutrient is affected by
various components in food.

Factors enhancing and inhibiting absorption of none
heme iron
Enhancers Inhibitors
Vitamin C Phytates
Amino acids Tanins
High altitude Polyphenols
Hydrochloric acid Heavy metals
Fermentation Fibers
Alcohol Low altitude
Deficient stores Replete stores
Achlorgydria

Food sources:
Bread, enriched
Cheese, cheddar
Egg yolk , meat, chicken, fish
Chickpeas, lentils
Pumpkin seeds, seaweed
Walnuts, wheat germ, whole-grain products

Note:
 Plant sources and dairy products contain nonheme
iron.
 The hgb and myoglobin in meats, poultry, and fish
provide heme iron.
 While nonheme iron makes up over 85% of the iron in
our diet, heme iron is more easily absorbed.

Functions:
 Prevents and treats iron-deficiency anemia due to
dietary iron deficiency or other causes
 Stimulates bone marrow production of hgb
 Forms part of several enzymes and proteins in the
body.
 Replace iron lost during menstruation.
 Iron is an essential component of hgb, myoglobin and a
co-factor of several essential enzymes.
 Of the total iron in the body, 60 to 70% is stored in hgb
(the red part of red blood cells).

 The heme compound myoglobin is an iron-protein
complex in muscles.
 This complex helps muscles get extra energy when
they work hard.
Listlessness (lacking energy)
Heart palpitations upon exertion
Fatigue, irritability
Paleness of skin
Cracking of lips and tongue

Deficiency…
Difficulty swallowing
General feeling of poor health
Poor Physical growth in children
Poor work out put in adults
Poor attention span and learning ability in children
Infection( Impaired neutrophil function)

Age RDA Males
0-6 months 5mg 11-18 yrs 12mg
6 months-10 yrs 10mg 19+ yrs 10mg
Females
11-50 years 15mg
51+ years 10mg
 Pregnant (30mg), lactating (15mg)

3) Zinc
 Zinc is in every cell of the body and is a part of over 200
enzymes.
 Essential for the maintenance of vision, taste and
smell, it is also necessary for immune function, protein
synthesis, and cell growth.
 It is required for the activity of the antioxidant enzyme
superoxide dismutase.
 Zinc has been used successfully in the treatment of
rheumatoid arthritis, acne, and macular (eye)
degeneration.

 While severe deficiencies of zinc are uncommon,
marginal deficiencies are frequent in the elderly, those
suffering from abnormal eating behaviour, and AIDS
pts.
 Deficiencies may be responsible for many of the
secondary conditions in AIDS pts, including
gastrointestinal malfunction, diarrhea, anorexia,
impaired immunity, CNS malfunction
 Supplements have led to improvements in memory,
comprehension, communication, and social interaction
in these pts

 Zinc is central to male sex hormone and prostate
function.
 Deficiencies may lead to prostate enlargement and
decreased testosterone and sperm count.
Functions:
 Functions as antioxidant.
 Maintains normal taste and smell.
 Aids wound healing.
 Promotes normal fetal growth.
 Helps synthesize DNA and RNA.

 Promotes cell division, cell repair, cell growth.
 Maintains normal level of vitamin A in blood.
 Zinc is a part of the molecular structure of 80 or more
known enzymes.
 These particular enzymes work with RBCs to move
carbon dioxide from tissues to lungs

Moderate deficiency
 Loss of taste and smell
 Suboptimal growth in children
 Alopecia, rashes, poor taste acuity
 Multiple skin lesions
 Glossitis, stomatitis, blepharitis (eyelid
inflammation)
 Paronychia, sterility
 Low sperm count
 Delayed wound healing

Serious Deficiency:
 Delayed bone maturation
 Enlarged spleen or liver
 Decreased size of testicles
 Testicular function less than normal
 Decreased growth or dwarfism

Age RDA Males
0-12 months 5mg 11+ yrs 15mg
1-10 years 10mg
Females
11+ yrs 12mg
 Pregnant (15mg)
 Lactating (1st 6 mos- 19mg & 2nd 6 mos- 16mg)

 Alcohol, even in moderate amounts, can increase the
excretion of zinc in urine and can impair body's ability
to combine zinc into its proper enzyme combinations
in the liver.
 Coffee should not be consumed at the same time as
zinc because it may decrease absorption of zinc.

WATER

Water
Learning objectives:
At the end of completing this unit, the students are
expected to:
 Describe the amount and distribution of water in the
body
 Describe the roles of water in the body
 Describe water balance and recommended intakes
 List the common water sources
 Know the health effects of water

 Water constitutes about 60% of an adult's body wt and
a higher percentage of a child's.
 Because water makes up about three-fourths of the wt
of lean tissue and less than one-fourth of the wt of fat,
a person's body composition influences how much of
the body's wt is water.
 The proportion of water is generally smaller in females,
obese people, and the elderly b/c of their smaller
proportion of lean tissue.
 In the body, water is the fluid in w/c all life processes
occur.

Water’s role in the body:
Carries nutrients and waste products
Maintains the structure of large molecules
Participates in metabolic reactions
Solvent for minerals, vitamins, amino acids, glucose
and others
Lubricant and cushion around joints, inside the eyes,
the spinal cord, and in amniotic fluid during
pregnancy
Regulation of body temperature
Maintains blood volume

Water Balance and Recommended Intakes
 Intracellular fluid (inside the cells) makes up about
two-thirds of the body’s water.
 Extracellular fluid (outside the cells) has two
components- the interstitial fluid and plasma.
 These fluids continually lose and replace their
components, yet the composition in each
compartment remains remarkably constant under
normal conditions.
 B/c imbalances can be devastating, the body quickly
responds by adjusting both water intake and
excretion as needed.

Water Intakes:
 Thirst is a conscious desire to drink and is regulated by
the mouth, hypothalamus, and nerves.
 Dehydration occurs when water output exceeds input
due to an inadequate intake or excessive losses.
 1-2% loss of body wt- thirst, fatigue, weakness,
vague discomfort, and loss of appetite
 3-4% loss of body wt- impaired physical
performance, dry mouth, reduction in urine, flushed
skin, impatience, and apathy.

 5-6% loss of body wt- difficulty in concentrating,
headache, irritability, sleepiness, impaired
temperature regulation, and increased respiratory rate
 7-10% loss of body wt- dizziness, spastic muscles, loss
of balance, delirium, exhaustion, and collapse
 Water intoxication, on the other hand, is rare but can
occur with excessive water ingestion and kidney
disorders that reduce urine production.
 The symptoms may include confusion, convulsions,
and even death in extreme cases.

Water sources:
 The obvious dietary sources of water are water itself
and other beverages, but nearly all foods also contain
water.
 Most fruits and vegetables contain up to 90% water,
and many meats and cheeses contain at least 50%.
 Also, water is generated during metabolism.
 When the energy-yielding nutrients break down, their
carbons and hydrogens combine with oxygen to yield
carbon dioxide (CO2 ) and water (H2O).

Water losses:
 The body must excrete a minimum of about 500 ml
(about 2 cups) of water each day- as urine- enough to
carry away the waste products generated by a day's
metabolic activities.
 Above this amount, excretion adjusts to balance
intake.
 If a person drinks more water, the kidneys excrete
more urine, and the urine becomes more dilute.
 In addition to urine, water is lost from the lungs as
vapor and from the skin as sweat; some is also lost in
feces.

 The amount of fluid lost from each source varies,
depending on:
The environment (such as heat or humidity) and
Physical conditions (such as exercise or fever).
 On average, daily losses total about two and half
liters.
 Maintaining this balance requires healthy kidneys and
an adequate intake of fluids.

Water recommendations:
 B/c water needs vary depending on diet, activity,
env’tal temperature, and humidity, a general water
requirement is difficult to establish.
 Recommendations are sometimes expressed in
proportion to the amount of energy expended under
average env’tal conditions.
 The recommended water intake for a person who
expends 2000 kcals a day, for example, is 2 to 3 liters of
water (about 8 to 12 cups).
 This recommendation is in line with the Adequate
Intake (AI) for total water set by the DRI Committee.

Health Effects of Water:
Meeting fluid needs (major function)
Protect the bladder, prostrate, and breast against
cancer
Protect against kidney stones
 Even mild dehydration seems to interfere with daily
tasks involving concentration, alertness, and short-
term memory.
 The kind of water a person drinks may also make a
difference to health.
 Water is usually either hard or soft.

A) Hard Water:
Water with high calcium and magnesium content
May benefit hypertension and heart disease
B) Soft water
Water with high sodium and potassium content
May aggravate hypertension and heart disease
Dissolves contaminate minerals in pipes
Practical advantages

Other types of water:
 Artesian water- water drawn from a well that taps
a confined aquifer in which the water in under
pressure
 Bottled water- drinking water sold in bottles
 Carbonated water- water that contains carbon
dioxide gas, either natural or added
 Distilled water- free of dissolved minerals
 Filtered water- water treated by filtration with
lead, arsenic, and some microorganisms removed.

Other types of water…
 Mineral water- water from a spring or well that
contains about 250-500 parts per million of minerals
 Natural water- water from a spring or well that is
certified to be safe and sanitary
 Public water- water from a city or county water
system that has been treated and disinfected
 Purified water- water that has been treated to
remove dissolved solids
 Spring water- water originating from an
underground spring or well
 Well water- water drawn from ground water by
tapping into an aquifer

COMMON NUTRITIONAL
PROBLEMS OF PUBLIC HEALTH
IMPORTANCE IN ETHIOPIA

Introduction
 Ethiopia, as many other developing countries, is
affected by several nutritional deficiencies.
 Nutritional problems of public health
importance in Ethiopia include:
 Macronutrients:
Protein energy malnutrition (PEM)
Introduction…
 Micronutrients:
Iron deficiency anemia (IDA)
Iodine deficiency disorders (IDD)
 Vitamin A deficiency (VAD)
Vitamin D deficiency (Rickets)
Fluorine deficiency (or excess)
A) Protein-Energy Malnutrition (PEM)
Definition:
 Protein-energy malnutrition (PEM) is a diagnosis that
includes several overlapping syndromes.
 The scientific basis for PEM was questioned in the early
20th century and different terms were introduced to
describe it.
 Controversies raged since 1930 and in 1935 cicely
William’s introduced the Ghanaian dx, Kwashiorkor (a
disease of child disposed from breast by birth of the
next one).
PEM…
 The term kwashiorkor -remained constant in
spite of the criticisms because it doesn’t
describe the cause.
 Over the following 20 years since then, around
50 different alternative names have been given
to the same syndrome.
 In 1959, Jelliffe, proposed the term protein
calorie malnutrition (PCM) to include all
syndromes relating to inadequate feeding.
PEM…
 This has been largely replaced by protein-
energy malnutrition (PEM) or malnutrition.
Epidemiology
 PEM is the major nutritional problem of the
third world countries.
 Its prevalence ranges from 20-40% in Africa and
Southeast Asia.
Epidemiology…
 PEM is mostly common in children under five
yrs of age.
 Marasmus is common in children less than 12
months of age and,
 Kwashiorkor is prevalent in children less than 5
years, commonly in the age groups of 2-3 yrs.
 Many studies show that this problem is
associated with different factors like:
Epidemiology…
 Improper weaning practice (early abrupt
weaning with dilute and dirty formula)
 Infections (diarrhea, measles, tuberculosis,
pertusis, etc.)
 Harmful traditional practices (age bias in
feeding, sex bias in feeding, food prejudices-
omission from family diet) and
 Child neglect
 These factors do operate in the Ethiopian
context.
Epidemiology…
 In Ethiopia, there is a cyclic occurrence of
malnutrition in most rural agrarian communities
ff the turn of the seasons.
 The winter (rainy) season is therefore called the
hunger (lean) season and that of the summer
(dry) season is the harvest season.
 This seasonality of energy and protein intake is
reflected in the variations in the prevalence of
PEM in those two seasons.
Causes, etiology and pathogenesis
Causes:
 Causes of PEM are multi-factorial having a
number of interwoven factors operating
simultaneously.
 The causes could be categorized as immediate,
underlying and basic.
 The following diagram depicts the causes
operating at different levels.
Causes…
At the level of the individual child, one or more of the ff
factors may operate:
 Lack of knowledge: people do not understand the
nutritional nature of their child’s health problem
 Poverty: lack of means to obtain and provide food to
their child (as in the case of war)
 Famine and vulnerability: destitution, being orphan
(Example HIV taking away parents lives)
 Infections: there is a reciprocal r/ship b/n malnutrition
and infection.
Causes…
During infection, the requirement for nutrients
increases,
There will be increased loss of nutrients due to
diarrhea, genesis of fever and other acute phase
reactants
Malnutrition in turn leads to infection.
 Emotional deprivation: in orphan children and in
children whose parents are negligent in giving care to
their children due to different reasons, children will
lose appetite for feeding and hence end up in state of
malnutrition.
Causes…
 Cultural factors: different biases as to who
should take the lion’s share of the family’s food
(Example, age bias- older children are given
more food than the smaller ones).
 Sex bias: male children are more favored in
getting nutritious food than female children in
some families, etc.
Pathogenesis
 Marasmus and Kwashiorkor in their extreme
forms have basically different pathogenesis.
 The initiation of the pathogenesis of both
problems can be traced back to the time of
weaning.
 Kwashiorkor develops ff the additional demand
levied on the body’s already marginalized
nitrogen balance due to infection of a child that
is on monotonous starchy family diet.
Pathogenesis…
• As a result of fragile nitrogen balance that the

child has, negative nitrogen balance sets in
when the available nitrogen is used to
produce antibodies or other acute phase
reactants in the face of infection.

Pathogenesis…
 On the other hand, Marasmus develops due to
negative energy balance as a result of
“starvation therapy” that follows the bouts of
diarrhea.
 The following diagram depicts the scenario.
Clinical Features
 The severest clinical forms of PEM are Marasmus,
kwashiorkor and features of both called Marasmic-
kwashiorkor.
 The following symptoms and signs clinically
characterize them:
Marasmus:
 Marasmic children have retarded growth with specific
clinical manifestations including:
 Wasting of subcutaneous fat and muscles (flabby
muscles),
 Wizened monkey (old man face), increased appetite,
sunken eye balls, mood change (always irritable) and
mild skin and hair changes.
Normal
hair Alert and
irritable
Severe wasting
Thin, -prominent
flaccid skin ribs, spine,
hanging in scapulae
folds -Old man face
(baggy
pants)
Source: Nutrition Works
Clinical Features…
Kwashiorkor:
 Children with the kwashiorkor syndrome may have the
ff clinical manifestations:
Growth failure,
Wasting of muscles and preservation of
subcutaneous fat,
Edema (pitting type),
Fatty liver (hepatomegaly),
Psychomotor retardation (difficulty of walking),
Moon face due to hanging cheeks as a result of
edema and preserved subcutaneous fat,
Kwashiorkor…
Loss of appetite,
Lack of interest in the surrounding (apathy) and
appear miserable
Skin changes (ulceration and de-pigmentation or
hyper-pigmentation), and
Hair changes (de-pigmentation, straightening of hair
and presence of different color bands of the hair
indicating periods of malnourishment
 Marasmic-kwashiorkor can have the clinical features of
both Marasmus and kwashiorkor.
Hair -
thinner and
lighter Apathetic
and
Moon face miserable
No appetite
Oedema
(symmetrical
oedema
involving at
Skin least the
lesions feet)
 In children with PEM, there are usually
deficiencies of micronutrients like:
Riboflavin,
Vitamin A,
Iron and Vitamin D.
 Therefore, it is advisable to have high index of
suspicion and look for the signs and symptoms
of deficiencies of these nutrients.
Diagnosis
 The dx of PEM rests mainly on meticulous clinical
examination for the symptoms and signs of the
syndrome plus anthropometric assessments using
different methods.
 Additionally, one may need laboratory investigation for
the assessment of complications and other health
problems associated with malnutrition.
 Epidemiological considerations also contribute to the
dx of malnutrition
 The anthropometric assessments can be done using

the ff methods:
1) Gomez classification (weight-for-age)
% of NCHS reference Level of malnutrition
90-109 Normal
75-89 Mild (Grade I)
60-74 Moderate (Grade II)
< 60 Severe (Grade III)
Disadvantages of this classification:
o The cutoff point 90% may be too high as many well-
nourished children are below this value,
o Edema is ignored and yet it contributes to weight and
o Age is difficult to know in developing countries
2) Welcome classification (weight-for-age)
% of NCHS Reference Level of malnutrition
Edema No edema
60-79% Kwashiorkor Undernourished
< 60% Marasmic-kwash Marasmus
 Shortcoming of this method is that it does not

differentiate acute from chronic malnutrition.
Welcome classification…
 In the clinical setups, it is preferable to use welcome
classification in order to clearly distinguish the
different clinical forms like Marasmus, kwashiorkor,
Marasmic-kwashiorkor or undernourished.
 However, in the field (community) set ups, the milder
forms of malnutrition like stunting and wasting are
very rampant.
 These two forms do reflect different situations
prevailing in the community.
 Therefore, it is preferable to use Water low
classification in the field set up to distinguish the acute
and chronic forms of malnutrition.
3) Water low-classification (HFA and WFH)
Index % of NCHS reference Level of malnutrition
HFA 90-94% (Mild)
85-89% (Moderate) Stunting (Chronic)
< 85% (Severe)
WFH 80-89% (Mild)

70-79% (Moderate) Wasting (Acute)
< 70% (Severe)
PEM…
 In adults, protein energy malnutrition is called
chronic energy deficiency (CED).
 It is characterized by weight loss and lack of
energy to produce and to move about even for
socializing in extreme cases.
 The 3 degrees of CED below are parallel to the
Gomez classification of PEM in children.
Grades of CED Body mass index (BMI)
0 18.5 kg/m2
I 18.4-17.0 kg/m2
II 16.9-16.0 kg/m2
III < 16.0 kg/m2
 BMI less than 16 kg/m2 is associated with:

Low birth weight in 50% of the cases
Decreased work capacity and
Poor resistance of infection
Laboratory Diagnosis
 Laboratory investigation for protein energy
malnutrition is to determine:
The level of serum protein,
Hemoglobin and
Co-infections due to pathologic organisms that can
be viral, bacterial or parasitic origin.
 Besides determination of micronutrient deficiencies
can also be done.
Case Management
 Mgt of a case of PEM focuses on the correction of specific
nutrient deficiencies (dietary management), treatment of
complications and supper imposed infections.
The treatment approach is classified into two phases:
 The acute stabilization phase, in w/c the main focus is:
 Treatment of infection and
Complications like DHN, hypoglycemia, hypothermia and
other electrolyte imbalances.
 The rehabilitation phase, focuses on the restoration of the
lost tissue and promotion of catch-up growth.
Dietary management
1) Acute Phase:
 Children are most at risk of dying.
 Dehydration, infection and severe anemia are
the main dangers.
 In protein energy malnutrition, cardiac and
renal functions are impaired.
Dietary management…
 In particular, malnourished children have a
reduced capacity to excrete excess water and a
marked inability to excrete Sodium.
 The amount of fluid given and the Sodium load

must be carefully controlled to avoid cardiac
failure.
Acute Phase…
 A cautious approach is required; aiming at
administration of about 100kcal/kg/day and 1-1.15g of
protein/kg/day.
 Small frequent feeds (as much as 12 times in 24 hrs

for the first 2 days and,
 Gradually tapering the number of feeds to be 6 in 24

hrs after a week) are ideal as they reduce the risks of
diarrhea, vomiting, hypoglycemia and hypothermia.
The maintenance formula can be made as follows:
Acute Phase…
 It is important to give additional:
Potassium (4mmol/kg/d),
Magnesium (2mmol/kg/d),
Zinc (2mg/kg/d),
Copper (0.2mg/kg/d)and
A multivitamin preparation and folic acid.
 Do NOT give iron early before infection is controlled.

 High dose vitamin A should be given even if there are
no eye signs of deficiency.
Acute Phase…
 On this regimen, edema will disappear and the general
condition will improve.
 High energy or high protein diets should not be

introduced too early or too rapidly (Recovery
syndrome)
 Return of a good appetite is a sign that a child is ready

to progress to the next phase (rehabilitation phase).
2) Rehabilitation Phase
 The aim of this phase is to:
Restore wasted tissues and
Promote a rapid rate of catch-up growth
via administration of high energy and
protein.
 In this phase, there is no danger of recovery
syndrome.
 The synthesis of new tissue requires protein
and other nutrients.
Rehabilitation Phase…
 Synthesis also requires a considerable amount
of energy.
 The aim is to provide all necessary nutrients, so
that none limits the rate of recovery.
 Normal rate of growth of children is such that
they gain a weight of 1gram/kg/day by taking
105 kcal/kg/d and 0.78gram of protein /kg/d.
Rehabilitation Phase…
 To increase this rate of growth by 20 times the normal,
the energy and protein intakes need to be increased to
200kcal/kg/day and 5gram/kg/day, respectively.
What to give:
 The choice of ingredients will vary with local
circumstances.
 There are many advantages in using milk as the basic
ingredient, since milk can be modified very effectively
and easily, by adding sugar and vegetable oil, to
produce a high-energy formula.
What to give…
 Considerable flexibility exists in the ingredients that
can be used, provided the target requirements are
met.
 Where milk is a not available, high-fat legume, nuts
and oilseeds (such as groundnuts, Soya, sesame
seeds) provide both energy and protein in a relatively
compact form.
 The formulas above provide ~ 100kcal and 3g
protein/100ml.
How much to give
 The greater the intake of energy and protein,
the faster will be the growth.
 Hence, one should give the high-energy and
protein formula of at least 180ml/kg/day (6
feeds at 30ml/kg/feed).
 This amount will provide 180 kcal/kg/day and
5-gram protein/kg/day.
Assessing Progress
Pts should be weighed at least weekly,
preferably daily, and the weights plotted.
Failure to maintain rapid catch-up may signal an
undiagnosed infection and/or inadequate
intake.
Keeping a record of the child's food intake helps
to elucidate the cause of poor weight gain.
Assessing Progress…
Almost all malnourished children have diarrhea,
but it is rarely due to lactose intolerance.
Chronic diarrhea may result from gut parasites
(e.g. Giardia) or bacterial overgrowth of the
small bowel.
The introduction of the high-energy formula
may cause mild diarrhea initially, but this is not
a cause for concern unless stool frequency
exceeds 8 per 24 hrs.
Role of the family diet
 Transfer to a family-type of diet is important in
rehabilitation.
 Introducing a family-type diet at an early stage of
treatment is unlikely to permit catch-up growth b/c
the traditional diet usually does not provide enough
energy and protein.
There are two options:
1. Feed a high-energy formula until the child reaches his
normal WFH and then transfer to a family-type diet.
Options…
2. Make an early transition to a modified family diet
having a high energy and protein concentration to
support catch-up growth.
 Local circumstances will influence which option to
choose.
 In the first option, weight deficits should be corrected
in 4-6 wks even in the most severe cases.
 The second option provides an opportunity for catch-
up growth and for demonstrating improved feeding
practices.
Where to Rehabilitate
1) In Hospital:
 In many hospitals, treatment of PEM is unsatisfactory
due to cross infection and frequent relapses.
 Moreover, it is expensive and does not give a chance
for parental education.
 Therefore, not all children with PEM be admitted to
hospitals merely for the purpose of feeding.
 Admission of children to a hospital be targeted to
those children with severe PEM plus other admission
criteria.
Where to Rehabilitate…
2) At Home:
 Even severe cases could be successfully rehabilitated at
home.
 But, this is successful only after one wk of medical

care to treat infections and other complications.
 This method is also proved to be the most cost-

effective, and parents prefer the method, even though
no food supplements are provided.
3) Day-care Nutrition Rehabilitation Centers (DCNRCs):
 These centers provide treatment for uncomplicated
cases of PEM.
 Children receive 3 meals for 6 days of each week, for 3-
5 months, i.e. a period sufficiently long to enable
parents to understand 'why' and 'how' to improve
infants' feeding practices.
 The primary long-term objective of DCNRCs is to
prevent PEM.
4) Residential Nutrition Rehabilitation centers (RNRCs):
 These are usually convalescent centers for children

treated initially in hospitals.
 In Ethiopia, this approach is used in some areas under

the NGOs.
 The primary objective of this approach is preventative

rather than curative.
Prevention of PEM
 Many children attending outpatient clinics are
malnourished.
 Prevalence of mild forms of malnutrition like stunting
and wasting is 40-50% while those severe cases is 5-
10% in most of the developing countries.
 If these cases of PEM can be recognized early enough
by routine wt and ht measurements (GM in under five
clinics) and relevant action taken, then severe
malnutrition can often be prevented easily.
Prevention of PEM…
 It is not sufficient to treat only severe cases of
malnutrition coming to the health institution, as those
coming to the health institution are the tips of an
iceberg.
 Therefore, further approaches at the grass root

community level are required.
 The ff are some of the nutritional intervention

approaches to be considered in the community.
A) Dietary Diversification and Nutrition Education
 This approach focuses on educating mothers/care
givers on the importance of having a balanced diet
via diversification of food.
 It also aims at the production foodstuffs at the

backyard garden and intensification of horticultural
activities.
The nutrition education should focus on:

Dietary Diversification and Nutrition Education…
 Cultural malpractice and beliefs in child feeding and
weaning process, weaning foods, exposure of children
to sun light, time of weaning and food prejudices.
 Intra household mal-distribution of food (age and sex
bias)
 Effects of emotional deprivation and neglect on
nutritional status of children and proper child
treatment practices
 Importance of BF
Dietary Diversification and Nutrition Education…
 Hygiene (personal hygiene, food hygiene,
environmental hygiene)
 Importance of immunization
 Importance of growing fruits and vegetables in the

backyard garden and consumption by the household
members regardless of their age and sex.
B) Dietary Modification
 This approach focuses on modifying the energy,
protein and micronutrient content of the weaning
foods.
 In order to reduce dilution of the energy and protein
contents of the weaning foods and their level of
contamination:
We need to educate mothers and
Demonstrate to them the benefits of sprouting
(germination) and fermentation.
Dietary Modification…
On top of this:
 Supplementation of micronutrient like
vitamin A and iron to children below five
years of age and
 Fortification of salt with iodine could also be

considered based on the local needs.
C) Economic Approach
 This approach aims at improving the incomes of the
target community as a solution to their nutritional
problems.
 It is considered usually in areas where there are many
poor people and if their purchasing power is low as:
 In the case of urban slums and
People displaced because of war and other

natural calamities.
Economic Approach…
This approach includes different methods like:
Food for work
Food subsidy
Income generating projects
Iron Deficiency Anemia (IDA)

Iron Deficiency Anemia (IDA)
Definition:
 Anemia is defined as a reduction of the red blood cell
volume or hemoglobin concentration below the level
considered normal for the person's age/sex.
 The term nutritional anemia is used to describe the
type of anemia caused by:
Decreased intake (deficiency) of a nutrient/s that
has a role in hemoglobin synthesis or RBC formation
or
W/c may be gradually corrected by administration
of such a nutrient
Epidemiology
 Anemia is a major health problem world wide affecting
two billion people mainly in developing countries.
 The two major groups at risk are children and
pregnant women
 IDA is a problem of serious public health significance,
given its impact on psychological and physical
development, behavior and work performance.
 Iron deficiency is by far the commonest nutritional
cause of anemia; it may be associated with folate
deficiency, especially during pregnancy.
Epidemiology…
 Malaria, nutritional deficiencies and intestinal
helminthes all predispose to anemia.
 It is estimated severe malaria associated anemia

causes 190,000 - 974,000 deaths per year in children
under the age of five years, with the highest mortality
observed among infants.
 In areas in w/c intestinal helmenthiasis exists in a large

proportion of the population, IDA is nearly universal.
Etiology and Pathogenesis
 Anemia can be caused by one or more of the ff
independent mechanisms:
A) Decreased Red Blood Cell (RBC) production:
 Anemia will ultimately result if the circulating RBC mass
that is normally destroyed each day is not replaced.
The causes for reduced RBC production include:
Lack of nutrients such as Iron, copper, vitamin B-6,
vitamin B-12 or folate.
Deficiency of protein in the serum.
Failure of bone marrow to produce RBC due to
tumor infiltration, drugs, chemical poisoning, etc.
Etiology and Pathogenesis…
B) Increase in RBC destruction (Hemolysis):
 The essential feature of hemolysis is a shortened RBC
life span.
 This is due to destruction by:
Infections like malaria
Drugs like dapsone
Chemical poisoning such as lead
Genetic diseases such as sickle cell anemia
C) RBC loss:
 Blood loss is the commonest cause of anemia
 The bleeding may be due to:
Trauma, including surgical procedures
Parasites, like hook worm and schistosomiasis.
Intestinal bleeding, e.g. peptic ulcer disease
(PUD), and gastrointestinal cancer
Menstrual loss
Iron deficiency anemia can be caused by:
I) Deficient iron content of the food:
 This is common in infants who are kept too long
exclusively on milk diet.
 Iron deficiency may occur in older people due to their

limited food intake like meat due to dental problem
and poverty.
Iron Deficiency Anemia…
II) Deficient absorption of iron:
 Deficient absorption usually follow:
Poor dietary practice like, less consumption of diets
rich in vitamin C w/c enhance iron absorption,
Drinking coffee and tea immediately after meal
inhibits iron absorption,
Gastrointestinal tract operation,
It may occur also in chronic mal-absorption states or
diseases and consumption of antacids, fibrous diet
and heavy metals like calcium, zinc & magnesium.
III) Deficient transport:
 A decrease in transferrin (iron-binding protein) is
associated with a number of inflammatory conditions
particularly rheumatoid arthritis.
 This may result in a decreased body iron content and
finally production of less pigmented (hypochromic) red
blood cells.
IV) Abnormal loss of iron:
 It is commonly caused by loss of circulating red cells via
hemorrhage, excessively heavy menstruation or due
to parasites like hookworm and schistosomiasis.
V) Increased physiologic requirements:
 This occurs primarily in children during active growth
and in pregnant women.
 When the infant is put on prolonged exclusive milk

diet, the need for iron is not met.
 Pre-term infants require more iron.
 Pregnancy and lactation also places heavy demands on

the iron stores of the mother.
Anemia decreases the capacity of blood to carry
oxygen.
This may result in:
Decreased oxygen concentration in the tissue
(hypoxia) and
Damage to different organs
Clinical features
 Anemic pts may present with the ff manifestations:
A) Symptoms:
Tiredness, weakness or fainting, fatigue
Breathlessness (shortness of breath)
Exercise intolerance, head ache
Tinnitus (ringing in the ear), blurred vision
Nausea, poor appetite
Palpitation (uncomfortable awareness of ones heart
beat)
Excessive desire to eat unusual substances (pica)
such as clay or ice.
Clinical features…
B) Signs:
Paleness (skin and mucus membranes)
Edema in chronic and sever cases
Irritability
Poor growth and development in children

Diagnosis of anemia
Anemia can be identified using the ff methods:
 History:
Detect clinical symptoms of anemia, dietary history.
 Physical Examination:
Examine mucous membrane (mouth, conjunctiva),
palm and finger nails.
 Laboratory Examination:
Measure hemoglobin or hematocrit
Management of Anemia
The general aims of management of anemia are:
I) To raise the level of hemoglobin to normal value
 The hemoglobin level can be raised by:
Provision of foods rich in iron like meat, liver, fish,
leafy vegetables and vitamins.
Administration of medicinal iron is the most
important choice of therapy if iron deficiency
anemia is diagnosed.
Administration of folic acid and vitamins.
Blood transfusion.
Management of Anemia…
II) To treat underling causes (consider multiple causes)
III) To make proper follow-up
 During follow-up, the important factors to consider are:
Subsequent hgb tests and clinical progress.
Decision on added treatment if necessary.
Decision on when to stop treatment.
Decision on when to stop hgb tests.
Further care in health post.
Health and nutrition education.
Prevention and control
 Early detection and treatment of underlying causes
 Assessment and appropriate mgt of high risk groups:
Examples:
Pregnant women
Pre-term infants
Lactating mothers
People with malnutrition
 Preventing the underlying causes of anemia
 Prevention of malaria
Prevention and control…
 Prevention of parasites like hook worm infestation
 Prevention of chemical poisoning, like lead poisoning.
 Safety measures for the prevention of trauma causing
blood loss.
 Other public health measures such as:
Birth spacing, Immunization.
Improved water supply and sanitation.
Dietary improvement.
Food fortification.
Supplementation with iron tablets.
Prevention and control…
 Health education pertaining to the causes, mgt and
prevention of anemia.
 Nutrition Education emphasizing the avoidance of

inhibitors of iron absorption with food and increased
intake of enhancers of iron absorption with food.
Inhibitors of Iron absorption
 Phytates (in cereals and legumes)
 Fiber (cereals and legumes)
 Tanins (in tea, coffee)
 Heavy metals (Ca, Zn, Mg)
 Achylohydria
 Low altitude
 Antacids
 Depleted stores
Enhancers of iron absorption
 Ascorbic acid (in Juices, fruits)
 Amino acids (in meat, fish, chicken)
 Alcohol
 High altitudes
 HCL
 Deficient stores
Deficiency of Vitamin A (VAD)
 Vitamin A deficiency (VAD) is a disease caused by lack
of adequate vitamin A intake.
 It is manifested by:
Night blindness,
Xerophthalmia, and
Keratomalacia (If deficiency is severe and
prolonged)
Epidemiology
 Some countries have carried out assessments using
clinical ocular indicators such as Bitot's spots.
 However, these ocular signs are associated with

advanced stages of VAD.
 Women and children may have sub-clinical VAD long

before any eye problems are evident.
 One of the first clinical signs of VAD is difficulty or

inability to see in dim light, such as dusk or at night.
Epidemiology…
 This condition is called 'night blindness’.
 However, the vast majority of children with VAD have

no clinical signs or symptoms (i.e. they show no eye
damage).
 Globally, 3 million children suffer from clinical VAD, in

w/c half of them dying within 12 months of losing
their sight.
Epidemiology…
 However, the full extent of VAD often remains hidden:
 An estimated 140-250 million children under five

years of age are at risk of sub-clinical VAD, mainly in
Asia and Africa.
 About 30% of the world's childhood blindness is due

to VAD.
 600,000 women die during childbirth due to

complications from VAD.
Epidemiology…
 VAD is a major public health problem in Ethiopia.
 According to WHO standards:
 A prevalence of Bitot’s spots greater than 0.5 % in

under five children indicates that VAD is a significant
public health problem.
Etiology and Pathogenesis
 Vitamin A, like other vitamins, should be supplied
exogenously.
 One way deficiency of vitamin A occurs is lack of
adequate intake of vitamin A from food.
 But, other conditions exacerbate the deficiency:
1) Children begin life with an urgent need for vitamin A.
 Full-term infants — even those of well-nourished
mothers in wealthy countries — are born with barely
enough vitamin A to sustain them during the first few
days of life.
 Young children in developing countries are deficient
in vitamin A.
2) Pregnancy and lactation compromise vitamin A
status.
 It poses additional burden on a woman’s vitamin A
stores.
 VAD is most severe and night blindness most

common during the latter half of pregnancy.
3) VAD is common in population groups with decreased
or absent intake of GLVs and limited animal sources.
4) VAD also results from inadequate intestinal

absorption, with chronic intestinal disorders or fat
mal-absorption as can occur with prolonged diarrhea.
5) Low intake of fat also results in low vitamin A

absorption
6) Vitamin A excretion is increased in cancer, urinary
tract disease and chronic infectious disease.
7) Low protein intake or PEM results in deficient RBP and

high plasma vitamin A concentrations.
 This results in retinol in the blood not being
delivered to tissues to use.
 It is related with the most rampant PEM in the
country.
Deficiency of vitamin A causes the ff changes in
the body:
I) The 1st tissues to be affected in the retina are the light
responsive cones and rods.
 The pathology develops gradually first with low
adaptation to dark and then to light.
II) Cxtic changes in the epithelium:
Proliferation of basal cells,
Hyperkeratosis, and
Formation of stratified, cornified squamous
epithelium.
Changes in the body…
 This will lead to the formation of cornified (keratinized)
epithelium.
 This occurs especially on the cornea
 This causes corneal wrinkling and laceration due to
friction with the dry and cornified conjunctiva.
III) Epithelial changes in the respiratory system may
result in bronchiolar obstruction.
 Squamous metaplasia of the renal pelvis, ureters,
urinary bladder, and the pancreatic and salivary ducts
may lead to increased vulnerability to infections in
these areas.
Changes in the body…
IV) Vitamin A and infection interact in cyclic pattern of
increasing susceptibility to infection (see diagram
below).
V) Increased severity of some diseases like measles,
SAM, diarrheal diseases and ARI resulting in increased
toll of mortality from these diseases.
 This has to do with role of vitamin A both in the non

specific immunity (epithelial barrier) and the cell
mediated immunity that will be compromised
during VAD.
Clinical manifestations of VAD
 Before the clinical signs and symptoms occur, the
person has to go via different sub-clinical VAD states.
 People with sub-clinical VAD have higher rates of

infections like diarrhea or measles.
A.Occular:
 Eye lesions develop insidiously, with an impairment of
dark adaptation resulting in night blindness.
 Later comes dryness of the conjunctiva (“xerosis
conjunctivae”) and cornea (“xerosis cornea”).
Occular…
 The parents may describe the presence of whitish
material in the child’s eye.
 Clinically it is called Bitot’s spot.
These are foamy and whitish cheese-like tissue spots
that develop in the lateral side of the eyeball.
These spots do not affect vision in the daylight.
 More severe VAD will lead to corneal ulceration or

extensive wrinkling and cloudiness of the cornea
called “keratomalacia”.
Occular…
 Xerophthalmia is a range of clinical signs secondary to
VAD. It includes:
Night blindness,
Bitot spots,
Corneal dryness and ulcerations, and
Finally the occurrence of full-blown blindness.
B. Skin:
 Dry and scaly skin and
 Follicular hyperkeratosis may be seen on shoulders,
buttocks, and extensor surface of the extremities.
Clinical manifestations of VAD…
C. Organ systems:
 Epithelial metaplasia in the urinary tract may
be associated with infections,
 Late in the disease state, wide separation of
the fontanels and increased intracranial
pressure may occur.
Diagnosis
 Diagnosis is based on mainly history and P/E.
 The pt may have the ff symptoms and signs
A) Symptoms:
Night blindness
Feeling of dryness in the eye
Sometimes parents may complain of whitish plaque
in the child’s eye
Blindness
Diagnosis…
B) Signs
Poor dark adaptation
Bitot’s spots
Bruises and scratches (from injuries
attributed to poor vision)
Case Management and Treatment
1) Treatment of a child with clinical VAD:
 For a child less than 6 months, 50,000 IU on the 1st, 2nd
& 7th (or 14th or 21st)day.
 For a child 6 to 12 months, 100,000 IU on the 1st, 2nd &

7th (or 14th or 21st) day.
 In a child more than 12 months and adults, 200,000 IU

on the 1st, 2nd & 7th (or 14th or 21st)day.
Case Management and Treatment…
2) Treatment of Women with Clinical VAD:
 Women of reproductive age with night blindness or
Bitot's spots during pregnancy should be treated with
a daily oral dose of 5,000-10,000 IU of vitamin A orally
for at least 4 wks once daily.
 This low dose schedule over a period of 4 wks is to

reduce any toxicity risks to the fetus.
 Maternal night blindness during the time they are not
pregnant should be treated with mega doses, 200,000
IU of vitamin A.
Treatment of Women with Clinical VAD…
 Balancing the risk to the fetus with the risk to
the mother when a woman has more active
signs of xerophthalmia.
Low dose of vitamin A; that is 25,000 to
50,000IU orally, the 1st, 2nd and 7th days
can be given.
Prevention and control of VAD
(Reading Assignment?)
Iodine Deficiency Disorders (IDDs)
Definition:
 Iodine Deficiency Disorders refer to a spectrum of
health consequences resulting from inadequate intake
of iodine.
 The adverse consequences of iodine deficiency lead to

a wide spectrum of problems ranging from abortion
and still birth to mental and physical retardation and
deafness, w/c collectively known as Iodine Deficiency
Disorders (IDDs).
Epidemiology
 Iodine deficiency is the single most important cause of
preventable mental retardation.
 Globally, more than two billion (or over 38% of the
population living in 130 countries) are estimated to be
at risk of IDD and 260 million people in Africa are at
risk and 150,000 are affected by goiter.
 The most recent national survey of IDD conducted by
Ethiopian Health and Nutrition Research Institute
(EHNRI, 2005) indicated a high prevalence of goiter
rate as nearly as 40% in school age children and 36% in
mothers.
Epidemiology…
 According to WHO a goiter rate above 5% constitutes a
public health problem
 A profile analysis from different studies in different
countries showed that from all babies born to iodine
deficient mothers:
3% will have severe mental and physical damage,
10% show moderate mental retardation and
The remaining 87% show some form of mild
intellectual disability.
Etiology and pathogenesis
 Iodine deficiency occurs when either iodine intake is
inadequate or the presence of goitrogens (anti
thyroid) in the diet is high.
 The erosion of soils in areas with river due to loss of
vegetation from clearing for agricultural production,
over grazing by livestock and tree cutting for firewood,
results in a continued and increasing loss of iodine
from the soil.
 Groundwater and foods grown in these areas lack
iodine.
Etiology and pathogenesis…
 When Iodine intake falls below recommended levels,
the thyroid gland may no longer be able to synthesize
sufficient amounts of thyroid hormone.
 The resulting low level of thyroid hormones in the
blood (hypothyroidism) is the principal factor
responsible for the damage done to the developing
brain and the other harmful effects known collectively
as the Iodine Deficiency Disorders (IDDs).
Etiology and pathogenesis…
 Consequently, if severe enough, iodine
deficiency will impair thyroid function, resulting
in a lower metabolic rate, growth retardation
and brain damage.
 The long-term consequence is irreversible

mental retardation.
Clinical Features (Signs and Symptoms)
 Clinical features of IDD in general have a wide
spectrum according to age of the individual.
Fetus:
Abortion - Congenital anomalies
Still birth - Increased perinatal mortality
Endemic cretinism
Neonate:
Neonatal goiter - Neonatal hypothyroidism
Endemic mental retardation
Child and adolescent:
Goiter
Impaired mental dev’t and function
Hypothyroidism
Retarded physical development
Adult:
Hypothyroidism
Impaired mental function
 Most important consequences of the spectrum of IDD
are:
Goiter
Mental retardation
Hypothyroidism
Cretinism
Increased morbidity and mortality of infants and
neonates
All consequences of Iodine deficiency stem from
associated hypothyroidism:
I) Goiter:
 Children and adolescents most commonly present
with diffuse goiters, while adults have nodular goiter.
 More common in girls than in boys.
 Iodine deficient goiter for many subjects is a cosmetic
concern
 In some, particularly, older adults goiter may be large
enough to cause compression of trachea or
oesophagus.
Goiter…
 The size of enlarged palpable goiter indicates the
degree of longstanding iodine deficiency.
 Based on thyroid size and degree of goiter WHO grades
goiter in 3 stages/grades as follows:
Grade 0: No palpable or visible goiter
Grade 1: A goiter that is palpable but not visible
when the neck is in the normal position
Grade 2: A swelling in the neck that is visible
when the neck is in a normal position
II) Hypothyroidism
 Manifestation may occur at different age groups
 Rarely recognized in the new born since the
signs and symptoms are usually not sufficiently
developed and difficult to diagnose.
 Have various manifestations particularly in
children
Hypothyroidism…
1) Children:
Feeding difficulty and chocking during feeding
Prolonged launder, sluggishness
Large tongue with respiratory difficulties.
Cry little, sleep much
Constipation
Cold and mottled skin particularly extremities.
Retarded physical and mental growth (3-6 month)
Stunted, short extremities
Hypothyroidism…
2) Adult:
 Hypothyroidism in adults, cause the following:
Tiredness, weakness
Feeling cold, Dry skin
Difficult to concentrate and poor memory
Constipation
Weight gain with poor appetite
Hoarse voice
Myxedemia (putty face, hand & feet)
III) Cretinism
 Severe mental retardation and
 Other neurological defects
Diagnosis
A) History, physical examination
B) Lab
Diagnosis…
Iodine level is best assessed by measurement of:
 Urinary iodine
 Thyroid size
 Serum T3, T4, TSH and Thyroglobulin
 Saliva /serum iodine ratio
Urinary Iodine concentration indicate current iodine
nutrition
Thyroid size and serum thyroglobulin reflect iodine
status over a period of months or years.
Management of IDD
 Treatment of IDD prevents further complication of the
disease and its impact on socio-economic effects.
 Correction of the deficiency dramatically improves
school performance, agricultural out put and per
capita income as it typically results in educable and
economically productive population
 Preventing IDD is a more superior approach than
treatment as there are non-reversible consequences ff
treatment.
Management of IDD…
There are two components of IDD management:
A)General medical care:
Correction of an iodine deficiency
 Multi vitamins that contain iodine typically contain
150mcg of iodine for adults or more for children and
lactating mother.
 Use of Iodized salt
 Alter feeds like milk, egg yolk, and fish.
 Adding iodine drops to drinking well water or injecting
with iodized oil.
General medical care…
Supportive care:
 Maintain air way patent and normal breathing pattern
 Encourage activities with no restrictions as tolerated
 Maintain normal body temperature
 Relieve the patient’s anxiety feeling
 Encourage the patient to take high calorie and high
protein diet to improve nutritional status
 Patient education
 Manage and prevent infections and potential
complications
B) Specific management
1) Treatment of non toxic goiters:
 Sodium L thyroxin (L-T4)
Decrease goiter size
But it is said to be generally not effective in adults
and older children
Not routinely recommended for goiter pts because
of deleterious effect on cardiac and bone health.
Treatment of non toxic goiters…
 Potassium Iodide
Like lugol’s solution, SSKI (saturated solution of
potassium iodide)
Equilibrates iodine concentration in ECF and is
specifically concentrated in the thyroid gland
2) Surgical Management:
 Goiter for most pts is a cosmetic concern
 Thyroidectomy is indicated for pts with compressive
symptoms of a large goiter.
Prevention and Control of IDD
(Reading Assignment)
Rickets- Vitamin D Deficiency
 Rickets is a disease caused due to vitamin D deficiency.
 It is characterized by weakness and deformity of bones.
 Deficiency states occur due to lack of Calcium in the
body, w/c in turn is mainly due to defective absorption
because of VDD.
 Unhealthy child-care practices such as non-exposure of

infants to sunshine and complete covering while
outdoors for fear of evil eyes contribute to the
occurrence of rickets in Ethiopian children
Vitamin D Deficiency…
Deficiency state is termed as:
 Rickets in children
Failure of the bone to mineralize in infants and
children
Weight-bearing activity causes deformity
 Osteomatacia in adults
Imparied Ca & P absorption
Bone matrix not re-mineralized
At risk groups
 Insufficient sunlight exposure
 Aging reduces D synthesis in skin
 Fat mal-absorption
 Anticonvulsant drug therapy
 Breast-fed infants
 Renal disease
Epidemiology:
 Since sunshine is adequately available in Africa, rickets
is uncommon.
 But, in countries like Ethiopia, traditional and cultural

practices of child-care have contributed to the
occurrence of rickets.
 Rickets is more commonly associated with PEM and

improper weaning practices.
Sources:
 Liver, eggs, dairy products
 Herring, salmon, tuna, sardines
 Synthesis in skin from exposure to UV light
 Irradiation of ergosterolergocalciferol (D2)
Prevention of Rickets
Nutrition education focusing on the:
 Importance of exposing ones child to sunlight (direct
exposure with no filtration of the sunlight by smoke,
fog or window glass).
 A daily exposure for 10 minutes nude, for 30 minutes

dressed is sufficient to result in vitamin D synthesis
 The importance breast feeding and proper weaning

practices.
NUTRITIONAL ASSESSMENT

Nutritional Assessment
Definition:
 Nutritional assessment is an interpretation of
anthropometric, biochemical (laboratory), clinical and
dietary survey data to tell whether a person/group of
people is /are well nourished or malnourished (over
nourished or under nourished).
 The ABCD’s of assessing nutritional status include
collection of nutritional data using the ff methods( A=
anthropometry, B= biochemical/biophysical, C=
Clinical, D= Dietary).

A) Anthropometric Assessments
 The word anthropometry came from two words:
Anthropo = Human, and Metry = measurement.
Definition:
 Anthropometry refers to measurement of variations of
physical dimension and gross composition of human
body at different levels and degrees of nutrition (Jelliff,
1966).
 Anthropometric measurements could be used both in
the clinical and field set-ups.

 In the clinical set-ups they are used to assess the
nutritional status of:
Post-operative pt,
Post traumatic pt (after acute trauma or surgery),
Chronically sick medical pt,
Pt preparing for operation,
Severely malnourished pt to assess the impact of
nutritional intervention.

The Building Blocks of Anthropometry: Indices

Purposes of Anthropometric measurements
 Anthropometric measurements are performed with
two major purposes in mind:
 IN CHILDREN: to assess physical growth
 IN ADULTS: to assess changes in body composition or
weight
1) Anthropometric measurements of growth
 Growth performance of children is an excellent
reflection of their underlying nutritional status.
 Children adapt to the chronic nutritional insult by
either reducing their rate of growth or by totally failing
to grow.
 Therefore, assessment of growth performance of
children is one very important purpose of
anthropometric measurements.
 The ff body measurements are good indicators of
growth performance of children at different ages
when combined with the cut-off points.
I) Head circumference (HC):
 Measured using flexible measuring tape around 0.6cm
wide to the nearest 1mm.
 It is the circumference of the head along the supra
orbital ridge anteriorly and occipital prominence
posteriorly.

 HC is useful in assessing chronic nutritional problems
in under 2 children.
 But after 2 yrs as the growth of the brain is sluggish it
is not useful.
II) Length:
 A wooden measuring board (also called sliding board)
is used for measuring length.
 It is measured in recumbent position in children <2 yrs
old to the nearest 1mm.
 An assistance of two people is needed in taking the
measurement
 Measurement is read to the nearest mm

Child length measurement – children < 2 years

 Is measured in children > 2 yrs and adults in standing
position to the nearest 0.1 cm.
 The head should be in the Frankfurt plane during
measurement, knees should be straight and the
heels, buttocks and the shoulder blades, should touch
the vertical surface of the stadiometer
( anthropometer) or wall.

Child Height Measurement – children > 2 years

III) Weight:
 Weighing sling (spring balance) also called salter scale
is used for measurement of wt in children < 2 yrs.
 In children, the measurement is performed to the
nearest 10g.
 In adults and children >2 years, beam balance is used
and the measurement is performed to the nearest 0.1
kg.

Child weight measurement – weight for 0 – 59
months

The difference is the weight of the child.

Indices derived from these measurements
What is an index?
 It is a combination of two measurements or a
measurement plus age.
 The following are few of them:
Head circumference-for age
Weight -for-age (WFA)
Height-for age (HFA)
Weight for height (WFH)

Meanings of the indices derived from growth
measurements
Weight for Age = Weight of the child x 100
Weight the normal child of
the same age
Weigh for height = Weight of the child x 100

Weight of the normal child of
the same height
Height for age = Height of the child . X 100

Height of the normal child of
the same age

 Both WFA and WFH are indices sensitive to acute
changes to nutritional status
 HFA of children in a given population indicates their
nutritional status in the long run.
 The best example is change in the average ht of
children in the industrialized countries towards higher
values ff improvements in nutrition, control of
infectious problems etc.
 This is called secular change (trend) in height.

Indicator
An indicator is an index + a cut-off point.
E.g.
 WFA < 60% = is indicator of severe malnutrition
 MBI < 16 kg/m2 = indicator of severe chronic energy
deficiency
 WFH < 7o% = is indicator of sever wasting

2) Anthropometric measurements of body
composition
 Linear growth ceases at around the age of 25-30 yrs.
 Therefore, the main purpose of nutritional assessment
of adults using Anthropometry is determination of the
changes of body wt and body composition.

Five levels of body composition Assessment
Atomic level (C, H, N, P, Ca, O)
Molecular level (fat, water, protein)
Cellular level (body cell mass, intra/extra cellular
water, intracellular solids)
Tissue level (adipose tissue, muscle, bone)
Whole body level (Weight, height, skin folds)

Assessment of body composition using
anthropometry
 Whole body level assessment is used
 In assessing body composition, we consider the body
made up of two compartments:
 The fat mass and the fat free mass.
 Total body mass= fat mass + fat free mass.
 Therefore, different measurements are used to assess
these two compartments:

Measurements used for assessing fat free mass:
Mid upper arm circumference (MUAC)
Mid upper arm muscle area
Mid thigh circumference
Mid thigh muscle area
Mid calf circumference
Mid calf muscle area

Mid upper arm circumference
(MUAC)
 Is used for screening purposes especially in emergency
situations where there is shortage of human resource,
time and other resources as it is less sensitive as
compared to the other indices.
 It is measured half way b/n the olecranon process and
acromion process using non stretchable tape
 In children the cut-off points are:
Normal > 13.5 cm
Mild to moderate malnutrition: 12.5-13.5 cm
Severe malnutrition < 12.5 cm
MUAC…
 It is a sensitive indicator of risk of mortality
 Useful for screening of children for community based

nutrition interventions
 Useful for the assessment of nutritional status of

pregnant women

Mid-Upper Arm Circumference Measurement

MUAC Measurement…

Measurements used to assess fat mass
 Body mass index
 Waist to hip circumference ratio
 Skin fold thickness

Indices derived from the measurements
Different indices could be derived by measuring the

wt and ht of an adult
 Body mass index (Quetelet’s index) = Wt/(Height in
meter)2
 Weight/height ratio (Benn’s index)
 Ponderal index = Wt/ (ht)3

Body mass Index(BMI)
 Body mass index the best method for assessing adult
nutritional status as the index is not affected by the
age of the person
 Therefore, it is most frequently used for assessing

adult nutritional status

Cut-off points for BMI
 > 40 kg/m2 = very obese
 30-40 kg/m2 = obese
 26-30 kg/m2 = overweight
 18.5-25kg/m2 = normal
 17-17.9 kg/m2 = mild chronic energy deficiency
 16-16.9kg/m2 = moderate chronic energy deficiency
 < 16 kg/m2 = severe chronic energy deficiency

Waist to hip circumference ratio
 It is the circumference of the waist measured mid-way
b/n the lowest rib cage and anterior superior illiac
spine divided by the circumference of the hip
measured at the level of the greater trocanter of the
femur.
 If the ratio is > 1 in male, and > 0.87 in female there is
high risk of coronary heart disease.

Skin fold thicknesses (SFT)
Skin fold thicknesses (SFT):
 Measurement of SFT can be doe in 5 places of the
body.
 These are: Biceps, Triceps, sub-scapular, supra-iliac
and mid-axillary (on the maxillary line at the level of
Xyphoid process).
 The measurement should be performed using
precision SFT calipers, b/c other ordinary SFT calipers
result in underestimation of the subcutaneous fat as a
result of compression.

Advantages and Disadvantages of Anthropometric
Measurements
Advantages Disadvantages
 Quick  Difficulty Of Selecting

Appropriate Cut-Off Points
 Cheap  Have Limited Diagnostic

Relevance (Only For
Diagnosing PEM)
 Objective  Need Reasonably
Precise Age In Children
 Gives Gradable Results
 More Accepted By The

Community
 Non Invasive

 N.B: For Adults we use body mass index w/c is wt /(Ht
in meters) 2, the normal range is b/n 18.5 - 25 kg/m2
 If an adult person has a BMI of less than 16kg/m2,
There is a 50% chance that a pregnant woman with
such a condition will give rise to a LBW child
There is poor physical work out put as a result of
poor energy stores
There is increased risk of infection due to impaired
immunity

 Risk of mortality and morbidity is associated to the
nutritional status as assessed by the BMI has a “U”
shaped appearance.
 As the risk of mortality and morbidity increases ff a
decrease in the BMI, same holds true when the body
mass index increases over 25 kg/m2.
 This relationship could be demonstrated by the ff
graph.

Mortality Chronic diseases
Malnutrition
And (hypertension,
related The
Morbidity diabetes, cancer,
infections and Safe zone
In % coronary heart
deficiency
disease
diseases
18.5
16
30
40
25
Body mass index KG/M2

B) Biochemical/Biophysical (Laboratory)
Methods
 Involves measurement of either total amount of the
nutrient in the body, or its concentration in a particular
storage site (organ) or in the body fluids.
 This group includes those that are indicative of defect
in intermediary metabolism in other words they occur
when there is a biochemical lesion (Depletion).
 The depletion could be detected:
By biochemical tests and/or by tests that measure
physiological or behavioral functions dependent on
specific nutrient.

1) Static biochemical tests
 This involves measurement a nutrient or its
metabolites in pre-Selected biological material (blood,
body fluids, urine, hair, fingernails etc.)
Example, E.g. Biochemical Tests (laboratory)
1. Serum ferritin level
2. Serum HDL
3. Erythrocyte Folate
4. Tissue stores of Vitamin A, D

Factors affecting the validity of static
biochemical tests
 Physiological factors (pregnancy, diurnal variation,
homeostatic regulation, physical exercise, age, sex,
recent dietary intake)
 Pathological (inflammatory stress, infection, weight
loss)
 Analytical (sample collection, sensitivity & specificity of
the test, hemolysis, sample contamination, accuracy
and precision of the method)

2) Functional Biochemical Tests (Biophysical
Tests)
 These are diagnostic tests used to determine the
sufficiency of host nutriture to permit cells, tissues,
organs or the host to perform optimally the intended
nutrient dependent biological function.
These functional biochemical tests:
Are useful for sub-clinical deficiency states
Are based on measurement of functional
impairment
Have greater biological value and significance than
static tests, as they measure the extent of functional
consequence of a specific nutrient deficiency.
Types of Functional Tests
A) Abnormal metabolic products in urine/blood:
 Vitamins and minerals act as co-enzymes/prosthetic
groups for enzyme systems
 Deficiency  Decreased activity or enzymes 
accumulation of abnormal products
E.g. Vitamin B-6 is a co-enzyme for Kynureninase in
the tryptophan-niacin pathway.
B-6 def.  decreased Kynureninase activity 
Increased formation and excretion of xanthuremic
and kynuremic acids

B) Changes in enzyme activities in the blood
 This involves measuring a change in the enzyme that is
dependent on a given nutrient.
Examples:
Lysl oxidase for copper
Glutathion reductase for riboflavin
Transketolase for thiamin

C) Load and Tolerance Tests
Load Test:
 is usually performed for water-soluble vitamins.
 The principle is that after loading a person with a dose
of the nutrient (vitamin) orally, IM or IV.
 Then a timed sample of urine is collected and
excretion/retention level assessed.
 In carrying out this test, it is assumed that there will be
increased retention of the nutrient if the person is
deficient of it and vice versa.

Tolerance Test:
 This is also called plasma appearance test and is
performed based on the assumption that there will be
increased absorption of the nutrient if the person is
deficient of it.
E.g. absorption of nutrients (Zn, Fe, and Manganese) is
increased in the deficiency states.

D) Spontaneous in vivo responses
This includes impairment of some body functions
resulting from deficiency of a particular nutrient
Examples:
Capillary fragility in Vitamin C deficiency
Dark adaptation in Vitamin A deficiency
Taste acuity in zinc deficiency
Muscle function in PEM

E) Growth or developmental responses:
 Both physical growth and mental development are
adversely affected by the deficiency of many nutrients.
 This is manifested by either failing to thrive or poor
school performances, lagging milestones of
development etc.
Example: cognitive function= Iron

Advantages and disadvantages of biochemical tests
 Detect sub-clinical  No ideal specimen or storage site
Malnutrition  Many quality control problems
 Give gradable during sample taking, carrying
nutritional information out the test, analysis, etc.
 Are more objective  Some times low values may not
have any health implication
 No ideal biomarker for each
nutrient
 Need sophisticated instruments
 Need highly trained staff
 Involve invasive procedures

C) Clinical methods
 These are methods used to detect deviations from the
normal state of nutrition just by observing and
interpreting clinical signs and symptoms of deficiency
or excess.
 The following table summarizes some examples of
these.

Sign/ symptom Nutritional abnormality
 Inability to see during the evening or dim Vitamin A deficiency:
light (Night blindness also called nyctalopia)
 Bitot’s spots
 Easy bruising of skin Scurvy (vitamin C deficiency)
 Spongy bleeding gums
 Pale: palms, conjunctiva, tongue Anemia: Which may herald,
 Easy fatigability, loss of appetite shortness deficiency of: Iron, Vitamin
of breath B12, Folic acid, copper,
protein (main causes of
nutritional anemia)

D) Dietary Methods
 These methods include assessment of past or current
intakes of nutrients from food by individuals or a group
in order to know their nutritional status.
 Dietary data could be gathered at the national,
household or individual levels
I) At National Level
 Estimation of food available for consumption per
capita for a year is called food balance sheet also called
national food disappearance data or food going in to
consumption.

 These are rough estimates of the amount of food
available for national consumption and do not take the
food that is produced by the subsistence farmers in to
consideration.
 They can be used as one of the indicators for food self-
sufficiency but not for food security.
 Market data bases (for fortified foods by FDA)

II) At a Household Level
 At the household level, the food and nutritional
situation could be roughly predicted by gathering data
on the amount of food available for consumption and
the amount of income spent for purchasing food, that is:
Household food inventory method
Food account methods
List recall method
Household food record method

Methods used to assess current intake (at group
or individual level)
a) Weighed record method:
 In this method, the subject will be asked to weigh
whatever he consumes including drinks both before
cooking and after cooking and the portion sizes he
consumed and the left over.
Advantages:
It is more accurate
There is no respondent memory loss

Weighed record method…
Disadvantages
 High respondent burden
 Change of the dietary habit during the survey due fear
of burden
 Needs literate and numerate respondents, costly.

b) Observed Weighed Method:
 In this method, the investigator him/herself records
the amount and type of food consumed by the study
subjects over specified period of time.
 Is usually applied for disabled people, infants and small
children, mentally ill people or institutionalized elderly
people or pts admitted to a hospital.
Advantages VS disadvantages
The same as the weighed record method

c) Food Diary method
 In this method, the subject/s are asked to record what
ever they eat including beverages for specified period
of time with estimation of the portion sizes consumed.
Advantage
 May give relatively accurate estimate of the nutrient
intake if done properly
Disadvantages
High respondent burden
Literacy and numeracy of subjects needed
High coding burden

Methods used to assess past intake
I) 24 hrs dietary recall
 The subjects are requested to remember whatever
they consumed within the last 24 hrs.
 This involves all beverages, snacks deserts etc. that
have been ingested from x time yesterday to x time
today.
 The portion sizes consumed during this time should
also be determined by the respondents by assessing
them to use either photographs or the common food
being consumed at different sizes, etc.

 Relatively cheap  A single day 24 hrs recall
 Quick does not indicate the
 Less respondent burden usual intake of
individuals
 No chance for the
 Respondent memory
respondents to change
their dietary habit laps
 The usual intake of a  Social desirability bias
group can be determined (the flat slop syndrome)
from a single 24 hrs  Has less precision
recall  Accuracy depends on the
respondent’s ability to
estimate portion sizes

II) Dietary history
 This method is used to assess the nutrient
intake of an individual or a group from food
over a longer period of time, usually to see the
association b/n diet and disease.

 It gives the dietary habits  It over emphasizes the
of an individual or a group regularity of the dietary
of people over a longer pattern
periods of time  It is very difficult to
 It is possible to target the validate
dietary questions to  It needs a very highly
specific dietary habits or trained interviewer
intake of specific nutrients  It gives just a relative if
of interest not an absolute
 Less respondent burden information

III) Food frequency questionnaire
 Is based on the preparation of a food frequency
questionnaire, w/c is based on the local staple diet to
determine the frequency of consumption of a
particular nutrient.
 This could be achieved via self or interviewer
administration of the questionnaire.
 Sometimes the quantities consumed could be
included, in such circumstances, the FFQ is called semi
quantitative FFQ.
 The ff table indicates the frame of a food frequency
questionnaire.

Example of semi quantitative FFQ for Vitamin A
friendly foods
Frequency of consumption
Every Once Once Portion size
Food list
Daily other per per consumed
day week month
Carrot
Cabbage
Papaya
Mango
Cod liver oil
Liver

Advantages and Disadvantages of FFQ
 It is usually used for areas  It is very difficult to
where there is a develop especially in
geographically widely multi-cultural society
scattered study population where different staple
 It is less costly especially if foods are consumed
self administered  It needs literate and
 Less respondent burden numerate subjects

ESSENTIAL NUTRITION
ACTIONS (ENA)

Essential Nutrition Actions (ENA)
Contents
 What is ENA?
 When to intervene?
 What actions to take?
Seven action areas
 Where to take these actions?
Six contact points
 Key program components

Essential Nutrition Actions (ENA)…
 Action oriented approach to addressing
nutrition problems of mothers and children
for all sectors

Over all Goals of ENA
 To be able to prioritize the key nutrition behaviors
w/c meet the health and nutrition needs of children
and women in vulnerable communities, and integrate
these behaviors into:
– Ongoing interventions in health facilities and
communities,
– Pre-service training, and
– Policies

 Over the past 30-40 years, nutrition interventions
were often:
– Not integrated
– Viewed as separate vertical programs
– In compitition with one another
– Not action oriented
– Focused only on GM/P activities

 In the past 10 years, growing consensus is that
nutrition interventions need to be:
Integrated conceptually & programatically
Infant & Young Child feeding
Maternal nutrition
Micronutrients
 Based on proven impact
 Action oriented with clear guidance « who should
take what action when »
When should we intervene?
Majority of the growth faltering occurs during the
first year of life.
Many babies are born malnourished due to poor
maternal nutrition before & during pregnancy.
Points of no return in the life cycle

At birth
At about three years of age
Next generation

What to Integrate?
 Seven action areas !

Seven action areas
1. Breast feeding 5. Vitamin A

2. Complementary 6. Iron
feeding 7. Iodine
3. Feeding of sick
children
4. Women’s Nutrition

Promotion of breastfeeding
Exclusive breast feeding

for the first six months
of life

Promotion of breast feeding…
Key messages
Early Initiation of BF
 Exclusive Breast feeding until 6 months
 BF day and night at least 10 times
 Correct positioning & attachment
 Empty one breast and switch to the other

Complementary Feeding
to Breast Feeding
Complementary feeding
has to be initiated at the
age of Six months

Complementary feeding to BF…
Key Messages
 Continue breast feeding until 24 months of age
 Increase the number of feeding with age
 Increase the density, quantity and variety with age
 Responsive feeding
 Food hygiene

Feeding the sick child
Key Messages
 Increase BF and
complementary feeding
during and after illness
 IMCI-Integrated
management of child
hood illnesses
 Appropriate therapeutic
feeding

Women’s nutrition
Key messages
 During pregnancy and lactation
– Increase feeding
– Iron/folic acid
supplementation
– Treatment and prevention
of Malaria
 Deworming during pregnancy
 Vitamin A capsule after
delivery up to six weeks post
partum

Control of Vitamin A deficiency
Key messages
 Breast feeding : source of
Vitamin A
 Vitamin A rich foods
 Maternal supplementation
 Child supplementation
 Food fortification

Control of Anemia
Key messages
 Supplementation for women
and children ( IMCI)
 Deworming for pregnant
women and children
(twice/year)
 Malaria control
 Iron rich foods
 Fortification

Control of iodine deficiency disorders (IDDs)
 Access and consumption by

all families of iodized salt

Where to integrate?
Seven proven behaviors !

Six critical contact points !

Six critical contacts in the life cycle
1.PREGNANCY:TT,
2. DELIVERY: safe
ANC,Iron/folate,de
delivery, EBF,
worming,antimalar
Vitamin A
ial,diet,EBF,risk
,Iron/folic acid,
signs,
diet, FP, STI
FP,STI Prevention,
referral
safe delivery,
iodized salt
3.POSTNATAL 4.IMMUNIZATION:
AND FP: Vaccination,
EBF, Diet, Vitamin A,
iron/folic ,diet, Deworming, assess
FP, STI, and treat infant’s
Prevention, anemia, FP, and STI
child’s vaccination refferal

Six critical contacts in the life cycle…
5.WELL CHILD AND GMP:
Monitor growth, assess
and counsel on feeding,
iodized salt, check and
complete vaccination
/Vitamin A /Deworming
6. SICK CHILD :
Monitor growth ,assess and treat per
IMCI counsel on feeding, assess and
treat for anemia, check and complete
Vitamin A
/Immunization/deworming
Where to integrate?
Health sector at facilities
& communities: Other sectors and contacts
Antenatal visit School programs
Delivery Agriculture extension
Postnatal visit Emergency
Immunization Community development
Well baby visit/GM Micro-credit project
Sick child visit

ENA
 Health facility level: integrate ENA actions into
existing health contacts at all health services
 Community-level: work with community based
organizations and networks from all sectors and
 Behavioral change: re-enforce ENA actions via
behavior change communication at all levels,
including inter-personal communication, mass media
and community mobilization.

Lessons learnt from ENA
 The ENA strategy has given a clear framework for
specific action to improve nutrition
 The ENA strategy is pulling together all the existing

vertical programs in a sensible “action oriented” way
 The ENA strategy has greatly expanded “nutrition”

contacts far beyond the traditional GMP programs.

Adequate nutrition for human and
sustainable development!!!

Nutrition PPT (PC-II, Medicine)

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Course title: Human Nutrition

Kiday H.(MSc, in Nutrition) 1

Kiday H.(MSc, in Nutrition) 2

Kiday H.(MSc, in Nutrition) 3

 Effects of an inadequate intake, and for some nutrients

 The digestion of food, absorption of end products, their

Kiday H.(MSc, in Nutrition) 4

 Nutrients: the chemicals in foods that are critical to

 Diet: the foods and beverages a person eats and drinks.

Kiday H.(MSc, in Nutrition) 6

Kiday H.(MSc, in Nutrition) 7

Kiday H.(MSc, in Nutrition) 8

Kiday H.(MSc, in Nutrition) 10

Kiday H.(MSc, in Nutrition) 12

Kiday H.(MSc, in Nutrition) 13

Kiday H.(MSc, in Nutrition) 14

Kiday H.(MSc, in Nutrition) 15

 But nutrition is a major, modifiable, and powerful factor

Kiday H.(MSc, in Nutrition) 16

Table: Relationship between nutrition and health. NCD,

Kiday H.(MSc, in Nutrition) 19

Kiday H.(MSc, in Nutrition) 20

Kiday H.(MSc, in Nutrition) 22

 What are carbohydrates?

Kiday H.(MSc, in Nutrition) 23

Kiday H.(MSc, in Nutrition) 24

Generic names Examples

Kiday H.(MSc, in Nutrition) 25

 They are represented by the formula (CnH2nOn).

 The different elements of carbohydrates are brought

 The chlorophyll in plants uses the solar energy from the

 Carbohydrates are classified in to different categories

Kiday H.(MSc, in Nutrition) 27

Kiday H.(MSc, in Nutrition) 30

 Absorbed actively coupled with sodium (glucose-sodium

 Is used as intravenous fluids (e.g. Dextrose normal saline,

Kiday H.(MSc, in Nutrition) 31

Kiday H.(MSc, in Nutrition) 33

 Is absorbed by diffusion without any consumption of

Kiday H.(MSc, in Nutrition) 34

 Also called milk sugar,

 During lactation, glucose is converted to galactose so

Kiday H.(MSc, in Nutrition) 35

 White and brown sugars are almost 100% sucrose,

 Also found in maple syrup, molasses, sorghum and corn

 Also called table sugar and used at home in daily diet.

Kiday H.(MSc, in Nutrition) 36

Kiday H.(MSc, in Nutrition) 37

Kiday H.(MSc, in Nutrition) 38

Kiday H.(MSc, in Nutrition) 39

Kiday H.(MSc, in Nutrition) 40

 The amount is 6.8 gram/100ml and 4.8 gram/100ml in

 When hydrolyzed, yields galactose and glucose.

Kiday H.(MSc, in Nutrition) 41

Kiday H.(MSc, in Nutrition) 42

 Three types of polysaccharides are important in

Kiday H.(MSc, in Nutrition) 43

Kiday H.(MSc, in Nutrition) 44

Kiday H.(MSc, in Nutrition) 45

Kiday H.(MSc, in Nutrition) 46

Kiday H.(MSc, in Nutrition) 48

 The large starch molecules require extensive breakdown;