2. • Nutrients are substances that are not synthesized in sufficient amounts in the body
and therefore must be supplied by
• The absence of essential nutrients leads to growth impairment, organ dysfunction,
and failure to maintain nitrogen balance or adequate status of protein and other
nutrients.
• The amounts of essential nutrients required by individuals differ by their age and
physiologic state.
3. ESSENTIAL NUTRIENT REQUIREMENTS
• Energy For weight to remain stable, energy intake must match energy output.
• The major components of energy output are
1. Resting energy expenditure (REE) and
2. Physical activity;
• Minor components include
3. The energy cost of metabolizing food (thermic effect of food, or specific dynamic
action) and
4. Shivering thermogenesis (e.g., cold- induced thermogenesis).
ENERGY
4. • The average energy intake is ~2600 kcal/d for men and ~1800 kcal/d for women,
although these estimates vary with body size and activity level.
• Thus, for males, REE = 900 + 10m, and for females, REE = 700 + 7m, where m is mass
in kilograms.
• The calculated REE is then adjusted for physical activity level by multiplying by
• 1.2 for sedentary,
• 1.4 for moderately active, or
• 1.8 for very active individuals.
5. • The final figure, the estimated energy requirement (EER)
• It provides an approximation of total caloric needs in a state of energy balance for a
person of a certain age, sex, weight, height, and physical activity level.
6. • Dietary protein consists of both essential and nonessential amino acids that are required for
protein synthesis.
• The nine essential amino acids are
1. Histidine
2. Isoleucine
3. Leucine
4. Lysine
5. Methionine/ Cystine
6. Phenylalanine/ Tyrosine
7. Threonine
8. Tryptophan, and
9. Valine.
Protein
7. • For adults, the recommended dietary allowance (RDA) for protein is ~0.8 g/kg body mass per
day.
• Current recommendations for a healthy diet is least 10–14% of calories derived from protein.
• Biological value tends to be highest for animal proteins, followed by proteins from legumes
(beans), cereals (rice, wheat, corn), and roots.
• Combinations of animal and plant proteins can increase biological value and lower total
protein intakes necessary to meet requirements.
• Protein needs increase during growth, pregnancy, lactation, and rehabilitation after injury or
malnutrition.
8. • Fat and Carbohydrate Fats are a concentrated source of energy and constitute, on average, 34% of
calories in diet is derived from Fat & Carbohydrates.
• However, for optimal health, fat intake should total no more than 30% of calories.
• Saturated fat and Trans fat should be limited to <10% of calories and
• Polyunsaturated fats to <10% of calories, with monounsaturated fats for the remainder of fat intake.
• Carbohydrates should constitute around 45–55% of total calories.
• The brain requires ~100 g of glucose per day for fuel; other tissues use about 50 g/d.
• Some tissues (e.g., brain and red blood cells) rely on glucose supplied either exogenously or from
muscle proteolysis.
Fat and Carbohydrate
9. • For adults, 1–1.5 mL of water per kilocalorie of energy expenditure is sufficient under usual
conditions to allow for normal variations in physical activity, sweating, and solute load of
the diet.
• Water losses include
1. 50–100 mL/d in the feces;
2. 500–1000 mL/d by evaporation
3. ≥1000 mL/d in the urine.
• If external losses increase, intakes must increase accordingly to avoid under-hydration.
• Fever increases water losses by ~200 mL/d per °C;
• Diarrheal losses vary but may be as great as 5 L/d in severe diarrhea.
• Heavy sweating, vigorous exercise, and vomiting also increase water losses.
Water
10. FACTORS ALTERING NUTRIENT NEEDS
Physiological Factors that increase needs for energy and several essential nutrients
• Growth
• Strenuous physical activity
• Pregnancy and lactation.
• Energy needs rise during pregnancy due to fetal growth demands and increased
energy required for milk production during lactation.
Physiologic Factors
11. • Dietary composition affects the biological availability and use of nutrients.
• For example:
1. Iron absorption may be impaired by large amounts of calcium or lead;
2. Non-heme iron uptake may be impaired by a lack of ascorbic acid and amino
acids in the meal.
3. Total protein may be decreased when essential amino acids are not present in
sufficient amounts.
Dietary Composition
12. • Dietary deficiency diseases include
1. Protein-calorie malnutrition,
2. Iron-deficiency anemia,
3. Goiter (due to iodine deficiency),
4. Rickets and Osteomalacia (vitamin D deficiency),
5. Xeropthalmia (vitamin A deficiency),
6. Megaloblastic anemia (vitamin B12 or folic acid deficiency),
7. Scurvy (vitamin C/ascorbic acid deficiency),
8. Beriberi (thiamin deficiency).
9. pellagra (niacin and tryptophan deficiency)
Diseases affecting nutrition needs
13. Dietary Assessment
Nutrition assessment in clinical situations involves:
• screening for malnutrition,
• assessing the diet and other data to establish either the absence or the presence of
malnutrition and its possible causes,
• planning and implementing the most appropriate nutritional therapy,
• reassessing intakes to make sure that they have been consumed.
• Some disease states affect the bioavailability, requirements, use, or excretion of
specific nutrients.
14. 1. Abnormal weight for height or body mass index (e.g., BMI <19 or >25);
2. Reported weight change (involuntary loss or gain of >5 kg in the past 6 months)
3. Diagnoses with known nutritional implications (e.g., metabolic disease, any disease
affecting the gastrointestinal tract, alcoholism);
4. Present therapeutic dietary prescription;
5. Chronic poor appetite;
6. Presence of chewing and swallowing problems or major food intolerances;
• The nutritional status of hospitalized patients should be reassessed periodically—at least
once every week.
The factors assessed for Nutritional Assessment Include
15. Calorie Requirement Calculation in Illness
• The simplest type of calculation used to estimate caloric needs is based on a
standard number of calories per kilogram (kcals/kg) of body weight per day.
• The typical standards are
• 25 to 30 kcals/kg/day for normal, healthy individuals;
• 30 to 35 kcal/kg/day for patients with moderate illness, injury, or malnutrition;
• 35 to 40 kcals/kg/day for patients with critical illness or injury.
Methods of Calculation
16. • For example, A 56.8 Kg patient with moderate illness,
• The daily estimate for calories ranges from
• 1,704 kcals (56.8 x 30) to 1,988 kcals (56.8 x 35).
• This is a range of almost 300 calories and provides only a general guide.
17. • The second way to estimate caloric needs is by using a mathematical formula.
• These formulas use information such as gender, weight, height, and age to predict BEE (
Basal Energy Expenditure)
• BEE then is converted to TEE( Total Energy Expenditure) by adding factors for injury and
activity.
18. The total number of daily calories is derived using the following formula:
Calorie requirements = BEE (activity factor + injury factor) +/-
calories for desired loss or gain + fever factor.
19. List of Four common energy prediction equations.
21. • Protein-Calorie Malnutrition (PCM) refers to a nutritional status in which reduced
availability of nutrients leads to changes in body composition and function.
• The condition has mild, moderate, and severe degrees.
• It is considered as the primary nutritional problem in India.
• Also called the 1st National Nutritional Disorder.
Protein-calorie malnutrition
22. Protein-calorie malnutrition is separated into three forms
1. Kwashiorkor- it is a state of acute, severe protein-calorie malnutrition resulting in
edema and hair changes, often accompanied by encephalopathy.
2. Marasmus -it is the chronic form of this disorder and causes apathy and growth
failure.
3. Marasmic kwashiorkor- it is characterised by marked protein deficiency and marked
calorie insufficiency signs present, sometimes referred to as the most severe form of
malnutrition.
23. • Protein energy malnutrition is more common in low-income countries, including
children from large urban areas in low socioeconomic neighbourhood’s.
• This may also occur in children with chronic diseases, and children who are
institutionalized or hospitalized for a different diagnosis.
• PCM is fairly common worldwide in both children and adults and accounts for 6 million
deaths annually.
Epidemiology
24. • Different combinations of many aetiological factors can lead to PEM in children.
They are:
1. Economic and Social Factors
2. Environmental Factors
3. Age
4. Biological Factors
Etiology
25. 1. A primary diagnosis of intellectual disability,
2. Cystic fibrosis,
3. Cardiovascular disease,
4. End stage renal disease,
5. Oncologic disease,
6. Genetic disease,
7. Neurological disease,
8. Multiple diagnoses, or
9. Prolonged hospitalization
Risk factors
26. • PCM is caused by starvation.
• It is the disease that develops when protein intake or energy intake, or both,
chronically fail to meet the body's requirements for these nutrients.
• This state makes the body to start adjusting metabolically and in terms of hormone
secretion.
• Like the production of thyroxine is decreased inorder to reduce the metabolic rate so
that less energy is required.
• Fat loss is slowed by a reduction in energy expenditure that the body accomplishes
both by reducing the metabolic rate.
• As a result growth is suspended.
• This accounts for retardation that is seen in malnourished child.
Pathophysiology
27. • The body literally digests itself to maintain the serum levels.
• As a result there is progressive loss of fat and muscle tissue as well as depletion of
electrolytes.
• This accounts for the severe wasting seen in malnourished child
• As a result immune system does not work properly which lead to infections and may
worsen the condition of children.
• As long as the starvation ratio of energy and protein is not too low, successful
adaptation will reduce energy and protein requirements to match it, restoring
homeostasis and maintaining key physiologic functions.
28.
29. • Poor weight gain
• Slowing of growth
• Edema: Areas that are most affected are the distal extremities.
• Abdominal distension secondary to poor abdominal musculature
• Hepatomegaly secondary to fatty infiltration
• Dry peeling skin with raw exposed areas
• Hyper pigmented plaques over areas of trauma
• Nails become fissured or ridged.
• Hair is thin, sparse, brittle, easily pulled out, and turns a dull brown or reddish colour.
Clinical Presentation
30.
31. Treatment strategy can be divided into three stages.
• Resolving life threatening conditions
• Restoring nutritional status
• Ensuring nutritional rehabilitation.
Treatment
32. • There are three stages of treatment.
1. Hospital Treatment -The following conditions should be corrected. Hypothermia,
hypoglycaemia, infection, dehydration, electrolyte imbalance, anaemia and other
vitamin and mineral deficiencies.
2. Dietary Management -The diet should be from locally available staple foods -
inexpensive, easily digestible, evenly distributed throughout the day and increased
number of feedings to increase the quantity of food.
3. Rehabilitation -The concept of nutritional rehabilitation is based on practical
nutritional training to patients attenders or caretakers.
33. • One of the major aspects of a correct diet plan for protein-energy malnutrition is to include
macronutrients in the patients diet.
• In PEM Affected Children An optimum choice of treatment is the inclusion of milk-based formulas
which help provide both proteins and sufficient energy to the child.
• Doctors usually advice giving to the patient during the beginning of the dietary treatment and within
7 days.
• The rate for children should reach an approx. of 4g/kg of protein and 175 kcal/kg.
• In adults, it should be 2g/kg of protein along with 60kcal/kg. It is absolutely essential to add a daily
multivitamin along with the diet for quick recovery from Protein-Energy Malnutrition (PEM).
Diet plan for protein energy malnutrition
34. • Good sanitation and hygiene can play a major role in places where there is not a regular
supply of healthy food and clean water.
• Poor sanitation and hygiene can lead to infections that can worsen the symptoms of
marasmus and other types of malnutrition and make it harder to recover.
• Cooking foods at high heat to destroy bacteria and reheating it before eating.
• Boiling water before drinking, cooking, or bathing in areas where clean water is difficult to
access is essential to prevent spreading waterborne diseases.
• Breastfeeding infants for 6 months can help protect them from nutritional difficulties,
especially in places where food is short.
Sanitation and Hygiene
