Nutrition ppt

GOLLIS UNIVERSITY
DEPARTMENT OF PUBLIC HEALTH
Course: Nutrition
Lecturer: Sa’ad Ahmed Abdiwali
Dean of Public Health, Nutrition and Laboratory
BSc, MPH
1

Course content
1. Introduction
– Human nutrition
– Public health nutrition
– Nutrition and development
– Causes of malnutrition
– Malnutrition and infection
2. Nutritional requirements
– Energy
– Proteins
– Fat
– Carbohydrates
– Vitamins
– Minerals
2

Course content…
3. Nutritional assessment
– Methods of nutritional assessment
– The present nutrition situation
– Nutritional surveillance
4. Nutrition through the lifecycle
– Maternal nutrition through the lifecycle
– Low birth weight
3

Course content…
5. Nutritional problems of public health importance
– Protein-energy malnutrition
– Vitamin A deficiency
– Iron deficiency anemia
– Iodine deficiency disorders
– Zinc deficiency
6. Nutrition interventions
– Essential nutrition actions
– Emergency Nutrition Interventions
– Somaliland National Nutrition strategy
7. Nutrition and Development
8. Nutrition in emergencies
9. Food security
10. Infant and young child feeding in emergencies
situation
4

Course Objective
Enable the student acquire theoretical
knowledge (principles) and analytical skills
(methods) in Human Nutrition
5

Course Organization
• Course delivery modalities;
– Lectures
– Group Assignments
• Literature Review and Presentations
– Reading Assignments
6

Examples of topics for Literature
Review and Presentation
• Breast feeding and cognitive development
• Breast feeding and Social
development/family attachment
• Developmental origins of diseases
• HIV/AIDS and infant feeding
• Biofuels and Nutrition security
• Climate change and food security
• Etc.
7

Unit one: Introduction -
Outline:
– Definitions
– Forms of Malnutrition
– Causes/Etiology of Malnutrition
8

Nutrition
The science of Nutrition:
• Nutrition studies the interaction between the
individual and the environment mediated by food
• Study of food in relation to man, and study of
man in relation to food
• Science of food as it relates to optimal health
and performance
9

Nutrition…
• Human Nutrition is a scientific discipline,
concerned with the access and utilization
of foods and nutrients for life, health,
growth, development, and well- being
10

The science of Nutrition:
• Areas of Study
– Food production
– Diet composition (including non-nutritive
substances)
– Food intake, appetite, food preferences
– Digestion and absorption of nutrients
– Intermediary metabolism, nutritional
biochemistry
11

The Science of Nutrition:
 Areas of Study
– Biological actions of essential nutrients
– Nutrient requirements in individuals and
populations
– Heath effects of nutrient deficiencies and
excesses
– Long-term effects of diet constituents
– Therapeutic and preventive effects of foods
12

Nutrition…
• Dietetics
– Science/ art of applying the principles of
nutrition in feeding
– Older subject, practiced by Hippocrates 460-
360 BC.
13

Public Health Nutrition
• Public Health Nutrition focuses on issues
that affect the whole population rather
than the specific dietary needs of
individuals
• The emphasis is on promoting health and
disease prevention
14

Malnutrition
• A pathological state resulting from a
relative or absolute deficiency or excess
of one or more essential nutrients, this
state being clinically manifested or
detected only by biochemical,
anthropometric or physiological tests
15

Forms of Malnutrition
• Under nutrition
– Pathological state resulting from the consumption of
an inadequate quality/ quantity over an extended
period of time
• Over-nutrition
– Pathological state resulting from the consumption of
an excess quantity of food, and hence an energy
excess, over an extended period of time
16

The Scale of the Problem
– Protein−energy malnutrition (PEM),
– vitamin A deficiency,
– iodine deficiency disorders (IDD) and
– nutritional anaemias − mainly resulting from
iron deficiency or iron losses −
• are the most common serious nutritional problems
in almost all countries of Asia, Africa, Latin
America and the Near East.
17

Global Distribution of Malnutrition
18

Prevalence of chronic undernutrition in
developing regions (1969-1992)
19

Estimated prevalence and number of underweight
children 0−5 years old 1990−2005
20

Trends of malnutrition in Sub-Saharan
Africa (1983-2001)
21

Population at risk of and affected by micronutrient
malnutrition (millions) - 1992
22

What Is a Healthy Diet?
– Fulfills energy needs (macronutrients)
– Provides sufficient amounts of essential
nutrients (micronutrients)
– Reduces risk of disease
– Is safe to consume (low contaminants or
potentially harmful added substances)
25

Causes of Malnutrition
• Malnutrition, is not a simple problem with a
single, simple solution
• Multiple and interrelated determinants are
involved in why malnutrition develops, and
a similarly intricate series of approaches,
multifaceted and multisectoral, are needed
to deal with it
27

Causes of Malnutrition…
• Causes could be categorized as:
– Immediate causes
– Underlying causes, and
– Basic causes
28

Malnutrition - Immediate causes
Immediate causes
• The interplay between the two most significant
immediate causes of malnutrition - inadequate
dietary intake and illness - tends to create a
vicious circle:
• A malnourished child, whose resistance to
illness is compromised, falls ill, and
malnourishment worsens
30

Malnutrition - Immediate causes…
• Children who enter the malnutrition-infection
cycle can quickly fall into a potentially fatal spiral
as one condition feeds off the other
• Malnutrition lowers the body’s immune-response
mechanisms.
– This leads to longer, more severe and more frequent
episodes of illness
31

Inadequate dietary intake/disease cycle
Disease:
- incidence
- severity
- duration
Inadequate dietary intake
Weight loss
Growth faltering
Immunity lowered
Mucosal damage
Appetite loss
Nutrient loss
Malabsorption
Altered metabolism
32

Malnutrition - Immediate causes…
• Infections cause loss of appetite,
malabsorption and metabolic and
behavioral changes.
• These, in turn, increase the body’s
requirements for nutrients, which further
affects young children’s eating patterns
and how they are cared for
33

Malnutrition - Underlying causes
• Three clusters of underlying causes lead
to inadequate dietary intake and infectious
disease:
– inadequate access to food in a household;
– insufficient health services and an
unhealthful environment; and
– inadequate care for children and women
34

(HHFS)…
Household food security (HHFS)
– is defined as sustainable access to safe
food of sufficient quality and quantity -
including energy, protein and micronutrients -
to ensure adequate intake and a healthy life
for all members of the family
35

(HHFS)…
• In rural areas, HHFS may depend on access to land
and other agricultural resources to guarantee
sufficient domestic production
• In urban areas, where food is largely bought on the
market, foods must be available at accessible prices
• Other potential sources of food are by exchange, gifts
from friends or family and in extreme circumstances food
aid provided by humanitarian agencies
36

(HHFS)…
• HHFS depends on access to food -
financial, physical and social - as
distinct from its availability
37

(Services and sanitation)…
• Health services, safe water and
sanitation
– access to curative and preventive health
services that are affordable and of good
quality
– Families should have a health centre within a
reasonable distance, and the centre’s staff
should be qualified and equipped to give the
advice and care needed
38

(caring)…
• Caring practices
– even when there is adequate food in the house and a
family lives in a safe and healthful environment and
has access to health services, children can still
become malnourished
– Inadequate care for children and women, the third
element of malnutrition’s underlying causes, has only
recently been recognized and understood in all its
harmful ramifications
39

(caring)…
• Care is manifested in the ways a child is
fed, nurtured, taught and guided
• Nutritionally, care encompasses all
measures and behaviors that translate
available food and health resources into
good child growth and development
40

(caring)…
• In communities where mothers are
supported and cared for, they are, in turn,
better able to care for young children
• Among the range of caring behaviors that
affects child nutrition and health, the
following are most critical:
41

(caring)…
• Feeding:
– The introduction of complementary foods is a critical
stage. A child will be put at increased risk of
malnutrition and illness if these foods are introduced
much before the age of six months, or if the
preparation and storage of food in the home is not
hygienic
– Good caring practices need to be grounded in good
information & knowledge and free of cultural biases
and misperceptions
42

(caring)…
– Other behaviors that affect nutrition include
whether children are fed first or last among
family members, and whether boys are fed
preferentially over girls
• Protecting children’s health:
– Ensure that children receive essential health
care at the right time (e.g. immunizations, and
early treatment)
43

(caring)…
• Support and cognitive stimulation for
children:
– For optimal development, children require
emotional support and cognitive stimulation,
and parents and other caregivers have a
crucial role in recognizing and responding to
the actions and needs of infants
– Breastfeeding affords the best early occasion
to provide support and stimulation
44

(caring)…
– Verbal stimulation by caregivers is particularly
important for a child’s linguistic development
– Ill or malnourished children who are in pain
and have lost their appetite need special
attention to encourage them to feed and take
a renewed interest in their surroundings
during recovery
45

(caring)…
• Care and support for mothers:
– As long as the unequal division of labour and
resources in families and communities continues to
favour men, and as long as girls and women face
discrimination in education and employment, the
caring practices vital to the nutritional well-being of
children will suffer
– Adolescent pregnancy is a major risk factor for both
mother and infant, as the girl may not have finished
growing before her first pregnancy, making childbirth
dangerous
46

Malnutrition - Basic causes
– It is often said that poverty at the family level
is the principal cause of child malnutrition
– Political, legal and cultural factors at the
national and regional levels may defeat the
best efforts of households to attain good
nutrition for all members
47

Malnutrition - Basic causes…
– These include:
• the degree to which the rights of women and girls
are protected by law and custom;
• the political and economic system that determines
how income and assets are distributed; and
• the ideologies and policies that govern the social
sectors
48

Nutrition Intervention
• A wide variety of policies and programs can
improve nutrition
• Could be seen as short or long-term
interventions
• Several short route interventions can improve
child nutrition fast - in 2 to 5 years, within the
time frame in which politicians need to see
results
49

Nutrition Interventions – short routes
• Community-based nutrition and health services
(community growth promotion programs, community
Integrated Management of Childhood Illnesses [C-IMCI])
• Facility-based nutrition and health services (health and
nutrition services, and antenatal care)
• Micronutrient supplements, Micronutrient fortification
• Targeted food aid
50

Nutrition Interventions – short routes…
• Conditional cash transfers
• Food supplementation
• Food stamps
51

Nutrition Interventions – short routes…
Behavior change
• Maternal nutrition, knowledge, and care-seeking during
pregnancy and lactation
• Infant and young child feeding
• Hygiene education
• Promoting healthy life styles (increase physical activity;
consume more fruits and vegetables and less salt,
sugar, and fat, and so on)
52

Nutrition Interventions – Long routes
• Primary health services (such as family planning) and infectious
disease control
• Safe water and sanitation
• Policies on marketing breast milk substitutes
• Food and agricultural policies to increase supply of safe and healthy
food, or of healthier foods
• Food industry development and market incentives (disincentives) for
developing healthy (unhealthy) food
53

Nutrition Interventions – Long routes…
• Economic development (incomes of the poor)
• Employment creation
• Food price policies to increase poor peoples’
purchasing power for the right kind of foods
• Marketing regulation of unhealthy food
54

Nutrition Interventions – Long routes…
Behavior change
• Improving women’s status
• Reducing women’s workload, especially in
pregnancy
• Increasing women’s education
55

The energy requirements of
individuals depend on
• ♦ Physical activities ♦ Body size and
composition ♦ Age may affect
requirements in two main ways
• – During childhood, the infant needs more
energy because it is growing
• – During old age, the energy need is less
because aged people are engaged with
activities that requires less energy.
• ♦ Climate: Both very cold and very hot
climate restrict outdoor activities. 57

• In general feeding is dependent on the
controlling centres, appetite and satiety in
the brain. There are a variety of stimuli,
nervous, chemical and thermal, which may
affect the centres and so alter feeding
behaviour.
58

Daily calorie requirements of
individuals
• Š Infants 1 - 3 years need 1,000 cal/day
Š
• Children 5 years need 1,500 cal/day Š
• Children 5 – 8 years need 1,800 cal/day Š
• Children 10 – 12 years need 2,000 cal/day
Š
• For adolescents and adults calorie
requirements depend on the degree of
physical activities 59

From 13 – 20 years of age
Office worker Heavy work
2, 800 cal/day 3,500 cal/day
Adults
2,300-cal/day 2,700 cal/day
60

• Very heavy work up to 4,000 cal/day
• For pregnant woman, the daily figure must
be increased by 150 calories for the first
trimester and 350 for the second and third
trimester. For the nursing mother the daily
figure must be increased by 800 calorie.
61

Staple foods
• Staple foods are foods, which form the
largest part of a nation’s diet.
They are of plant origin and are classified
into three main groups: Š
• The grain and cereals Š
• The roots and tubers Š
• The starchy fruits
62

Good nutrition enhances your quality of life andGood nutrition enhances your quality of life and
helps you prevent disease. It provides you with thehelps you prevent disease. It provides you with the
calories and nutrients your body needs for maximumcalories and nutrients your body needs for maximum
energy and wellness.energy and wellness.
NUTRITION:NUTRITION: THE PROCESS BY WHICH THE BODY TAKES INTHE PROCESS BY WHICH THE BODY TAKES IN
AND USES FOOD.AND USES FOOD.
NUTRIENTS:NUTRIENTS: SUBSTANCES IN FOODS THAT YOUR BODYSUBSTANCES IN FOODS THAT YOUR BODY
NEEDS TO GROW, TO REPAIR, AND TO PROVIDE ENERGY.NEEDS TO GROW, TO REPAIR, AND TO PROVIDE ENERGY.
CALORIES:CALORIES: UNITS OF HEAT THAT MEASURE THE ENERGYUNITS OF HEAT THAT MEASURE THE ENERGY
USED BY THE BODY AND ENERGY SUPPLIED TO THE BODYUSED BY THE BODY AND ENERGY SUPPLIED TO THE BODY
BY FOODS.BY FOODS.

33.. Environment:Environment:
•Family and Friends
4.4. CulturalCultural andand EthnicEthnic Background:Background:
•Race, Religion, Heritage
5.5. ConvenienceConvenience andand Cost:Cost:
•Where you live, On the go lifestyle, Family income
6.6. Advertising:Advertising:
•Health messages, Influence your looks
1.1. Hunger and Appetite:Hunger and Appetite:
Hunger:Hunger: Natural need to eat and not starve.
Appetite:Appetite: A desire to eat.
2.2. Emotions:Emotions:
•Stress, Anger, Happy, Sad, Boredom, etc,

66 GROUPSGROUPS OFOF NUTRIENTS:NUTRIENTS:
•CarbohydratesCarbohydrates
•ProteinsProteins
•FatsFats
•VitaminsVitamins
•MineralsMinerals
•WaterWater

•Body’s preferred source ofBody’s preferred source of
energy.energy.
• Body converts all carbohydratesBody converts all carbohydrates
to glucose, a simple sugar.to glucose, a simple sugar.
• Glucose is not used right awayGlucose is not used right away
and it is stored asand it is stored as glycogenglycogen..
• Too many carbohydrates willToo many carbohydrates will
cause the body to store the excesscause the body to store the excess
as fat.as fat.
Carbohydrates:Carbohydrates: are the starchesare the starches
and sugars present in food.and sugars present in food.
They are classified as either simpleThey are classified as either simple
or complex.or complex.
ComplexComplex carbohydratescarbohydrates areare
starches. Examples include:starches. Examples include:
•whole grainswhole grains
•seedsseeds
•legumeslegumes
-- FiberFiber is an indigestible complexis an indigestible complex
carbohydrate that helps move wastecarbohydrate that helps move waste
through the digestive system.through the digestive system.
Simple carbohydrates:Simple carbohydrates: areare
sugars. Examples include:sugars. Examples include:
•glucoseglucose
•fructosefructose
•lactose.lactose.

carbohydrate
• Carbohydrates
provide a great part of
the energy in all
human diets.
• In the diet of poor
people, especially in
the tropics up to 85%
of the energy may
come from this source
• On the other hand, in the
diet of the rich people in
many countries the
proportion may be as low
as 40%.
• However, the cheapest
and easily digestible fuel
of humans is
carbohydrate.
67

carbohydrate
• Carbohydrates are
components of body
substances needed
for the regulation of
body processes.
Heparin, which
prevents blood from
clotting, contains
carbohydrate
• Nervous tissue,
connective tissue,
various hormones,
and enzymes also
contain carbohydrate.
68

carbohydrate
• Ribose, another
carbohydrates are
part of
Deoxyribonucleic acid
(DNA) and ribonucleic
acid RNA), the
substance that carry
the hereditary
factorsin the cell.
• Carbohydrate is also
a component of a
compound in the liver
that destroys toxic
substances.
69

carbohydrate
• Carbohydrates are
necessary for the
proper use of fats.
• If carbohydrate
intake is low, larger
than normal amounts
of fats are called on to
supply energy.
• The body is unable to
handle the excessive
breakdown of fat. As a
result, the fat does not
burn completely, and
abnormal amounts of
certain breakdown
products accumulate in
the blood, causing a
condition known as
ketosis
70

71
CLASSIFICATION OF CARBOHYDRATES
Free
Sugars
Oligo-
saccharid
es
Polysaccharides (Complex
Carbohydrates)
1. Monosacch
arides (One
CHO
molecule)
e.g.
 Glucose
 Fructose
 Galactos
e
 manose,
 Ribose
 Deoxirib
ose
2.
Disaccharides
(Two CHO
molecule) e.g..
 Maltose
 Sucrose
 Lactose
 Trehalo
s
3.Sugar
alcoholes e.g.
 Sorbitol
 manitol
 Inisitol
 Dulcitol
These are
carbohydrate
s that
contain from
3-10
Monosaccha
rides units in
their
molecules.
The
following are
some
examples
 Raffinos
e
 Stachyo
se
 Verbasc
ose
 Fructans
 Galactan
s
1.Starch Polysaccharides.
 Amylose(straight chain
starch)
 Amylopectin (branched
chain starch)
2. Non starch polysaccharides
 Cellulose
 Pectin
 Hemicellulose
 Gums
 Mucilage
3. Glycogen
Glycaemic index

Classification of carbohydrates
Types of carbohydrates
• Monosaccharides:
• Š Glucose
• Š Fructose
• Š Mannose
• Š Galactose
72

• Disaccharides:
ŠSucrose (a disaccharide present taste
sugar)
ŠLactose (a disaccharide present in milk)
ŠMaltose (a disaccharide present in starch)
73

cont,,,,
• Sugar alcohol: is found in nature and
also prepared commercially.
• Mannitol and dulcitol are alcohol derived
from mannose and galactose. Both have a
variety of uses in medicine and food
manufacture.
74

cont,,,,
• Honey: is a mixture of glucose and fructose.
It is a balanced diet as it contains all the
nutrients in sufficient amount and proper ratio.
Honey has also medicinal effect. The bees first
cover the beehive with antibiotics to prevent the
growth and multiplications of microorganisms.
• If you keep honey for a long time, it will not be
spoiled because of antibiotics.
75

cont,,,,
Glycogen:
is the animal equivalent of starch
present in the liver and muscle. In most
foods of animal origin it is a negligible
source of dietary carbohydrate.
• The glycogen in the liver is a reserve fuel
and it serves between meals and over
night. The breakdown of glycogen in the
liver is facilitated by the hormone
glucagons. 76

cont,,,,
• Starch: is one form of carbohydrate
that is stored in granules in the roots
and seeds of plants.
77

78
How does fiber prevent different health
problems?
Cancer (Colonic, breast..)
• Prevents secondary bile acid circulation
• Decrease intestinal transit time
• Decrease contact of carcinogens with
intestinal cells
• Fermentation product butyrate has apoptotic
effect
• Decreases absorption fats and sugars

79
WHY DO WE NEED CARBOHYDRATES TO
SURVIVE?
We need this amount of carbohydrate because:
– 45% - 65% of calories should come from carbohydrate
– Carbohydrates are the body’s main source of fuel.
– All of the tissues and cells in our body can use glucose for
energy.
– Carbohydrates are needed for the central nervous system, the
kidneys, the brain, the muscles (including the heart) to function
properly.
– Carbohydrates can be stored in the muscles and liver and later
used for energy(glycogen).
– Carbohydrates are important in intestinal health and waste
elimination (e.g.. Dietary fiber).

Digestion and absorption of
carbohydrates
• The digestion of carbohydrates begins in the mouth
by Ptyalin(amylase) produced by the salivary
glands.
• No carbohydrate digestion takes place in the
stomach. Digestion occurs mainly in the small
intestine through the action of pancreatic and
intestinal juices:
• Š Amylase
• Š Lactase
• Š Sucrase
• Š Maltase 80

• Dextrin is degradation products of
starch in which the glucose chains
have been broken down to smaller
units by partial hydrolysis.
• Dextran is a carbohydrate polymer
obtained from bacterial cell wall. This
has no part in dietetics but is used in
medicine as plasma expander.
81

82
Carbohydrate digestion
a. Digestion of starch and disaccharides
Absorbed by active transport
mechanism coupled with sodium
Sucrose
Glucose
+
Fructose
From the small
intestine
-Chemical
salivary Amylase
(Ptyalin) &
Pancreatic
amylase
 -Mechanical;-
biting action of
the teeth
Maltose
Glucose + Glucose
Lactose
Glucose
+
Galactose
Absorbed by simple
diffusion
Lactase
Sucrase
Maltase
Starch,
Dextrin,
Mouth and
small
intestine

83
They get fermented in the
colon by anaerobic bacteria
Oligosaccharides (eg. Raffinose, Stachyose)
and non-starch polysaccharides resistant
starch
Escape digestion in the
upper gut (small intestine
Increased faecal Biomass
resulting in increased
peristalsis
Production of
short chain fatty
acids (SCFA)
 Acetate
 Propionate
 Butyrate
Production of
gases likes co2,
methane and
hydrogen
sulphide
b. Digestion of oligosaccharides, resistant starch
and non-starch polysaccharides
Abdiwahab H

84
Metabolism of Carbohydrates
Fructose-6-phosphate
Fructose1, 6-diphosphate
Glycolysis
Crebs Cycle
Glyceraldehyde-3 phosphate
bGlyceraldehyde 3-phosphatephosphate
3-Dihydroxy Acetone phosphate
CO2+ Energy+H2O
Acetyl CoA
Glucose –6-Phosphate

• In Health and with normal diet, the available
carbohydrate is digested and absorbed completely
in the small intestine.
• If an excess of unabsorbed carbohydrate arise due
to a disorder of the absorption mechanisms or
occasionally to excessive intake, the osmotic
pressure (effects) leads to retention of fluids in the
lumen and as the result there will be watery
diarrhoea. This diarrhoea is known as osmotic
diarrhoea.
85

• The tissues use as fuel a mixture
of glucose and fatty acids. But the
brain normally uses only glucose
and requires around 80g daily.
86

• In starvation glucose may be provided by
gluconeogenesis from the amino acids in
tissues proteins, mainly from muscle
proteins, but fats cannot be converted into
glucose. With prolonged starvation the
brain adapts and can then utilize fatty
acids and ketone.
87

• The two hormones, which control the
metabolisms of carbohydrates,are insulin
and glucagons
ŠInsulin is secreted by the beta cells of the
islets of Langerhans and the secretion is
stimulated by:
– Hyperglycemias
– Parasympathetic nervous activity
88

Function of insulin
• Š To facilitate glucose transport to the
liver and muscle cells
• Š To facilitate formation of glycogen in the
liver and muscle cells
• Š To incorporate formation of protein from
the amino acids.
89

• Glucagons is secreted by the alpha cells
of the islet of Langerhans and the
secretion is stimulated by
Š Hypoglycaemia
Š Sympathetic nervous activity
90

Function of glucagons
• To facilitate the breakdown of glycogen in
the liver and muscle cells into glucose
91

Proteins are classified into twoProteins are classified into two
groups:groups: completecomplete andand
incompleteincomplete..
• Complete proteinsComplete proteins containcontain
amounts of all nine essentialamounts of all nine essential
amino acids.amino acids.
SOURCES INCLUDE:SOURCES INCLUDE:
*Fish, meat, poultry, eggs,*Fish, meat, poultry, eggs,
milk, cheese, yogurt, andmilk, cheese, yogurt, and
many soybean products.many soybean products.
• Incomplete proteinsIncomplete proteins lack onelack one
or more essential amino acids.or more essential amino acids.
SOURCES INCLUDE:SOURCES INCLUDE:
*Beans, peas, nuts, and*Beans, peas, nuts, and
whole grains.whole grains.
• Proteins have manyProteins have many
functions:functions:
- Help make new cells.- Help make new cells.
-Help make and repair-Help make and repair
tissues.tissues.
- Help make enzymes,- Help make enzymes,
hormones, and antibodies.hormones, and antibodies.
- Provide energy.- Provide energy.
ProteinsProteins are nutrients that help build and maintain body cells and tissues.are nutrients that help build and maintain body cells and tissues.

93
Proteins
• The basis of protein structure is the amino acid, of which 20 have
been recognized as constituents of most proteins
• All Amino acids have amino group(NH2) and Carboxylic
Group(COO2)
• But, they are differentiated by the remainder of the molecule (R)
as shown in the figure.
Those amino acids that cannot be synthesized in the body and need
to be taken from food are essential (indispensable) amino
acids.
C
H
COOHR
NH2

94
Cont..
• Absence Essential a.a.from the diet leads to poor growth
performance by a growing animal. Essential amino acids are
labelled by (**) sign in the following table .

95
WHY DO WE NEED PROTEIN TO SURVIVE ?
We need protein for:
 Growth (especially important for children, teens, and pregnant women)
 10% - 35% of calories should come from protein.
 Tissue repair
 Immune function
 Making essential hormones and enzymes
 Energy when carbohydrate is not available
 Preserving lean muscle mass
 Synthesis of enzymes, hormones all antibodies
 Control Fluid movement in the body
 Buffer(PH control): Due to the carboxyl or acid group (-COO) and amino
or basic group (- NH2
)

96
Classification of proteins
I. Based on chemical composition.
a)Simple protein - yield amino-acids upon
complete hydrolysis
E.g.: - albumin - in eggs, zein of corn
b.Compound/conjugated proteins
Protein + Non protein
E.g.: - Hgb (Protein + hem) - Blood

97
Cont..
II. Based on Nutritional Value:- This classification
depends on the essential amino acids content of the
protein.
a. Complete proteins: Contain all the essential amino
acids in the proportion that is required to support growth
and maintain tissues. E.g. Almost all animal proteins
except gelatine (lack two essential A.As.). They are
denoted as complete because they resemble body
protein (Egg & Milk).
b. Incomplete Proteins: This refers to proteins that do
not contain all essential amino acids in the proportion
that is required to maintain growth and tissue repair.

98
III. Based on Conformation of the Protein: This refers
to the three dimensional shape of the protein in its natural state.
Based on this proteins are classified as:
a.Globular proteins
-Tightly folded poly peptide chain - spherical or globular shape
-Mostly soluble in water
E.g.: - Enzymes, antibodies, and many hormones, Hgb
b. Fibrous proteins
-Polypeptide chains arranged in parallel manner along an axis
-Tough & in soluble in water
E.g.: - Collagen of tendons & bone matrix
- Keratin of hair, skin, nails and
- Elastin of blood vessels

99
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.
Eg. Ala---gyc---Phenala---histd---tyr---trp
b. secondary Structure: This refers to the folding of the polypeptide
chain upon itself resulting in alpha helix (right twisted or left twisted)
and or B-pleated sheet. This structure is held strong by intra
molecular hydrogen bonding.
1. Alpha helices OR
2. B-Pleated Sheath

100
c. Tertiary Structure: - This refers to the three dimensional arrangement of the protein
structure (whether it is folded upon itself giving rise to globular proteins or whether its
straight chain of poly peptides resulting in fibrous protein). This structure is maintained by the
sulfide bond.
Globular protein Fibrous protein
d. Quaternary Structure:- This refers to the aggregation of individual poly peptide chains by
electrostatic bonding. Hemoglobin is a typical example of the quaternary structure of protein.
Hemoglobin A1 A2
B1 B2

Proteins
• Proteins have long been recognized as
fundamental structural elements of
every cell of the body. Specific proteins
and protein derivatives have been
recognized as functional elements in
certain specialized cells glandular
secretion, enzymes and hormones.
101

Proteins
• A good quality or a
complete protein is
the one that supplies
all the essential
amino acids in
sufficient quantities
and in proper ratio for
normal growth and
maintenance
• In general all proteins
from animal source,
such as meat, poultry,
fish, eggs, milk and
milk products provide
good quality proteins.
102

Source of proteins
• Š Milk and milk
products such as
cheese, ice cream all
derive their protein
from milk.
• Š Meat, poultry, and
fish are all forms of
animal tissues
• Š Eggs are in a class
by themselves a
protein food of high
nutritive value.
103

Source of proteins
ŠVegetables are poor source of protein.
ŠLegumes provide more than 4 or 6 percent. They
are listed as meat alternates in the four-food
group chart because they provide one of the
better quality plant proteins.
ŠBread and cereals make an important contribution
to the protein of the diet, the protein of uncooked
grain ranges 7 to 14 percent.
104

Digestion and absorption of protein
• The digestion of protein in the alimentary tract is
accomplished by the action of several proteolytic
enzymes in the gastric, pancreatic and intestinal
juices.
• Any of these enzymes that have the power to
attack native proteins must be secreted in an
inactive form to prevent damage to the tissues
where they are formed.
105

Types of enzymes
• ƒ Pepsinogen is secreted by the gastric juice
and activated by the Hydrochloric acid
• ƒ Trypsinogen is secreted by pancreatic juice
and activated by entropeptidase
• ƒ Chemotrypsinogen is secreted by pancreatic
juice and activated by the active tripsin
• Peptidase intestinal juice
106

Summary of protein digestion
• See in your book/////
107

The Amino Acid Pool
• The amino acids from the food or from the body
tissues enter a common pool, which is drawn upon
for the synthesis of proteins, hormones, enzymes,
blood protein and nucleic acids,
• or some of the amino acids are degraded for
energy needs.
• Proteins are absorbed as amino acids. Ideally,
they are used to build or maintain body proteins. If
carbohydrates and fats are not meeting the energy
needs of the body, amino acids can be used to
provide energy. 108

Danger of the weaning period
• The weaning period is fraught with dangers for a large
proportion of the world’s children and nutritional disorders
are common at this time of life. In the West a general
awareness of the nutritional needs of the weaning, together
with the ability of the average family to provide the
necessary foods, have helped to remove most of the
dangers of the weaning period.
• In the peasant society of developing countries, however,
parents are generally are unaware of the dietary needs of
children, and several customs associated with weaning are
likely to give rise to nutritional deficiencies.
109

Danger of the Weaning period cont;;;;;
• In the traditional society, weaning is commonly
abrupt and unplanned. Often it is brought by the
occurrence of another pregnancy. There are
superstitions and beliefs concerning the effects of
another pregnancy on the quality of the breast
milk. It is believed that the heat from the womb
“poisons” the milk in the breast.
110

Danger of the Weaning period
cont;;;;;
• They also think that the baby in the womb is
jealous of the older sibling on the breast. It is
therefore considered urgent that the child should
be taken off the breast immediately
111

cont;;;;;
• The mother may
apply potions (bitter
material) to the
nipples so that when
the child takes the
breast the sharp bitter
taste makes him/her
give up suckling..
• The child has very
close relationship with
the mother, the
mother takes him/her
back wherever and
whenever she goes to
fetch water or to bring
firewood, the child
has also access to
breast milk on
demand.
112

cont;;;;;
• The child sleeps on
her back, but this
intimacy will be
interrupted when the
mother knows that
she is pregnant for
the subsequent child.
• This is a psychological
blow for the child and
causes poor appetite
and as the result the
child can develop
protein energy
malnutrition.
113

Protein energy malnutrition (PEM)
• PEM is today the most serious nutritional problem
in Africa and other developing countries. Its two
clinical forms are Kwashiorkor and Marasmus.
• The diseases occur mostly in children between
one and three years of age, after they have been
taken of the breast.
114

PEM:
• Although there is no final clarity about the etiology
of kwashiorkor in biomedical terms, it is
nevertheless, clear that it is related to nutritional
deficiencies
117

PEM:
• Therefore, all factors that could possibly contribute to the
child malnutrition in general should be avoided.
These include: Š
 Seasonal food shortage Š
 Unfavorable family condition, Š
 Inadequate water supply and sanitary facilities,
 Š Certain traditional attitudes during pregnancy, prenatal
period, breast-feeding and weaning periods, and
 All infectious diseases, which generally reduce immunity.
118

PEM:
Other diseases may sometime play an important role
in precipitating the onset of kwashiorkor in already
malnourished child.
E.g. ƒ Gastrointestinal tract infection
ƒDiarrhea
Intestinal worms share the diet and cause other ill-
health and
poor appetite ƒ
Constipation ƒ
Childhood diseases such as measles, whooping
cough, etc, 119

Signs and symptoms of kwashiorkor
• ƒ Growth failure occurs always ƒ
• Wasting of muscle is also typical but may not be
evident because of edema
• ƒ There may be mental change ƒ
• Hair and skin color change ƒ
• Diarrhea and vomiting ƒ
• Sign of other micronutrient deficiencies
120

Skin changes
• Mild: localized hyper pigmentation and skin
cracks
• Moderate: skin peals off, desquamation.
• Severe: superficial ulceration, bleeding
121

Hair changes
• Hair changes are classified into three categories:
Mild: beginning of visible color and structural
changes
• Moderate: color and structural changes, loss of
hair
• Severe: loss of hair together with ulceration of
head
122

Physiological functions of the various
systems are markedly disturbed with:
• ƒ Diarrhea ƒ
• Electrolyte disturbance ƒ
• Circulatory insufficiency ƒ
• Metabolic imbalance ƒ
• Poor renal functions
• Hence the child with kwashiorkor should be
thought of as an emergency in need of referral to
the nearest health facility.
123

Nutritional Marasmus
• ƒThere is a failure to thrive ƒ
• Irritability, restlessness and diarrhea are frequent.
ƒ
• Many infants are hungry, but some anorexic. ƒ
• There are little or no subcutaneous fats. ƒ
• The weight is much below the standard for age. ƒ
Temperature may be subnormal. ƒ
• The abdomen may be shrunken or distended with
gas. ƒ
124

Nutritional Marasmus
• Because of the thinness of the abdominal wall,
peristalsis may be easily visible. ƒ
• The muscles are weak and atrophic and this
makes the limbs appear as skin and bone ƒ
• Evidence of vitamin deficiencies may or may not
be found.
125

Criteria for referral to the nearest health
facility
• Š Substantial weight def.<60%WAF or <70%
HFA
• Š Severe generalized edema and any of the
following:
– Anorexia
– Diarrhea and vomiting
– Dehydration
– Loss of consciousness and convulsion
126

Criteria for referral ……….
• ƒSevere anemia <15%of Hematocrit ƒ
• Respiratory distress ƒ
• Hypothermia <35.50c ƒ
• Jaundice
127

After discharge management of PEM:
• ƒTo prevent relapse and future deterioration,
through nutrition education and demonstration of
the parents.
• ƒTo achieve long term follow up
128

Child status after discharge from
hospital
• ƒ Mental state has improved as shown by
smiling, response to stimuli, awareness, and
interest in the surroundings ƒ
• Appetite has returned and he/she is eating well ƒ
• Shows physical activity ƒ
• Temperature is normal ƒ
• No vomiting or diarrhea
• ƒ No edema ƒ
• Starting to gain weight.
129

Protein energy malnutrition
Severe acute malnutrition

Outline for nutritional requirement
Feeding during the 1st
6 month of life –
BF
Feeding during the second 6 month of
life
Feeding problems during the 1st
year of
life
Feeding during second year of life
Feeding during later childhood

Objective
At the end of this lecture the students
should be able to
Describe the nutritional requirement of
infants and children
Identify common problems encountered
during feeding of infants

Breast feeding
 Feeding should be initiated as soon after birth
as possible unless contraindicated.
 maintains normal metabolism during transition
 Promotes maternal infant bonding
 The time required for an infant stomach to
empty may vary from 1-4 hrs
 6 – 9 feedings in 24 hrs
 Most infants take 80-90ml per feed
 Satisfactory feeding
 No more wt loss at the end of 1st
week
 Started to gain wt at the end of 2nd
week

Advantage of BF
 Always available at a proper temperature and
requires no preparation time
 Fewer feeding difficulties, low incidence to
allergy
 Contains bacterial and viral antibodies
 High conc. Of secretary IgA
 Substances that inhibit growth of many common
viruses
 Macrophages synthesize complement, lysozyme
and lactoferrin
 Lower incidence of diarrhea as well as otitis media,
pneumonia, bacteremia, and meningitis

Continued…
 Contains bile salt-stimulated lipase, which kills giardia lamblia
and enteameba histolytica
 Supply all necessary nutrients except flouride and
after several months vit. D
 The psychological advantage of BF to the mother and
the infant – well known
 Establishing and maintaining the milk supply
 Empting of the breast – most important stimulus
Suckling – afferent to hypothalamus –pituitary – prolactin and
oxytocin
 Tender or sore nipples- nursing more frequently, manually
expressing milk, nursing in diffirent conditions, and keeping
the breast dry
 Less relaxed anxious mother – express milk feeding

Maternal diet
 Should contain enough calories and other nutrients
 To compensate those secreted in the milk and those required
to produce it
 Role – to maintain wt and generous in fluid, minerals and
vitamin
 Milk is an important component of the diet
 No food need to be withheld from the mother
 Should not take drugs
 Antithyroid medications, lithium, anticancer agent, INH,
chloramphenicol, metronidazole
 Smoking cigarettes and drinking alcohol- discouraged

Feeding during the second 6 month
of life
 By 6 month of age infants capacity to
 Digest and absorb a variety of dietary components
 Metabolize, utilize and excrete the absorbed products of
digestion is near adult capacity
 Teeth are beginning to erupt
 Begin to explore his surrounding
 Addition of other foods is recommended ( weaning)
 Complementary foods – additional foods including
formulas, given to breast fed infants
 Replacement foods – foods other than formula given
to formula fed infants

 Weaning should be stepwise to both breast fed
and formula fed infants
 Cereals, a good source of iron, usually should be
the first food
 Vegetable and fruits are introduced next
 Meats follows shortly and finally eggs
 One new food should be introduced at a time
 Additional new foods should be spaced by 3-4 days
 Adverse reactions (families with food or other allergies)

 Either home prepared or manufactured
complementary foods can be used
 The latter are more convenient and likely to
contain less salt – have supplemental nutrients
( eg Iron)
 Egg containing products should be delayed
 Food should be served 3 -5 time per day
including night
 With this most infants receive adequate
nutrients

Feeding problems during the 1st
year of life
 Underfeeding
 Suggested by restlessness and crying
 Failure to gain wt
 Possible causes
 Check frequency of feeding, mechanics of feeding
 Abnormal mother infant bonding
 Possible systemic disease
 Rx – instructing mother about the art of BF and
psychological support
_ specific management of systemic illnesses

 Overfeeding
 Regurgitation and vomiting
 Reg. –return of small amount of swallowed food
 Vomiting – more complete emptying of stamach
 Too high in fat – delay in gastric emptying, cause
distention and abd. Discomfort,
 Too high in CHT- distention and flatulance
 Loose stools
 Milk stool – loose, greenish yellow containing
mucus with freq. of 6-8 times/24hrs
 All diarrhea - infectious

 Constipation
 Consistency rather than freq. is the basis for
diagnosis
 Perform PR exam
 Aganglionic megacolon, tight or spastic anal
sphincter
 May be caused by an insufficient amount of food or
fluid
 From diets that are too high in fat or protein or
deficient in bulk
 Functional constipation – the most common
 Enemas and suppositories – temporary use

Colic – infantile colic
Common in infants younger than 3 month
The attack usually begins suddenly with a
loud continuous cry
Etiology is not usually apparent
Holding the infant upside helps and burping
Occasionally sedation for prolonged attack

Feeding during the 2nd
year of life
 By the end of 1st
year- 3 meals a day plus 1-2 snacks
 Changes in eating behavior
 Reduced food intake –rate of growth declines
 Lack of interest in food – temporary
 Never force feed
 Self selection of diets – should be respected
 Self feeding by infant
 Basic daily diets
 Grains, fruits, vegetables, meats and dairy products-balanced
diet with
 Snacks between meals- orange or other fruit juice with biscuit
 Vegetarian diet – vitamin B12 and trace mineral deficiency

Feeding during later childhood
After the age of 2 years
The child's diet – the same as family diet
Emphasis on grains, fruits, and vegetables
 Restriction of dietary fat to 30% of total energy
 Saturated fatty acid -< than 10%
 Cholesterol – not more than 100mg/1000kcal
 Poly unsaturated fatty acid -7-8% of energy
 Unsaturated fatty acid – 12-13% of energy
Such diet support normal growth of children

Bread, cereals,rice and pasta group
6-11 servings
Milkand milk product
Meat, poultry, fish
2-3 servings
Vegetable and fruit groups
2-4 servings

These servings usually meat the daily
requirement of 1600kcal(less active
child) and 2800kcal ( more active child)

Severe malnutrition
Objective
At the end of this lecture the students
should be able to describe the def.,
pathogenesis, clinical feature and
management of severe acute malnutrition

Outline
 Introduction
 Epidemiology
 Cause
 Classification
 Pathogenesis
 Clinical feature
 Diagnosis
 Complications
 Principles of management
 Prognosis and mortality

HUMAN NUTRITION
 Nutrients are substances that are crucial
for human life, growth & well-being.
 Macronutrients (carbohydrates, lipids,
proteins & water) are needed for
 energy and
 cell multiplication & repair.
 Micronutrients are trace elements &
vitamins,
 which are essential for metabolic processes.

HUMAN NUTRITION/2
 Obesity & under-nutrition are the 2 ends of
the spectrum of malnutrition.
 A healthy diet provides a balanced
nutrients that satisfy the metabolic needs
of the body without excess or shortage.
 Dietary requirements of children vary
according to
 age,
 sex &
 development.

Assessment of Nutritional status
Clinical
Anthropometric
Dietary
Laboratory

Clinical Assessment
Useful in severe forms of PEM
Based on thorough physical
examination for features of PEM &
vitamin deficiencies.
Focuses on skin, eye, hair, mouth &
bones.

Clinical Assessment/2
ADVANTAGES
Fast & Easy to perform
Inexpensive
Non-invasive
LIMITATIONS
Did not detect early cases
Trained staff needed

ANTHROPOMETRY
Objective with high specificity &
sensitivity
Measuring Ht, Wt, MUAC, HC, skin fold
thickness, waist & hip ratio & BMI
Reading are numerical & gradable on
standard growth charts
Non-expensive & need minimal training

ANTHROPOMETRY/2
LIMITATIONS
Inter-observers’ errors in
measurement
Limited nutritional diagnosis
Problems with reference standards

Classification
 Wellcome classification
 based on the presence or absence of edema
and a deficit on body weight
 some children with features of kwashiorkor with
wt above 80% are classified
Weight(% of
standard)
Edema present Edema absent
60 - 80 kwashiorkor underweight
< 60 Marasmic
kwashiorkor
marasmus

Continued..
 Advantage
-simplicity
 Disadvantage
 If the age of the
patient is not
known-difficult to
use
 It doesn’t take into
consideration the
chronicity of the
disease process

continued
 Gomez classification
 Grade I – 90 -75 percent –mild malnutrition(1st
)
 Grade II – 75-60 % -moderate malnutrition (2nd
)
 Grade III -< 60 % -severe malnutrition (3rd
)
 Drawbacks –
 combines in one number two different kinds of
deficit: in wt for ht and in ht for age
 90% is too high as well nourished children are
labeled malnourished
 A child can have wasting but not stunting
 A child can have also wasting and stunting
 Doesn’t consider the presence of edema

Waterlow classification: takes Wt & Ht.
Wt/Ht (%)= Wt of subj/ Wt of Nl child of the same Ht Χ
100
HFA= Ht of subj/ Ht of child of same age x 100.
W F H
>90% ≤90%
H
F
>95% normal wasted
A ≤95% stunted Stunted
&wasted

Waterlow classification
% of reference standard
normal mild moderate
severe
Ht for age 95 90-95 85-90 85
(stunting)
Wt for age 90 80-90 70-80 70
(wasting)

Continued…
Indicators Age group Moderate
malnutritio
n
Severe
malnutritio
n
Bilateral
edema
Children
Adolescent
Adults
No Yes
Bilateral
edema
W/H % Children>6
months
Adolescent
70 To 79%
Moderate
wasting
<70 %
Severe
wasting
MUAC 11 to 12cm <11cm

LAB ASSESSMENT
Biochemical
Serum proteins,
creatinine/hydroxyproline
Hematological
CBC, iron, vitamin levels
Microbiology
Parasites/infection

4. Biochemical Examination
Marsmus Kwash
 Serum protein (alb)- Nl/mod ↓
 Hgb/hct- ↓
 Non ess to ess AA ratio- Nl
 Serum FFA- Nl
 Blood glu- Nl/low
 Total body protein- ↓
 Transaminases- Nl/high
 ↓
 ↓ ↓
 ↑
 ↑
 Nl/low
 ↓ ↓
 High

DIETARY ASSESSMENT
Breast & complementary feeding
details
24 hr dietary recall
Home visits
Calculation of protein & Calorie
content of children foods.
Feeding technique & food habits

OVERVIEW OF PEM
The majority of world’s children live
in developing countries
Lack of food & clean water, poor
sanitation, infection & social unrest
lead to LBW & PEM
Malnutrition is implicated in >50% of
deaths of <5 children (5 million/yr)

CHILD MORTALITY
The major contributing factors are:
Diarrhea 20%
ARI 20%
Perinatal causes 18%
Measles 07%
Malaria 05%
55% of the total have malnutrition

EPIDEMIOLOGY
The term protein energy malnutrition
has been adopted by WHO in 1976.
Highly prevalent in developing
countries among <5 children;
 severe forms 1-10% &
 underweight 20-40%.
All children with PEM have
micronutrient deficiency.

PEM
In 2000 WHO estimated that 32% of <5
children in developing countries are
underweight (182 million).
78% of these children live in South-
east Asia &
15% in Sub-Saharan Africa.
The reciprocal interaction between
PEM & infection is the major cause of
death & morbidity in young children.

Cycle
infection
Worsening of malnutrition
malnutrition

PEM in Sub-Saharan Africa
PEM in Africa is related to:
The high birth rate
Subsistence farming
Overused soil, draught & desertification
Pets & diseases destroy crops
Poverty
Low protein diet
Political instability (war & displacement)

PRECIPITATING FACTORS
• LACK OF FOOD (famine, poverty)
• INADEQUATE BREAST FEEDING
• WRONG CONCEPTS ABOUT NUTRITION
• DIARRHOEA & MALABSORPTION
• INFECTIONS (worms, measles, T.B)

Introduction
Malnutrition is defined as chronic
inadequacy in food instances
combined with high levels of illness
Is a long term year round
phenomena
Chronic problem found in majority of
households

More than half of the deaths in
children have stunting and wasting
as the underling cause
 Occurs more frequently when
infections impose additional
demands, induce greater loss of
nutrients

Most deaths in children have some form
of malnutrition as the background
Stunting is due to chronic malnutrition
Wasting and edema are due to acute
malnutrition
Is both medical and social disorder so
management includes both medical and
social problems identified and managed—
this prevents relapse of the problem

Epidemiology
Most malnourished persons live in
developing countries,
One of every three children under the
age of 5 years in the developing country
 177 million children –are or had been
malnourished
In industrialized countries, malnutrition is
seen mainly among
 young children of low socioeconomic groups,
 the elderly who live alone,
 adults addicted to alcohol and drugs

According to unicef the extent of
malnutrition in Ethiopia is
Stunting ( 24 -59 months) – 43%
Underweight ( 0 -4 yrs) – 38
Wasting (12 -23 months) – 19%

Cause
There are two types
Primary – nutritional insufficiency
Inadequate protein, calorie and nutrient
intake
Secondary – malnutrition following
infections, injury, chronic disease, excessive
nutrient loss as occurs in chronic diarrhea,
HIV, malabsorption syndrome etc…
Social, economic, biologic, and
environmental factors underlying
severe malnutrition

Social and economic –
 Poverty that results in
 low food availability,
 overcrowding and
 unsanitary living condition
ignorance by itself or associated with
poverty leads to poor infant and child
rearing practices
misconception about the use of certain
foods
inadequate feeding conduct during illness
 inadequate BF and weaning practices
-Social problems like child abuse,

Continued…
Biologic factors
 Maternal malnutrition prior or during
pregnancy
Infectious diseases like diarrheal disease,
measles, respiratory and other infections
Diets with low concentration of proteins and
energy like over diluted milk formulas or
bulky vegetable foods that have low nutrient
densities

 Infection
 Anorexic
 Malabsorption
 Intestinal damage
 Increased metabolic rate
 Redistribution of nutrients
 Activation of inflammatory responses
 End result –
 reduced nutrient intake,
 reduced nutrient absorption,
 nutrient loss,
 increased nutrient requirement

Environmental factors
Overcowded or unsanitary living
conditions
Agricultural patterns, drought, floods,
wars and forced migration lead to
cyclic, sudden or prolonged food
scarcities

Pathogenesis
1) Dietary theory –believed in 1960’s
Kwashiorkor-is primary protein malnutrition
accompanied by a relatively excess of
energy
Marasmus is under nutrition with lack of
predominantly energy
Marasmic kwashiorkor is a combination of
chronic energy deficiency and chronic or
acute protein deficit.
Early weaning and prolonged BF without
weaning

2) Maladaptation theory –
• kwashiorkor is essentially failure of
adaptation where the body utilized
proteins and conserve S/C fat
• marasmus is due to the elevated plasma
glucocorticoid concentration which are
associated with an increased rate of muscle
protein catabolism which provided
• energy for the body’s needs and
• released amino acids for the hepatic synthesis
of protein.

Continued…
Aflatoxin theory –
 kwashiorkor results from aflatoxin
poisoning but
 there is no difference in the
amount of aflatoxin in both
marasmus and kwashiorkor

Free radicals theory – Michael Golden
 Imbalance between the
production of toxic free radicals
(superoxide,peroxidase) and their
safe disposal
The factors that increase free
radicals are
infections,
 toxins,
 sunlight,
 trauma, and catalysts such as iron

Formation of free radicals is
decreased by the antioxidant function
of vitamin A, C, and E, by ceruplasmin
and transfferin
The toxic effect of free radicals would
be responsible for cell damage leading
to alteration seen in kwashiorkor, such
as edema, fatty liver, skin changes.
more comprehensive and include all
other theories

Summary
Low nutrient intake
 Dysadapted
 Small bowel
bacterial overgrowth
 Infection
 Aflatoxin
 Fe
kwashiorkor
 Reductive adaptation
marasmus
 Vitamin A, C, E
 Mn, Zn, Se
 Essential fatty acids
 Sulfur containing
amino acids

Birth / breast feeding
 Early abrupt weaning
 Dirty diluted formula
 Repeated infections
e.g GE
 Negative energy
balance
 Marasmus
 Marasmic
kwashiorkor
 Late gradual
weaning
 Starchy family diet
 Acute infections e.g
measles
 Negative nitrogen
balance
 Kwashiorkor
 Marasmic
kwashiorkor

Pathophysiology
Develops gradually allowing the body
to adapt for the low food intake,
enabling survival in a compensated manner.
The adaptive mechanisms:
1. functional limitation & ↓ interaction
with the physical & social environment.

↓ energy intake
↓Energy expenditure-
↓ activity
Body fat mobilizn
= wt loss
↓ dietary amino acids ↓Protein synt in viscera
& muscles
↑ muscle pro
Catabolism=↑
AA for visceral
Synt of alb, LP

2. hormonal changes in metabolism of
proteins, CHO, &fats.
- Marked recycling of aminoacids (AA),
- ↓ urea synth & excretion,
- t ½ of serum proteins ↑,
- rate of albumin synth ↓ ,  shift of
extracellular alb to intravascular space
(failure of this ↓ serum alb ↓ oncotic
pressure  edema).

Cont…
 Hormonal changes
def food intake
Low plasma
Glu & AA
stress
↓insulin & somatomedin
↑ epinephrine & GH
↑ Glucocorticoids
Reverse T3 ? ↓ T3 & T4
Infection, DHN

Cont…
 Adaptive endocrine changes result in:
- ↑ glycolysis & lipolysis,
- ↑ AA mobilization,
- ↓ storage of glycogen, fats, & proteins,
- ↓ energy expenditure.

Cont…
 3. hematological & Oxygen transport:

Low protein intake
↓ physical act ↓ lean body mass Low availability
Of AA for protein
synth
Lower tissue oxy
demand Reduced Hgb & RBC
synth
Lower Hgb levels as body adapts to Lower needs
for oxy transport (no tissue hypoxia b/c of ↓ demand)

Rx with dietary protein & energy leads to ↑
tissue synth & lean body mass, and ↑
physical activity  greater tissue oxy
demand
 greater needs for hematopoietic
factors.
This leads to:
 ↑ Hgb & RBC synth (when available),
 anemia & tissue hypoxia (if not
available).
► iron should only be given during the
recovery phase.

4. CV & Renal functions
 CV reflexes will be depressed, central circulation
takes precedence over the peripheral
 peripheral circulatory failure which sometimes
mimics hypovolemic shock.
 GFR & renal plasma flow will reduce
5. immune system:
- marked depletion of lymphocytes from the
thymus (atrophy of the gland),
- ↓ complement number & function (↓ opsonin
activity),

Cont…
- phagocytosis, chemotaxis, & IC killing are all
impaired,
- the circulating levels of B-cells & Ig remain
normal, except for IgA- slightly depressed.
6. electrolytes:
- total body K+ ↓(↓ muscle protein & loss of IC
K+,
- IC Na+ ↑ (low insulin action impt for
mobilization of Na+-K+ into & out of the cell
and ↓ in ATP & phosphocreatinine).

7. GI function:
a. atrophy/edema of intestinal epithelium,
b. ↓ brush border enzymes (e.g. disaccharidase)
 mal absorption,
c. gastric, pancreatic, & billiary secretions will all
be depleted,
d. GI mobility ↓  paralytic ileus,
e. def of enzymes, overgrowth of bacteria 
diarrhea,
f. fat accumulation in the liver from def of
lipoprotein.

Cont…
8. CNS & peripheral NS: a long term
complication and includes:
- decreased growth of the brain,
- decreased myelination,
- decreased neurotransmitters,
 decreased velocity of nerve conduction.

Pathophysiologic changes
 Kidney –
 reduced GFR and renal blood flow
 decreased capacity to concentrate or dilute urine or to excrete
an acid urine
 Heart – fragmentation of myofibril and atrophy,
 small flabby heart. Decreased rate and stroke volume.
 Low voltage EKG
 Intestine – thin atrophic wall with a reduction in villous
height.
 marked reduction in the functional capacity of the digestive,
bile salt and transport system for nutrient absorption.
 Liver –
 fatty liver is probably due to reduced release of fats from the
liver to plasma in lipoproteins

Continued…
 Endocrine –
 GH increased with decreased insulin
 cortisol increased,
 T3 and T4 decreased
 Hair – there is atrophy of hair roots of the
scalp.
 Fluid and electrolytes –
 an increased of total body Na
 with a loss of total body K . This loss of K is due to
loss of K rich tissues

 Immune response:
 Disruption of skin integrity and mucus membrane
 Impaired bactericidal action of phagocyte
 Impaired cell mediated immunity
 Low serum transferrin
 low complement level
 low activity of IL-1(poor febrile response),
cachectin, TNF
 Lower mucosal secretory IgA antibody titer
 Nervous system – decreased brain growth,
neurotransmitter prod’n

Clinical features
• PEM can affect all ages but
common among infants and young
children
• Marasmus – before 1 year of age
• Kwashiorkor – after 18 months of
age
• Diagnosis is principally based on
• dietary history and
• clinical features

MARASMUS
The term marasmus is derived from
the Greek marasmos, which means
wasting.
Marasmus involves inadequate intake
of protein and calories and is
characterized by emaciation.
Marasmus represents the end result
of starvation where both proteins and
calories are deficient.

MARASMUS/2
Marasmus represents an adaptive
response to starvation, whereas
kwashiorkor represents a maladaptive
response to starvation
In Marasmus the body utilizes all fat
stores before using muscles.

EPIDEMIOLOGY &
ETIOLOGY
Seen most commonly in the first year
of life due to lack of
 breast feeding and
the use of dilute animal milk.
Poverty or famine and diarrhoea are
the usual precipitating factors
Ignorance & poor maternal nutrition
are also contributory

Clinical Features of Marasmus
Severe wasting of muscle & s/c
fats(60% or less of wt for age)
Severe growth retardation(stunted)
Child looks older than his age
Alert but miserable
Hungry
Diarrhoea & Dehydration
No edema

• The hair sparce, thin, dry, and easily
pluckable
• The skin is dry, thin, and wrinkles –
‘baggy pant ‘

Irritable, ravenously hungry but vomit
easily
Loss of bichat fat pad, last fat tissue to
disappear (monkey’s or little old man’s
face)
Marked weakness
Abdominal distention(due to distended
bowel)

KWASHIORKOR
Cecilly Williams, a British nurse, had
introduced the word Kwashiorkor to
the medical literature in 1933.
The word is taken from the Ga
language in Ghana & used to describe
the sickness of weaning.

ETIOLOGY
Kwashiorkor can occur in infancy but
its maximal incidence is in the 2nd yr
of life following abrupt weaning.
Kwashiorkor is not only dietary in
origin.
Infective, psycho-socical, and cultural
factors are also operative.

ETIOLOGY (2)
Kwashiorkor is an example of lack of
physiological adaptation to unbalanced
deficiency where the body utilized
proteins and conserve S/C fat.
One theory says Kwash is a result of
liver insult with hypoproteinemia and
oedema.
Food toxins like aflatoxins have been
suggested as precipitating factors.

CLINICAL
PRESENTATION
Kwash is characterized by certain
constant features in addition to a variable
spectrum of symptoms and signs.
Clinical presentation is affected by:
• The degree of deficiency
• The duration of deficiency
• The speed of onset
• The age at onset
• Presence of conditioning factors
• Genetic factors

CONSTANT FEATURES OF KWASH
OEDEMA(doesn’t involve serous
membrane)
PSYCHOMOTOR CHANGES(Apathetic
and irritable, cry easily, and have an
expression of misery and sadnes
GROWTH RETARDATION

USUALLY PRESENT
SIGNS
MOON FACE
HAIR CHANGES
SKIN DEPIGMENTATION
ANAEMIA

OCCASIONALLY PRESENT
SIGNS
HEPATOMEGALY
FLAKY PAINT DERMATITIS
CARDIOMYOPATHY & FAILURE
DEHYDRATION (Diarrh. & Vomiting)
SIGNS OF VITAMIN DEFICIENCIES
 SIGNS OF INFECTIONS

Continued…
Kwashiorkor –
 soft, pitting, painless edema, usually in
the feet and leg
Subcutaneous fat is preserved
Weight deficit is not as severe as
marasmus
Height may be normal or retarded

Continued…
The hair is dry, brittle, easily
pulled out without pain, pigment
changed to brown, red, or
even yellow white
‘Flag sign’ – due to alternating
period of poor and good protein
intake

Anorexic and diarrhea is common
Hepatomegaly
Protuberant abdomen and peristalsis is
slow
Muscle tone and strength is reduced

Marasmic kwashiorkor
Combines clinical feature of both
kwashiorkor and marasmus
Edema
Muscle wasting and decreased
subcutaneous fat
When edema subsides, the patient
appearance resembles that of
marasmus
Wt less that 60%and edema

Diagnosis
 History – nutritional history
 Physical findings
 Anthropometric measurements
-most children have similar growth potential
regardless of ethinicity
-need for international reference standard
-WHO recommends NCHS as a reference
-wt for ht –index of current nutritional
status
-ht for age –index of past nutritional history
-Harvard status – for under 5th

Assessment of Nutritional Status
1. Nutritional Hx & Dietary measurement:
- hx of breast feeding (frequency, day & night ?),
- total duration of breast feeding,
- any additional food (when was it started? If cow’s milk is
used, is it diluted/not?),
- amount, frequency, & type of additional food. Nutritional
hx should continue until present age.
 Dietary measurement
- measuring the diet/replica of the diet the child is getting,
- referring to the reference diet .

2. Anthropometric Measurement
Wt, ht/length, MUAC, HC, & skin fold thickness
(SFT).
Interpretation:
1. NCHS (National Curve for Health Statistics): widely
employed, extends from 5th
to 95th
centile.
Children below the 5th
centile are considered abnormal. In
areas where PEM is prevalent a 3rd
centile is used as a
cut off point.
2. Harvard/Wellcome curve:
- impt for under five children,
- takes the wt & age,
- uses standard wt (expected wt for age, 80%) &
presence/absence of edema. The standard is equivalent
to the 50th
centile of the NCHS curve.

Gomez classification:
WFA(% of ref)= Wt of subj/ Wt of Nl child of the same
age
WFA (% of ref) Interpretation
90-100 normal
75-89 Grade I/ mild
malnutrition
60-74 G II/ moderate
malnutrition
<60 G III/ severe
malnutrition

Cont…
Wellcome’s Classification:
Wt for Age
(WFA)
edema no edema
60-80% Kwashiorkor Underweight
<60% Marasmic
kwash
Marasmus

Investigation
 Hct and Hgb
 WBC count and differential
 RBS
 Urinalysis and urine culture
 Chest X-ray
 Blood culture
 Total serum protein
 Ratio of non essential to essential a.a-
 Reduced urinary creatinine clearance

Poor prognostic signs
 Age less than 6 months
 Deficit in Wt for Ht > 30%
 Stupor, coma, or other alteration in mental status
 Infections, particularly pneumonia or measles
 Petechiae or hemorrhagic tendencies
 Dehydration and electrolyte disturbances, particularly
hypokalemia, and severe acidosis
 Heart failure, hypothermia, hypoglycemia
 Total serum protein below 3 gm/dl
 Severe anemia with clinical signs of hypoxia
 Clinical jaundice or elevated serum bilirubin
 Extensive exudative or exfoliative cutanous lesions

Complications
Hypoglycemia
Hypothermia
Dehydration
Infection especially pneumonia, sepsis,
UTI, gastroenteritis
Fluid and electrolyte imbalance
Anemia
Developmental delay

Hypoglycemia
Life threatening comp’n
At risk because of alteration in glucose
metabolism
Signs –low body temperature, lethargy,
eye lid retraction, twitching or convulsion
RBS <54 mg/dl
Immediately give glucose containing
solution po or iv

Hypoglycemia: a common cause of
death in the 1st
2 days.
Can be due to a systemic infec or not
being fed for 4-6 hr.
- often have hypothermia, limpness,
drowsiness, lethargy.

- rx should be immediate (before lab
confirmation): 5ml/kg of 10% glucose,
this can also be given orally.
- also consider broad spectrum
antibiotics.

Dehydration
Useful signs –
thirst,
dry tongue and mouth,
 low urinary output,
weak and rapid pulse,
 low blood pressure,
 cool and moist extremities, and
declining state of consciousness.
Unreliable signs – sunken eyeball,
decreased skin turgor, irritability and
apathy

Rehydration should be preferably orally
or through NG tube
Solution should contain less Na and
more K – ORS ( not ideal) Resomal
(best)
Indication for iv fluid – shock and coma

257
Types of ORS
Solution Glu
g/dl
Na
mEq/L
K
meq/L
Cl
meq/L
WHO 2.0 90 20 80
Rehydralyt
e
2.5 75 20 65
Pedialyte 2.5 45 20 35
Infalyte 2.0 50 20 40

particular renal problem that makes the
children sensitive to sodium overload.
Dehydration:
- ‘narrow therapeutic window”
inappropriate rehydration can lead to
fluid overload & cardiac failure

- rx when possible should be orally, even
for severe DHN, unless there is shock,
loss of consciousness, or confirmed
severe DHN.
- fluids: half strength Darrow’s solution,
RL with 5% dextr, half strength saline
with 5% dextrose,

- oral rehydration: 5ml/kg of ReSoMal q 30min
for the 1st
2 hr, orally/ NG tube, then adjust
according to wt,
i.e. if continued wt loss, ↑ the rate by
10ml/kg/hr;
if no wt gain, ↑ rate by 5ml/kg/hr;
if wt gained but still signs of DHN, continue
same rx;
wt gained & no signs of DHN, stop rehydration.
NB: continuous reassessment vital!!

- in kwash, increased total body water &
Na+,
- frequently hypovolemic due to dilatation
of the blood vessels with a low cardiac
output,
-

definite watery diarrhea, clinical
deterioration DHN.
- a fast weak pulse, cold peripheries,
disturbed consciousness, absence of
signs of heart failure shock
(hypovolemic/ septic).

- mx uses the same fluids as in marasmus,
amount 10ml/kg/hr for 2 hr.
- watch for signs of over-hydration: ↑ RR,
grunting, ↑ liver size, vein engorgement,
- as soon as the patient improves, stop
all IV intake.
- also treat hypoglycemia, hypothermia,
infection.

If pts is in shock
give 15ml/kg over the 1st
hr & reassess,
dose can be repeated if wt loss/ wt is
stable.
- as soon as consciousness improves/
PR drops, stop the drip &
Give NG tube with 10ml/kg/hr
ReSoMal.

SIGN OF OVERHYDRATION
.Engorged neck vein
RR increment by more than 10
PR increment by 15
RUQ tenderness
Liver size increased by 1cm
Peripheral edema
Any sign of respiratory distress like
grunting and cyanosis

Hypothermia
Body temperature <35.5 degree
Due to impaired thermoregulatory
mechanism, reduced fuel substrate or
severe infection
Use kangaroo technique, put a hat
and the room should be kept warm
(b/n 28 -32 degree)
The should always sleep with the mother

Anemia
Usually due to Fe and/or folic acid
deficiency
Clinically pale , low HGB/ HCT
Fe treatment in phase II
Indication for transfusion –HGB
<4gm/dl , HCT <12% or heart failure
10ml/kg of packed RBC/ whole blood
slowly over 3hr.

Infection
Clinical manifestations may be
mild
Classical signs ( fever,
tachycardia and leukocytosis)
may be absent
Assume that children with
severe malnutrition have a
bacterial infection

Gram positive and gram negative
Safer to treat all with broad spectrum
antibiotics
Po route is preferred unless the patient
is in septic shock (a fast and weak pulse,
cold extremities, low BP and disturbed
consciousness)

Management
 Ten essential steps in the routine care of severely
malnourished children
 Treat / prevent hypoglycemia
 Treat / prevent hypothermia
 Treat / prevent dehydration
 Correct electrolyte imbalance
 Treat infection
 Correct micronutrient deficiencies
 Initiate feeding
 Replete wasted tissue (catch-up growth)
 Provide sensory stimulation and emotional support
 Prepare for follow up after recovery

Admission criteria
Age 6mo to 18 yrs - W/H or W/L <70% or
- MUAC <11cm with L
>65cm or
- Bilateral pitting edema
Adults -MUAC <170mm or
- BMI <16 or
-Presence of bilateral
pitting edema (exclude
other causes)

Nutritional therapy
Routine medicines
• Vitamin A – one capsule on the day of
admission and discharge
• Folic acid – a single dose of 5mg folic
acid
• Other nutrients – no need b/c F75 and
F100
• Antibiotics – should be given to all
• 1st
line treatment – oral amoxacillin
(ampicillin)
• 2nd
line teatment – Add chloramphenicol or
gentamycin

Routine medicines
1. Vitamin A

Continued…
 Duration of antibiotic –
 every day during phase I and 4 more days –in
patient
 7 days total in out patient care
 Malaria
 Measles vaccine on the 4th
week of treatment
 Deworming – at the start of phase II
 worm medicine is only given children who can walk
 Albendazole 400mg PO STAT
 mebendazole 100mg TWICE DAILY FOR 3 DAYS

Cont…
2. Folic acid: on the day of admission, one dose of folic
acid (5mg) to children with anemia.
3. Antibiotics: should be given to every severely
malnourished patient, even if no clinical signs of
systemic infection (nearly all are infected).
- small bowel bacterial overgrowth occurs in all these
children: systemic infection, malabsorption, & chronic d.
- in children with kwash, bacteria that are normally not
invasive, such as S. epidermidis can cause systemic
infection/ septicemia.
- recommended also in those who go to phase II directly.

Antibiotic regimen:
 Oral amoxicillin (oral ampicillin, if unavailable): 1st
line,
 2nd
line rx: add chloroamphenicol, or
- add gentamicin, or
- change to amoxicillin/clavulinic acid.
4. Iron: given in phase II.

Phase I:
- pts with inadequate appetite and/or a
major medical cxn,
- formula used in this phase is F-75,
- promotes recovery of normal metabolic
fn & nutrition-ele balance,
- rapid wt gain is dangerous (F-75
ensures that).

Phase I
Diet – F75 (one sachet mixed
with 2 liters of water)
provides 75 kcal per 100 ml
8 feeds per day –larger volume
feeding can result in osmotic
diarrhea

 Naso-gastric feeding is used if
 the child takes less than 75% of the prescribed
diet
 pneumonia with fast breathing
 painful lesions of the mouth
 cleft palate or other physical deformity
 disturbance of consciousness
Surveillance using multichart

Transition phase
 Criteria to progress from phase I
 Return of appetite
 Beginning of loss of edema and
 No iv line, no NG tube
 Diet – F100 (100kcal in 100ml)
 The no. of feeds, their timing, and volume is the
same as phase I this leads to a 30% increase in
energy intake & thus the wt gain should be
~6g/kg/day,
 Transition phase should last 1-5 days

- criteria to move back to phase I include:
1. Increasing edema, new onset edema,
2. Rapid increase in liver size,
3. Significant refeeding diarrhea (& wt
loss),
4. Medical cxn, if NG tube needed,
5. Intake <75% of feeds in transition
phase,
6. Wt gain >10g/kg/d (excess fluid
retention).

Phase II
 Criteria to progress
 Good appetite (taking >90% of F-100)
 Loss of edema entirely
 designed for rapid wt gain (>8g/kg/day).
 Diet – F100
 Have unlimited intake
 5 feeds of F100 are given
 One porridge may be given
 Always offer plenty of clean water while eating
 Children must never be forced fed
 Provide additional quantity of diet after feeding

Phase II: amount increased to ~180-
225ml/kg/day of F-100,
 iron is added here

 .
- criteria to move back to phase I:
Development of edema,
refeeding diarrhea with wt loss,
Wt loss of >5% of body wt at any visit
Wt loss for 2 consecutive weighing,
Static wt for 3 consecutive weighing.

Criteria for failure to respond
 Primary failure to respond (phase I)
 Failure to regain appetite (Day 4)
 Failure to start to loss edema (Day 4)
 Edema still present (Day 10)
 Failure to enter phase II and gain 5g/kg/d (Day 10)
 Secondary failure to respond
 Failure to gain more than 5g/kg/d for three
consecutive days (during phase II)
 Measure to take
 Extensive history and examination or lab. Test
 Look for hidden infection

Cont…
Discharge criteria:
Age
6mo-18
yr
• W/L (W/H) ≥85% on
more than one occasion,&
No edema for 10 days.
• target wt gain reached &
no edema for 10 days.

Prognosis
 Upon treatment the acute signs of the disease
are corrected
 Catch-up growth in height may take long or
might never be achieved
 Mortality rate can be as high as 40%
 Immediate cause of death are comp’n
particularly infections, hypoglycemia, and
dehydration
 Mortality rates can be reduced to < 10% by
prevention and treatment of comp’n

• FatsFats are a type of lipid, a fattyare a type of lipid, a fatty
substance that do not dissolve in water.substance that do not dissolve in water.
• The building blocks of fats are calledThe building blocks of fats are called
fatty acidsfatty acids
• Fatty AcidsFatty Acids are classified as two typesare classified as two types
• Saturated:Saturated:
– Animal fats and tropical oilsAnimal fats and tropical oils
– High intake is associated with anHigh intake is associated with an
increased risk of heart diseaseincreased risk of heart disease
• Unsaturated:Unsaturated:
– Vegetable fatsVegetable fats
– Associated with a reduced risk ofAssociated with a reduced risk of
heart diseaseheart disease
• Fatty acids that the body needs, but isFatty acids that the body needs, but is
unable to make are called essential fattyunable to make are called essential fatty
acidsacids
• Transport vitamins A, D, E, and KTransport vitamins A, D, E, and K
• Sources of linoleic acid- essential fatty acidSources of linoleic acid- essential fatty acid
that is needed for growth and healthy skinthat is needed for growth and healthy skin
• High intake of saturated fats is linked toHigh intake of saturated fats is linked to
increased cholesterol productionincreased cholesterol production
• Excess cholesterol can lead to an increasedExcess cholesterol can lead to an increased
risk of heart diseaserisk of heart disease

Lipids
• are a group of organic compounds that are
insoluble in water but soluble in organic solvents.
• Lipids are fats and oils.
295

Lipids:
• ƒ Are the form of stored energy in animals
• Have high energy value 9 kcal/gm of fat ƒ
• Act as carriers for fat soluble vitamins ƒ
• Are palatable giving good taste and satiety ƒ
• Serve as insulator preventing heat loss from the
body ƒ
• Lubricate the gastrointestinal tract ƒ
• Protect the delicate organs such as Kidney,
Eyes, heart and the like.
296

Classification of lipids
Lipids are classified into 3 on the basis of their
chemical structure. ƒ
•Simple lipids = Fats and oils ƒ
•Compound lipid = Phospho-lipids and lipoproteins
ƒ
•Derived lipids= fatty acids and sterols
297

• ƒHuman beings cannot synthesize the Poly
Unsaturated Fatty Acids (PUFA), hence they are
termed as essential FA. ƒ
• Saturated fatty acids tend to raise blood
cholesterol level. ƒ
• Polyunsaturated Fatty Acids lowers blood
cholesterol and large amounts of unsaturated
Fatty Acids are of vegetable origin and have
lower melting point.
298

Phospholipids, sterols and lipoproteins
• Phospholipids are structural compounds found in
cell membranes.
• They are essential components of enzyme
systems and are involved in the transport of
lipids in plasma.
299

Sterols
• ƒThese are precursors of vitamin D, which are
found both in plants and animals. Cholesterol in
animal’s tissues, egg yolk butter. Ergosterol in
plants ƒ
• Lipids are transported in the blood in the form of
lipoprotein (soluble fat protein complexes). ƒ
• They are 25-30% proteins and the remaining as
lipids
300

Lipoprotein
• These are compound lipids that contain both
protein and various types and amounts of lipids.
• They are made mostly in the liver and are used to
transport water-soluble lipids throughout the body
and the types of lipoproteins are VLDL, LDL, HDL,
and Chylomicrons.
301

• Low-density lipoprotein (LDL) This is composed
mainly of cholesterol.
• LDL. Transports cholesterol from the liver to the
tissues. High serum level of LDL greatly increases
the risk of atherosclerosis ” is a disease in which
fatty deposits collect along the inside walls of
large or medium - sized arteries. These deposits
clog or narrow the passageway. If blood clots
become lodged in the narrowed vessels, the
blood flow to the heart or brain many be partially
or completely blocked, resulting in a heart attach
or stroke”. Diets that are high in saturated fatty
acids are associated with elevation in LDL
cholesterol. 302

Cholesterol
• Cholesterol is found
only in animal
products. Plant foods,
regardless of their fat
content, do not
contain cholesterol.
Cholesterol is a fatlike
lipid that normally
occurs in the blood
and all cell
membranes.
• It is a major part of
brain and nerve
tissues. Cholesterol is
necessary for normal
body functioning as
structural material in
the body cells, and in
the production of bile,
vitamin D and a
number of hormones
including cortisone
and sex hormone. 303

• Hereditary, diet, exercise, and other conditions
affect blood cholesterol levels. Persons with high
blood cholesterol levels appear to be more likely
than those with normal levels to develop
atherosclerosis.
• No recommended dietary allowance has been
established for total fat or essential fatty acids;
however, the reduction in total fat is
recommended.
304

The essential fatty acids are: Š
• Linoleic acid Š
• Linolnic acid Š
•Arachidonic acid
305

The essential fatty acids are:
• Essential Fatty Acids are needed for the normal
functioning of all tissues
• Essential Fatty Acids form a part of the structure
of each cell membrane.
• Essential Fatty Acids help transport nutrients
and metabolites across the cell membrane
• Essential Fatty Acids are also involved in brain
development
• Essential Fatty Acids are needed for the
synthesis of prostaglandin
306

Linoleic acid:
Linoleic acid: occurs abundantly in vegetable oils
such as: ƒ
•Corn oils ƒ
•Cottonseed oils ƒ
•Soybeans oils ƒ
•Sesame oils ƒ
•Sunflower oils
307

Digestion of fats:
• In the mouth
• Enzyme – lingual
lipase
• End products –
diglycerides
• In the stomach
• Enzyme – Gastric
lipase
• End products – Fatty
acids, glycerol,
diglycerides and
monglycerides
308

Digestion of fats:
• In small intestine
Triglycerides,
diglycerides
• Enzyme – Pancreatic
lipase
• End products –
monglycerides, fatty
acids, glycerol
Food source of fats ƒ
•Animal – Fish, butter,
beef, pork, and lamb
• ƒPlant - vegetable,
fruit avocado, nuts,
margarine, cooking oils
309

– Water-soluble vitaminsWater-soluble vitamins
dissolve in water and passdissolve in water and pass
easily into the blood duringeasily into the blood during
digestion. The body does notdigestion. The body does not
store these so they need to bestore these so they need to be
replenished regularly.replenished regularly.
Includes vitamins C, B1 ,B2,Includes vitamins C, B1 ,B2,
Niacin, B6, Folic acid, and B12.Niacin, B6, Folic acid, and B12.
– Fat-soluble vitaminsFat-soluble vitamins areare
absorbed, stored, andabsorbed, stored, and
transported in fat. Your bodytransported in fat. Your body
stores these vitamins in yourstores these vitamins in your
fatty tissue, liver, and kidneys.fatty tissue, liver, and kidneys.
Excess buildup can beExcess buildup can be
toxic.These include vitaminstoxic.These include vitamins
A, D, E, and K.A, D, E, and K.
VitaminsVitamins are compounds that help regulate many vital bodyare compounds that help regulate many vital body
processes that include:processes that include:
1.1. Digestion 2. Absorption 3. Metabolism 4. CirculationDigestion 2. Absorption 3. Metabolism 4. Circulation
Vitamins are classified into two groups:Vitamins are classified into two groups:
MineralsMinerals are substances that the body cannotare substances that the body cannot
manufacture but are needed for forming healthy bonesmanufacture but are needed for forming healthy bones
and teeth and regulating many vital body processes.and teeth and regulating many vital body processes.
ImportantImportant mineralsminerals iinclude:nclude:
-Calcium -Phosphorus –Magnesium -Iron-Calcium -Phosphorus –Magnesium -Iron

Vitamins;
• Vitamins: are defined
as organic
compounds, other than
any of the amino acids,
fatty acids and
carbohydrates that are
necessary in small
amounts in the diet of
higher animals for
growth, maintenances
of health and
reproduction.
• All animals need
vitamins, but not every
vitamin that has been
discovered is needed in
the diet of each animal
species. E.g. humans
and guinea pigs need
Vitamin C, but dogs,
rats, do not need
vitamin C in their diet
because they can
synthesis this vitamin in
their bodies.
311

Classification of vitamins:
• Š Vitamin A (Retinol)
• Š Vitamin B1 (Thiamine)
• Š Vitamin B2 (Riboflavin)
• Š Vitamin B6 (pyridoxine) Š
• Vitamin B12 (Cyanocobalamine) Š
• Niacin Š
• Panthotonic Acid Š
• Folacin Š
• Biotin Š
• Vitamin C (Ascorbic acid)
312

Classification of vitamins:
• Š Vitamin D (Cholecalciferol)
• Š Vitamin E (Tocopherol) Š
• Vitamin K (Antihemorrhagic vitamin)
• These vitamins are found in wholesome foods,
milk, vegetables, fruits, eggs, meat, beans,
wholegrain cereals etc
313

Function of vitamins:
• ƒTo promote Growth ƒ
• To promote Reproduction ƒ
• To promote Health & vigor ƒ
• To promote Nervous activity ƒ
• To promote Normal appetite ƒ
• To promote Digestion
• ƒTo promote Utilization ƒ
• To promote Resistances to infection.
314

Groups of vitamins:
Š Water soluble Vitamins are:
(C and B group) Š
Fat-soluble Vitamins are
(A, D, E, and K)
315

Characteristics of water soluble
vitamins
• ƒ They are widely distributed in natural foods ƒ
• B 12 is found only in animal products ƒ
• Soluble in water and absorbed in the intestine ƒ
• Excess will be excreted, thus not toxic. ƒ
• Most functions of these vitamins are as co-
enzymes ƒ
• They are important for energy production ƒ
• They are heat labile
316

Characteristics of fat - soluble
vitamins
• ƒ Metabolize along with fats ƒ
• Resistance to heat ƒ
• Stored in the liver and adipose tissue ƒ
• Slow to develop deficiency syndrome ƒ
• Present only in certain foods, mostly in animal
products, oily foods, yellow and green vegetable
ƒ
• Excess can be toxic to the body.
317

Function of vitamin A
It controls the general state of the epithelial cells
and reduces the risk of infection. ƒ
It is required for the regeneration of two pigments,
visual purple in the rods of retina and visual violet
in the cones of the retina.
 These two pigments are responsible for vision in
dim and bright light ƒ
It aids growth and development during childhood
ƒ
It helps to keep the cornea of the eye in healthy
condition.
318

Function of vitamin A
 Š Dietary Vitamin A is required for the growth and
survival of all animals and it is present in most
biological tissues. ƒ
 In the visual system the retina is dependent on
Vitamin A and its metabolites. ƒ
 In the auditory system vitamin A plays a role in
the maintenance of the middle and inner ear and
it also helps the olfactory system, ƒ
It is required for reproduction, embryonic
development and bone formation. 319

Who is affected by Vitamin A
deficiency?
• Vitamin A deficiency is a major health problem in
many developing countries. Many children do not
survive.
• Recent research findings suggest that improving
vitamin A status amongst deficient populations
can significantly reduce young child mortality.
• The population groups at highest risk of the
deficiency are infants and young children under
five years.
320

Vitamin A deficiency
• Vitamin A deficiency occurs when vitamin A
intakes (or liver stores) fail to meet daily metabolic
requirements. The most common cause is
inadequate consumption of vitamin A – rich foods.
Deficiency also occurs when there is problem of
absorption, conversion or utilization of vitamin A
or when there are repeated infections of diseases
such as measles or diarrhea. In the absence of
foods containing oils or fats in the diet, vitamin A
is not well absorbed and metabolized.
321

Animal source of vitamin A
• The best sources of
vitamin A is animal
products such as
organ meat like liver,
whole milk and milk
products, eggs,
butter, cheese, and
fish liver oils.
• Animal sources contain
preformed active
retinol, which can be
used effectively by the
body. The best source
of vitamin A for infants
is breast milk
• The mother’s secretion
of vitamin A into breast
milk, however, is
related to her own
vitamin A status. 322

Plant source of vitamin A
• Plants contain beta-
carotene that can be
converted into vitamin
A by the body.
• The best plant sources of
vitamin A are orange,
yellow colour fruits and
vegetables (papaya,
mango, pumpkin,
tomatoes, carrots, yellow
sweets potatoes)
• Dark green
vegetables.
323

What are the consequences of vitamin
A deficiency?
• Vitamin A deficiency has long been associated
with blindness. But more importantly, vitamin A
deficiency is associated with increased morbidity
and mortality among young children.
• Improvement of vitamin A levels among deprived
populations has been associated with reduction in
young child mortality.
324

The common symptoms of vitamin A
deficiency
• Š Night blindness:
The child cannot see
in the dark. He/she
has to go in to the
house early in the
evening.
• Š Conjuctival xerosis:
The conjuctival
covering the white
surface of the
eyeballs become dry
and rough instead of
being moist, smooth
and shining. The child
cannot open and
close his/her eyes
because it is painful.
325

The common symptoms of vitamin
A deficiency
• Bitot’s spots: A foamy or cheesy accumulation,
which forms in the inner quadrant of the cornea in
the eyes.
• The cornea the central transparent part of the eye
becomes cloudy.
• It reflects more advanced vitamin A deficiency,
but tends to be reversible with treatment.
326

The common symptoms of vitamin
A deficiency
• ŠCorneal ulceration: an ulcer on the cornea may
leave scar, which can affect vision. Š
• Keratomalacia: The eyeballs become opaque and
soft, jelly like substance; hereafter there will be a
rapid destruction of the eyeball and no hope of
recovery after the condition reached the stage of
keratomalacia.
327

• Diagnostic criteria for vitamin A deficiency at the
community level, WHO identifies a vitamin A
deficiency as a major public health problem if
prevalence of any one of the following in children
below six years of age exceeds the prescribed
levels.
328

Identifications of vitamin A deficiency at
the community level
Vitamin A deficiency sign/symptoms
Who cut - off level for identifying a
public health problem
Night blindness >1%
Bitot’s Spot(s) >0.5%
Conjuctival
Xerosis/ulceration/keratomalacia
>0.01%
Corneal scar >0.05%
329

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