The document outlines the various nutritional deficiency disorders, particularly focusing on Protein Energy Malnutrition (PEM), which affects children in developing countries and the elderly in developed nations. It discusses the classification of PEM based on severity and provides criteria for grading conditions like kwashiorkor and marasmus, emphasizing the importance of prevention and treatment strategies. Additionally, the document addresses the growing concern of childhood obesity, its causes, health implications, and prevention strategies, highlighting the role of nurses in managing these nutritional concerns.

1. NUTRITIONAL DEFICIENCY
DISORDERS
BY
MRS.HEPZIBAH ARULMANI.P
TUTOR
SRMTCON

2. INTRODUCTION
According to World Health Organization,protein
energy malnutrition (PEM) refers to “an imbalance
between the supply of protein and energy and the
body’s demand for them to ensure optimal growth and
function.”

3. DEFINITION
PEM is the condition of lack of energy due to the
deficiency of all the macronutrients and many
micronutrients.it can occur suddenly or gradually. It can
be graded as mild, moderate or severe.in developing
countries, it affects children who are not provided wit
calories and proteins.in developed countries, it affects the
older generation.

4. CLASSIFICATION OF PEM
Classification PEM may be classified according to
the severity, course and the relative contributions of
energy or protein deficit. Severity classifications are
based on anthropometric measurements, mainly weight
and height. Accordingly, several classifications are
suggested.

5. CLASSIFICATION OF PEM BASED ON
REFERENCE STANDARDS
 Classification according to weight for age.
 Indian Academy of pediatrics (IAP) classification
 Classification according to height for age
 Classification according to weight for height.

6. CLASSIFICATION ACCORDING TO
WEIGHT FOR AGE.
I.Gomez's Classification:
All cases with edema to be included in third degree
PEM irrespective of weight for age.
NUTRITIONAL STATUS WEIGHT FOR AGE
(% OF EXPECTED)
Normal > 90
First degree PEM 75 - 90
Second degree PEM 60 - 75
Third degree PEM < 60

7. INDIAN ACADEMY OF PEDIATRICS (IAP)
CLASSIFICATION
IAP classification is simple and the cut offs are suitable
for Indian population. If the patient had edema of
nutritional origin the latte K is placed along with grade of
PEM in order to denote Kwashiorkor.
NUTRITIONAL
STATUS
WEIGHT FOR AGE
(% OF EXPECTED)
Normal >80
Grade I PEM 71 - 80
Grade II PEM 61 - 70
Grade III PEM 51 -60
Grade IV PEM <50

8. CLASSIFICATION ACCORDING TO
HEIGHT FOR AGE
Height for age is used to grade stunting it indicates past
or chronic.
HEIGHT FOR
AGE % OF
EXPECTED
WATER LOW’S
CLASSIFICATI
ON
MC LAREN’S
CLASSIFICATI
ON
VISWEHRARA
O’S
CLASSIFICATI
ON
Normal > 95 > 93 > 90
First degree
Stunting / short
90 – 95 80 – 93 80 - 90
Second degree
Stunting
85 – 90 - -
Third degree
Stunting /
Dwarf
< 80 < 80 < 80

9. CLASSIFICATION ACCORDING TO
WEIGHT FOR HEIGHT
It is used to grade wasting. Wasting indicated recent or
acute PEM.
WEIGHT FOR
HEIGHT % OF
EXPECTED
WATER LOW’S
CLASSIFICATION
MC LAREN’S
CLASSIFICATION
Normal > 90 > 90
First degree wasting /
mild wasting
80 – 90 85 – 90
Second degree
wasting / moderate
wasting
70 – 80 75 - 85
Third degree wasting
/ severe wasting
< 70 < 75

10. PREVALENCE
PEM is the most widely prevalent form of
malnutrition among children. PEM affects every
fourth child worldwide.150 million 26.7% are
underweight while 182 million 32.5% are stunted. In
India, there has been a significant decline in severe
protein energy malnutrition

11. ETIOLOGY
• Poverty
• Low birth weight
• Infections:
Infections such as diarrhea, pneumonia, malaria, measles,
whooping cough and tuberculosis precipitate acute
malnutrition and aggravate the existing nutritional deficit.
• Population growth:
Lack of exclusive breastfeeding for first 6 months makes the
child prone to early onset malnutrition. prevailing dietary
practices and cultural taboos on consumption.

12. Cont;
•Social factors:
Repeated pregnancies, inadequate child spacing,
food taboos, broken homes and separation of a child
from his parents are the important social factors that
may play a part in etiology of PEM.
•Natural disasters:
Such as floods, earthquakes and droughts.

13. CLINICAL MANIFESTATION OF PROTEIN
ENERGY MALNUTRITION
ORGAN SIGNS
Hair Lack of luster, thinness and sparseness
straightness,dyspigmentation,flag sign ,easy
pluckability
Face Diffuse depigmentation ,Moon face
Eyes Pale conjunctiva,Bitot’s spots, conjunctival
xerosis, corneal xerosis, keratomalacia
Lips Angular stomatitis, Angular scars, cheilosis
Tongue Edema scarlet and raw tongue, atrophic papillae

14. ORGAN SIGNS
Teeth Mottled enamel
Gums Spongy, bleeding gums
Glands Thyroid and parotid enlargement
Skin Xerosis ,follicular hyperkeratosis
petechiae, pellagrous dermatosis ,flaky
paint dermatosis, scrotal and vulval
dermatosis
Nails Koilonychia
Subcutaneous tissue Edema amount of subcutaneous fat
reduced
Mascular system & Skeletal system Muscle wasting,craniotabes,Frontal and
parietal bossing, Epiphyseal
enlargement (tender / non tender)

15. KWASHIORKOR
Extreme expression of protein energy
malnutrition characterized by edema, growth failure,
hypoalbuminemia, fatty infiltration of the liver, and
specific dermatosis. First described in West Africa by
Cecily Williams. The word Kwashiorkor in Ghanian
means "red or yellow boy”.

16. PATHOPHYSIOLOGY
•Decreased protein intake leads to decreased
synthesis of visceral proteins.
•Decreased visceral protein, hypo – albuminemia
contributes to extravascular fluid accumulation and
•Impaired synthesis of B –lipoprotein produced a
fatty liver.

17. GRADING OF KWASHIORKOR
Grade I – pedal edema
Grade II – I + facial edema
Grade III – II + paraspinal and chest edma,
Grade IV –III + ascites

18. ESSENTIAL CLINICAL FEATURES
•Markedly retarded growth
•Psychomotor changes
•Edema
Edema may be caused by
Hypoalbuminemia
Retention of fluid and water due to increased
capillary permeability
Free radicals induced damage to cell membranes
•Mental changes
•Hepatomegaly
•Hair changes
•Skin changes

19. MARASMUS
Marasmus is characterized by gross wasting of
muscle and subcutaneous tissue resulting in
emaciation, marked stunting and no edema.

20. CLINICAL FEATURES
• The skin appears dry, scaly and inelastic and is prone to be
infected.
• The hair is hypo pigmented.
• The abdomen is distended due to wasting and hypotonia of
abdominal wall muscles.
• The mid arm circumference is reduced.
• The bony points appear unduly prominent due to emaciation.
• The baby appears alert, but is often irritable.
• Marasmus children may show voracious appetite.

21. GRADING OF MARASMUS
•Grade I – the wasting often starts in the axilla and
groin
•Grade II – thigh and buttocks
•Grade III – followed by chest and abdomen
•Grade IV – lastly the buccal pad of fat which is
metabolically less active

22. KWASHIORKOR
Edema, pot belly, swollen
legs
Mild to moderate growth
retardation
Low subcutaneous fat
Muscle atrophy
Round face (moon face)
Thin dry easily plucked
hair
Enlarged liver
Xerophthalmia
Anemia, diarrhea,
infection
MARASMUS
 No edema
 Weight loss upto 40%
 Severe growth failure
 Severe loss of subacute
fat
 Severe muscle atrophy
 Wrinkled face (old man’s
face)
 Rare skin changes
 Common hair changes
 Mildly enlarged liver
 Anemia, diarrhea,
infection

23. PREVENTION
• Oral rehydration therapy helps to prevent
dehydration caused by diarrhea
• Exclusive breast feeding for 6 months there after
supplementary foods may be introduced along with
breast feeds
• Immunization for infants and children
• Nutritional supplements
• Early diagnosis and treatment
• Promotion and correction of feeding practices
• Family planning and spacing of birth
• Periodic surveillance
• Nutritional rehabilitation

24. SEVERE ACUTE MALNUTRITION
•Severe acute malnutrition (SAM) results from
insufficient energy (kilocalories), fat, protein and/or
other nutrients (vitamins and minerals, etc.) to cover
individual needs.
•SAM is frequently associated with medical
complications due to metabolic disturbances and
compromised immunity. It is a major cause of morbidity
and mortality in children globally.

25. CHILDREN OVER 6 MONTHS OF AGE
The two principal forms of SAM are:
In marasmus:
Skeletal appearance resulting from significant loss of
muscle mass and subcutaneous fat.
In kwashiorkor:
• Bilateral edema of the lower limbs sometimes
extending to other parts of the body (e.g. arms and
hands, face).
• Discolored, brittle hair; shiny skin which may crack,
weep, and become infected.

26. The two forms may be associated (marasmus – kwashiorkor).
• In addition to these characteristic signs, SAM is
accompanied by significant physiopathological disorders
(metabolic disturbances, anemia, compromised immunity,
leading to susceptibility to infections often difficult to
diagnosis.)
• Complications are frequent and potentially life – threatening.
• Mortality rates may be elevated in the absence of appropriate
medical management. - Cont;

27. • Admission and discharge criteria for treatment programs for
SAM are both anthropometric and clinical:
Mid-upper arm circumference (MUAC) measures the
degree of muscle wasting. MUAC < 115 mm indicates
SAM and significant mortality risk.
Weight-for-height z-score (WHZ) indicates the degree of
weight loss by comparing the weight of the child with the
median weight of non-malnourished children of the same
height and sex. SAM is defined as WHZ < –3 with reference
to the WHO Child Growth Standards.

28. Cont;
•The presence of bilateral pitting edema of the lower
limbs (when other causes of edema have been ruled out)
indicates SAM, regardless of MUAC and WHZ.
•Usual admission criteria are – MUAC <115mm or W/H
-3 Z or presence of bilateral edema of the lower limbs.
•Usual discharge criteria are – W/H > -2 Z and absence
of bilateral edema and absence of acute medical
problems.

29. Medical complications
• Children with any of the following severe medical conditions
should receive hospital-based medical management:
• Pitting edema extending from the lower limbs up to the
face;
• Anorexia (observed during appetite test);
• Other severe complications: persistent vomiting, shock,
altered mental status, seizures, severe anemia (clinically
suspected or confirmed), persistent hypoglycemia, eye
lesions due to vitamin A deficiency, frequent or abundant
diarrhoea, dysentery, dehydration, severe malaria,
pneumonia, meningitis, sepsis, severe cutaneous infection,
fever of unknown origin, etc.
• In the absence of these conditions, children should be treated
as outpatients with regular follow-up.

30. Nutritional treatment:
•All children with SAM should receive nutritional
treatment.
•Nutritional treatment is based on the use of specialized
nutritious foods enriched with vitamins and minerals: F-
75 and F-100 therapeutic milks, and ready-to-use
therapeutic food (RUTF).
•Nutritional treatment is organized into phases:
Phase 1 (inpatient) intends to restore metabolic
functions and treat or stabilize medical complications.
Children receive F-75 therapeutic milk. This phase may
last 1 to 7 days, after which children usually enter
transition phase. Children with medical complications
generally begin with phase 1.

31.  Transition phase (inpatient) intends to ensure tolerance
of increased food intake and continued improvement of
clinical condition. Children receive F-100 therapeutic
milk and/or RUTF. This phase usually lasts 1 to 3 days,
after which children enter phase 2.
 Phase 2 (outpatient or inpatient) intends to promote
rapid weight gain and catch-up growth. Children receive
RUTF. This phase usually lasts 1 to 3 days when
inpatient, after which children are discharged for
outpatient care. Children without medical complications
enter directly into this phase as outpatients. The
outpatient component usually lasts several weeks.
•Breastfeeding should be continued in breastfed children.
•Drinking water should be given in addition to meals,
especially if the ambient temperature is high, or the child
has a fever or is receiving RUTF.

32. Routine management:
In the absence of specific medical complications, the
following routine treatments should be implemented in
both ambulatory and hospital settings.
Infections:
Measles vaccination on admission.
•Broad spectrum antibiotheraphy starting on D1
(amoxicillin PO: 50 mg/kg (max. 1 g) 2 times daily for 5
to 7 days)
Intestinal parasites:
•In transition phase or upon outpatient
admission, albendazole PO:
Children 12 to 23 months: 200 mg single dose
Children 24 months and over: 400 mg single dose

33. Management of common complications Diarrhoea and
dehydration:
•Diarrhoea is common. Therapeutic foods facilitate the
recovery of physiological function of the gastrointestinal
tract. Amoxicillin administered as part of routine
treatment reduces intestinal bacterial
overgrowth. Diarrhoea generally resolves without
additional treatment.

34. • Watery diarrhoea is sometimes related to another pathology
(otitis, pneumonia, malaria,)which should be considered.
Treat/prevent hypoglycemia with glucose immediately.
Treat /prevent hypothermia provide warm environment.
Treat/prevent dehydration maintain intake and output chart.
Correct electrolyte imbalance
Teat/prevent infection
Provide balance diet
Achieve catch – up growth.

35. NURSES ROLE TO TREAT MALNOURISHED
PATIENTS
• Treatment options vary depending on the cause of pt’s
malnutrition. The severity of malnourishment indicates
whether pt’s should be treated in a hospital or at home.
• Nurses educate patients about the nutritional content of food
and how to make healthy choices. If patients will not or cannot
eat, nurses may need to feed them intravenously.
• Nurses have a responsibility to address patient nutritional
needs by conducting screenings, performing assessments and
administering interventions

36. LOW BIRTH WEIGHT
An LBW newborn is any newborn with a birth
weight of less than 2.5 kg (including
2.499kg)regardless of gestational age.

37.  Maternal
malnutrition
 Anemia
o Illness/infections
o Short maternal
stature
o Very young age
o IUGR
o Hard physical
labor during
pregnancy
o Smoking
RISK FACTORS CAUSES

38. Prevention:
• Identification of mothers at risk – malnutrition, heavy work
load, infections, disease and high BP
• Increasing food intake of mother, supplementary feeding,
distribution of iron and folic acid tablets
• Avoidance if smoking , Improved sanitation methods
• Improving health and nutrition of young girls
• Early detection and treatment of medical disorders – DM
HTN
• Controlling infections – UTI, rubella, syphillis, malaria

39. OBESITY
INTRODUCTION
Childhood obesity is now an epidemic in India.
With 14.4 million obese children, India has the second
– highest number of obese children in the world, next to
china. The prevalence of overweight and obesity in
children is 15%.

40. DEFINITION
Childhood obesity is a serious medical condition that
affects children and adolescents. It is particularly
troubling because the extra pounds often start children
on the path to health problems that were once
considered adult problems – diabetes, high blood
pressure and high cholesterol. Childhood obesity can
also lead to poor self – esteem and depression.

41. CAUSES & RISK FACTORS
Behavioral factors:
Eating bigger portions, eating foods that are calorie - rich
but nutrient poor (junk foods),spending lots of time in front
of the television or computer, and spending too little time
doing physical activities.
Environmental factors:
Easy access to high – calorie junk foods, few opportunities
for physical activity, lack of parks and playgrounds in some
communities.

42. Genetic factors:
A child is at increased risk for obesity when at least one
parent is obese .
Medications:
Steroids, some antidepressants and others.
Medical conditions:
Genetic syndromes, such as praderwilli, and hormonal
conditions, such as hypothyroidism are among the
medical disorders that can cause obesity.

43. SYMPTOMS OF CHILDHOOD OBESITY
•Excess body fat, particularly around the waist.
•Shortness of breath when physically active, sleep apnea.
•Sweating more than usual.
•Shoring
•Trouble sleeping.
•Skin problems from moisture accumulating in the folds
of skin.
•Constipation ,gastroesophageal reflux
•Flat feet ,knock knees ,dislocated hip

44. HEALTH IMPLICATION OF CHILDHOOD
OBESITY
Obese children are at increased risk of
hypertension, osteoarthritis, high cholesterol and
triglycerides, type 2 diabetes, coronary heart disease,
stroke ,gallbladder disease, respiratory problems,
emotional disturbances, and some cancers.

45. COMPLICATIONS
Physical complications:
•Type 2 diabetes
•High cholesterol and high blood pressure
•Joint pain
•Breathing problems
•Nonalcoholic fatty liver disease

46. Social and emotional complications:
•Family eating habits
•Food advertising
•Unhealthy taste preferences
•Exposure to unhealthy food
•Availability of food
•Physical inactivity
•Increased sitting time
•Lack of fruits and vegetables
•Depression
•Skipping breakfast
•Obese parents

47. Increased risk of:
•Early onset diabetes
•Early onset heart disease
•Increased risk of lifestyle related cancers, such as
breast and colorectal cancers
•Bullying
•Depression
•Poor self esteem
•Increased risk of asthma attacks
•Early puberty
•Increased risk of death in early adulthood

48. PREVENTION
Set a good example:
Make healthy eating and regular physical activity a
family affair. Everyone will benefit and no one will feel
singled out.
Have healthy snacks available:
Options include air- popped popcorn without butter,
fruits with low – fat yogurt, baby carrots with hummus, or
whole grain cereal with low –fat milk.

49. Offer new foods multiple times:
Do not be discouraged if your child does not
immediately like a new food.it usually takes multiple
exposures to a food to gain acceptance.
Choose nonfood rewards:
Promising candy for good behavior is a bad idea.
Be sure your child gets enough sleep:
Some studies indicate that too little sleep may increase
the risk of obesity.

50. PROVEN AND SIMPLE STRATEGIES TO
PREVENT OBESITY INCLUDE
•Increase fruit and vegetable intake
•Reducing TV viewing
•Reduce sugar intake
•Encourage physical activity

51. NURSES ROLE
•Nurse can help parents and children by providing
nutritional advice and through weight management
programmes, offer strategies for decreasing caloric
intake and increasing physical activity.
•Encourage physical activity
•Encourage children to eat only when hungry. Tell them
to eat slowly.
•Don’t use food as reward.
•Nurses actions should always take a whole – family
approach because it is challenging for obese children to
alter their dietary or physical habits if not supported by
their families.

52. VITAMIN DEFICIENCY DISORDERS
Vitamin deficiency is the condition of a long – term
lack of a vitamin. when caused by not enough vitamin
intake it is classified as a primary deficiency, whereas
when due to an underlying disorder such as
malabsorption it is called as secondary deficiency.

53. VITAMIN A DEFICIENCY
Vitamin A deficiency results from a dietary intake
of vitamin A that is inadequate to satisfy
physiological needs. It may be exacerbated by high
rates of infection, especially diarrhea and measles. It
is common in developing countries, but rarely seen in
developed countries.

54. CAUSES OF VITAMIN A DEFICIENCY
Vitamin A deficiency may be caused by prolonged inadequate
intake of vitamin A .this is especially so when rice is the main
food in your diet.(rice does not contain any carotene).this may
occur in a variety of illnesses, including.
Celiac disease, Crohn’s disease ,Cystic fibrosis, Liver
cirrhosis , Disease affecting the pancreas, Giardiasis –(an
infection of the gut),Obstruction of the flow of bile from your
liver and gallbladder into your gut.

55. DEFICIENCIES
Blindness :
This causes you to have trouble seeing in low light.it
will eventually lead to complete blindness.
Xerophthalmia:
The eyes may become very dry and crusted, which may
damage the cornea and retina.
Infection:
Vitamin A deficiency can experience more frequent
health concerns as they will not be able to fight off
infections as easily.

56. Bitot spots:
This condition is a buildup of keratin in the eyes, causing hazy
vision.
Skin irritation
Keratomalacia:
This is an eye disorder involving drying and clouding of the
cornea – the clear layer in front of the iris and pupil.
Keratinization:
Stunted growth
Fertility

57. SIGNS AND SYMPTOMS

58. PREVENTION & TREATMENT
The best way to prevent vitamin A deficiency is to eat a
healthy diet that includes foods that contain vitamin A.
Vitamin A can be found naturally in:
• Green vegetables, such as leafy greens and broccoli.
• Orange and yellow vegetables, such as carrots, pumpkin,
sweet potatoes and squash.
• Orange and yellow fruits, such as oranges, mangos,
cantaloupe and papayas.
• Dairy products, Liver, beef and chicken.
• Certain types of fish, such as salmon, Eggs.
• Cereals, rice potatoes, wheat and soybeans fortified with
vitamin A.
• Vitamin supplementation given.

59. VITAMIN D DEFICIENCY
Vitamin D plays a significant role in keeping our
bones healthy, reducing anxiety and improving immune
function.it also helps in regulating the absorption of
calcium and phosphorous in the body, leading to the
normal growth and development of bones and teeth.

60. CAUSES VITAMIN D DEFICIENCY
Vit D caused specific medical conditions, such as:
Cystic fibrosis,crohn’s disease& celiac disease:
These diseases do not allow the intestines to absorb enough
vitamin D through supplements.
Weight loss surgeries:
Weight loss surgeries that reduce the size of the stomach and
/ or bypass part of the small intestines make it very difficult to
consume sufficient quantities of certain nutrients, vitamins,
and minerals.

61. Obesity:
Obesity often makes it necessary to take larger doses of
vitamin D supplements in order to reach and maintain
normal D levels.
Kidney and liver diseases:
These diseases reduce the amount of an enzyme needed
to change vitamin D to a form that is used in the body.
lack of this enzyme leads to an inadequate level of active
vitamin D in the body.

62. VITAMIN D DEFICIENCY LEADS TO MANY
HEALTH ISSUES
•Muscle weakness or spasm
•Mild to severe body pain
•Pain in muscles or bones
•Difficult to climb stairs or getting up from the floor
•Stress fractures
•Fatigue
•Feels depressed
•Weight gain
•Gut disturbances

63. Rickets:
Its mainly occur in children between 6 months and 2
years. It causes softening and weakening of bones and in
children, usually due to extreme and prolonged vitamin d
deficiency. Rare inherited problems like malabsorption
syndromes(celiac disease) also can cause rickets as the
inability of the intestines to adequately absorb nutrients
from foods.

64. CLINICAL MANIFESTATIONS
Signs and symptoms of rickets can include:
• Delayed growth
• Delayed motor skills
• Pain in the spine, pelvis and legs
• General body pain
• Muscle weakness
• Excessive tiredness
• Irritability
• Bowed legs or knock knees
• Thickened wrists and ankles
• Pelvic deformities.

65. Osteomalacia :
It is softening of the bones due to a lack of vitamin D
or a problem with the body’s ability to break down
and use this vitamin.
Symptoms:
•Hypocalcemia
•Muscle weakness
•Bone pain

66. •Skeletal deformities
•Dental problems
•Poor growth and development
•Fragile bones
•Bone fracture and injury
•Spasms of hands or feet
•Numbness of arms and legs

67. DIET MANAGEMENT
• Cod liver oil: 34.0 mcg (1,360 IU)/1 tbsp – 170% DV
• Trout (rainbow), farmed, cooked: 16.2 mcg (645 IU)/3oz
– 81% DV
• Salmon (sockeye), cooked: 14.2 mcg (570 IU)/3 oz – 71%
DV
• Mushrooms, white, raw, sliced, exposed to UV light: 9.2
mcg (366 IU)/ ½ cup – 46% DV
• Milk, 2% milkfat, vitamin D fortified: 2.9 mcg (120 IU)/1
cup – 15% DV
• Soy, almond, and oat milks, vitamin D fortified, various
brands: 2.5-3.6 mcg (100-144 IU)/1 cup – 13-18% DV
• Ready-to-eat cereal, fortified with vitamin D: 2.0 mcg (80
IU)/1 serving – 10% DV
• Sardines (Atlantic), canned in oil, drained: 1.2 mcg (46
IU)/2 sardines – 6% DV

68. Cont;
•Egg, scrambled**: 1.1 mcg (44 IU)/1 large – 6%
DV
•Liver, beef, braised: 1.0 mcg (42 IU)/3 oz – 5% DV
•Tuna fish (light), canned in water, drained: 1.0
mcg (40 IU)/ 3 oz – 5% DV
•Cheese, cheddar: 0.3 mcg (12 IU)/1 oz – 2% DV
•Mushrooms, portabella, raw, diced: 0.1 mcg (4
IU)/½ cup – 1% DV
•Chicken breast, roasted: 0.1 mcg (4 IU)/3 oz 1%
DV
•Beef, ground, 90% lean, boiled: 0 mcg (1.7 IU)/3 oz
– 0% DV (3).

69. MANAGEMENT OF VITAMIN D
DEFICIENCY
The amount of vitamin D required to treat the deficiency
depends largely on the degree of the deficiency and
underlying risk factors.
• Initial supplementation for 8 weeks with vitamin D3 either
6,000 IU daily or 50,000 IU weekly can be considered.
Once the serum 25 – hydroxyvitamin D level exceeds
30mg/mL ,a daily maintenance dose of 1,000 to 2,000 IU is
recommended. -Cont;

70. • A higher dose initial supplementation with VD3 at 10000 IU
daily may be needed in high risk adults who are vitamin D
deficient.
• Once serum 25 – hydroxyvitamin D level exceeds 30 ng
/mL,3,000 to 6,000 IU/ day maintenance dose is
recommended.
• Children who are Vit D deficient require 2,000 IU / day of
vitamin D3 or 5,000 IU of vitamin D3 once weekly for 6
weeks.
• Calcidiol can be considered in patients with fat malabsorption
or severe liver disease.

71. PREVENTION
•Maintaining a healthy body weight
•Treating medical conditions
•Being proactive about preventive health

72. VITAMIN C
Vitamin c cannot be made by the human body and
so is an essential component of the diet. It is needed
for the health and repair of various tissues in your
body, including skin, bone, teeth and cartilage.

73. CAUSES OF VITAMIN C
• Primary causes is imbalanced diet.
• A diet lacking vitamin C- rich fresh vegetables and fruits.
• A restrictive diet due to health conditions ,such as weak
digestive system, allergies, etc.
• Mental health issues and other disorders, such as anorexia
• Old age.
Some other causes of vitamin C
• Ulcerative colitis

74. •Intake of illegal drugs and high amounts of alcohol
•Chemotherapy
•Crohn’s disease
•Smoking
•Hyperthyroidism
•Pregnancy
•Surgery
•Prolonged diarrhea

75. DISEASES CAUSED DUE TO VITAMIN C
DEFICIENCY
The deficiency of vitamin C causes scurvy. Scurvy is
characterized by the following symptoms:
•Gingivitis or gum disease
•Loss of teeth
•Skin problems
•Anemia
•Weak immunity
•Shortness of breath
•Corkscrew hairs

76. In the long run, lack of vitamin c causes untreated
scurvy ,which can be life threatening and may lead to the
following conditions.
•Severe jaundice
•Neuropathy
•Hemolysis or destruction of RBCs
•Generalized edema
•Scurvy affect the fetal brain development

77. SYMPTOMS OF VITAMIN C DEFICIENCY
•Weakness ,fatigue or irritability
•Loss of appetite or weight loss
•Muscle pain, sunken eyes
•Pallor, diarrhoea
•Increased heart rate & shortness of breath
•Fever ,decreased ability to fight infection
•As deficiency continues, it can lead to joint pain and
poor wound healing
•Swelling in joints or gums
•Reopening of old wounds

78. TESTS FOR VITAMIN C DEFICIENCY
A blood test:
It is a simple yet effective way to test vitamin C
deficiency.
An iron deficiency test:
It can confirm low iron (or anemia)which is a
symptom of vitamin C deficiency
An X – ray test:
It can detect low bone density which is a strong
indication of vitamin C deficiency.

79. SIDE EFFECTS OF VITAMIN C
DEFICIENCY
•Bleeding from nose and gums
•Subperiosteal hemorrhage or bleeding between
joints
•Loose teeth
•Improper and delayed wound healing
•Weak bones
•Fever
•Nerve problems
•Shortness of breath
•Convulsions

80. TREATMENT & PREVENTION FOR
VITAMIN C DEFICIENCY
Treatment:
•Intake of foods rich in vitamin
•Through vitamin C supplements
Prevention:
The best and easiest way to prevent vitamin C
deficiency is by increasing intake of foods rich in the
vitamins.
•75g orally once a day for women
•90 g orally once a day for men
•An additional 35 mg/day for smokers.

81. VITAMIN B1 THIAMIN DEFICIENCIES
Wet beriberi:
It is characterized by cardiovascular manifestations
including edema of legs, face, trunk and serous cavities,
with breathlessness and palpitations, along with increase in
systolic and decrease in diastolic blood pressure.
Dry beriberi:
It is associated with neurological manifestations resulting
in peripheral neuritis, with progressive weakening in
muscles resulting in difficulty to walk.

82. Infantile beriberi:
It is seen in infants born to mothers suffering from
thiamine deficiency, characterized by sleeplessness,
restlessness, vomiting, convulsions and bouts of
screaming, these are due to cardiac dilatation.
Wernicke's Korasakoff Syndrome:
A kind of encephalopathy, which refers to damage or
disease that affects the brain. Extensive damage to parts
of the brain, particularly the thalamus and hypothalamus,
may cause severe confusion and memory loss, one of the
main signs of Korsakoff syndrome.

83. SYMPTOMS
• B1 deficiency is seen in populations consuming polished rice
as staple food.
• The deficiency of vitamin B1 results in a condition called
beriberi.
• The early symptoms of thiamine deficiency are loss of
appetite (anorexia), weakness, constipation, nausea, mental
depression, peripheral neuropathy, irritability etc.
• In adults, two types of beriberi, namely wet and dry beriberi
occur. Infantile type of beriberi is also seen.

84. TREATMENT
Thiamin deficiency can be treated with b – complex
vitamins rather than thiamin alone. Along with B –
Complex vitamins, a high – calorie and high – protein
diet is prescribed.

85. VITAMIN B2 RIBOFLAVIN
•Riboflavin deficiency also termed as ariboflavinosis
causes stomatitis including painful red tongue with sore
throat, red chapped, and fissured lips (also called
cheilosis), and inflammation of the corners of the mouth
(i.e. angular stomatitis), inflammation of the tongue,
mouth ulcers and cracks at the corner of the mouth (i.e.
angular cheilitis).
•Generally, a diet lacking this potent nutrient may cause
bloodshot eyes, high sensitivity to light, a burning
sensation in the eyes or itchy, watery eyes, split nails,
dry or oily hair, dandruff, indigestion, dizziness,
insomnia, etc.

86. Cont;
•Lack of riboflavin in the diet causes malfunctioning of
the adrenal glands leading to conditions like anemia,
cataract, and chronic fatigue syndrome. It can also lead
to scaly skin rashes on the male and female genitals,
rashes on the medial cleft of the upper lip or the smile
lines connecting the nose and chin (i.e. nasolabial fold).
•A diet deficient in this B vitamin for a pregnant woman
can also cause birth defects, congenital cardiac defects
and abnormal limbs and deformities in the foetus. It can
also lead to pellagra or malaria in adults. If the
symptoms of riboflavin deficiencies are not met with
for a long time period, it may also lead to degeneration
of the liver and neural system.

87. TREATMENT /MANAGEMENT
Riboflavin supplements come in 25 mg,50mg,and 100mg
tablets. According to the national Institutes of health, the
recommended daily nutrient intake of riboflavin is 1.3mg
for men,1.1 mg for women,1.3 mg for male adolescents
and 1.0mg for female adolescents. Recommendations are
that pregnant women take 1.4 mg, and breastfeeding
women take 1.6 m.g.

88. NIACIN
Niacin deficiency is called pellagra, meaning dry skin and
deficiency mainly affects skin, nervous system and digestive
system.
The major symptoms are pigmented rash on skin, exposed
to the sun
• Rough appearance to the skin
• Bright red tongue
• Fatigue or apathy
• Vomiting, constipation and diarrhea
• Circulatory problems
• Depression/ disorientation
• Headache
• In severe cases, hallucination

89. TYPES OF PELLAGRA
•Pellagra is characterized by 4 “D”s : diarrhoea
dermatitis, dementia and death
•There are 2 types:
•Primary pellagra and secondary pellagra.
Primary pellagra:
It is caused by intake of diets very low in niacin or
tryptophan. tryptophan can be converted to niacin in the
body, so not getting enough can cause niacin deficiency.

90. Secondary pellagra:
It occurs when the body can’t absorb niacin due to
certain conditions which prevent absorbing niacin
from body such as alcoholism, eating disorders,
certain medications, including anti – convulsants and
immunosuppressive drugs, gastrointestinal diseases,
such as crohn’s disease and ulcerative colitis,
cirrhosis of the liver, carcinoid tumors.

91. MANAGEMENT
Oral dose of 100mg twice a day for 3-4 weeks or till
symptoms subsides. Advice them to take niacin rich
food along with oral drugs.

92. PYRIDOXIN VITAMIN B6
Vitamin B6 is one of the central molecules in the
cells of living organisms. water – soluble vitamin B6
is widely present in many foods, including meat, fish,
nuts, beans, grains, fruits and vegetables.

93. DEFICIENCY MANIFESTATIONS
• Cracked and sore lips
• Sore, glossy tongue
• Skin rashes
• Nervousness, irritability
• Peripheral neuritis
• Mood changes, Seizures
• Weakened immune functions
• Tiredness and low energy
• Tingling and pain in hands and feet
• Insomnia, anemia, mental depression

94. TREATMENT
•The vitamin Is available therapeutically in both oral
and parenteral formulations
•Neonates with B6 deficiency seizures may require 10 to
100 mg intravenous (IV) for effective treatment of
active seizures. less serious or less acute presentations
can be supplemented with doses ranging from 25mg to
600 mg per day orally depending on symptom
complex.

95. • Importantly, vitamin B6 therapy can be life-saving in
refractory INH overdose – induced seizures.
• The dose is equal to the known amount of INH ingested or a
maximum of 5 g and is dosed 1 to 4 g IV as the first dose,
then 1 g IM or IV every 30 minutes.
• In ethylene glycol overdose, vitamin B6 is recommended at
50 to 100 mg IV every 6 hours to facilitate shunting the
metabolism of ethylene glycol to nontoxic pathways leading
to glycine instead of toxic pathways leading to toxic
metabolites’ such as formate.

96. PANTOTHENIC ACID(VITAMIN B5)
•Vitamin B5 deficiency is rare, but may include
symptoms, such as fatigue, insomnia, depression
,irritability, vomiting stomach pains, burning feet,
and upper respiratory infections.
•Vitamin B5 is a medication used in the management
and treatment of nutrient deficiencies.it is in the
dietary supplement class of medications.

97. BIOTIN(VITAMIN B7)
•Common symptoms appearing with a biotin
deficiency are,
•Thinning hair, scaly skin rashes around eyes, nose
and mouth, brittle nails, dermatitis, ataxia, seizures,
conjunctivitis.

98. FOLIC ACID(VITAMIN B9)
•Megaloblastic anemia
During pregnancy, folate deficiency increases the risk
of congenital irregularities.
Some symptoms of folate deficiency(MGA)are:
•Weakness
•Fatigue, trouble concentrating
•Headache
•Irritability
•Heart palpation
•Sore on the tongue and inside the mouth
•Shortness of breath.

99. CYANOCOBALAMIN(VITAMIN B12)
Deficiency manifestations:
•Most important is pernicious anemia.
•Characterized by low hemoglobin levels.
•Decreased number of erythrocytes.
•Neurological manifestations.
•Degeneration of myelin sheath and peripheral nerves
also occurs
Oral manifestation:
•Beefy red tongue – with glosopyrosis, glossitis and
glossodynia.
•Hunter’s glossitis or Moeller’s glossitis – which is
similar to “bald tongue of sand with seen in
pellagra”.

100. CALCIUM
Calcium is the most abundant mineral in the human body
and helps in the formation and maintenance of strong bones
and teeth. Blood calcium level is regulated by vitamin D and
several hormones, including parathyroid hormone,
thyrocalcitonin, and cortisol that control absorption,
excretion and bone turnover of calcium. Old age and
inadequate calcium in the diet can lead to calcium deficiency,
also known as hypocalcemia.

101. SYMPTOMS
•Muscle pain, spasms and twitching
•Tingling in fingers, toes and face
•Fragile bones prone to fractures
•Brittle nails
•Coarse hair
•Pale and dry scaly skin
•Tooth decay
•Loss of memory
•Confusion
•Insomnia

102. DIAGNOSIS & TRAETMENT
Diagnosis:
Diagnosis is carried out by blood testing. The test is designed
to measure total calcium. Abnormal levels of total calcium
indicate an underlying problem, in which case other tests
including ionized calcium and urine calcium may also be
required.
Treatment:
Calcium carbonate supplements at a dose of 600 mg/day for
adults.

103. IODINE
Iodine is an essential trace element in the diet
responsible for the production thyroid hormones. Iodine
deficiency can cause pregnancy-related complications.
Deficiency Symptoms:
•Lethargy, muscular weakness, and chronic fatigue
•Unusual weight gain
•Hair loss
•Puffy face
•Mental retardation (in infants and children whose
mothers were iodine deficient during pregnancy)

104. Diagnosis:
Iodine deficiency is generally not measured in
individual patients, but only in case of population-
based studies. Indirect diagnosis is made based on its
effect on thyroid function. Clinical observation of
any enlargement of the thyroid gland (goiter) is
indicative of iodine deficiency. A definitive diagnosis
of hypothyroidism can be made by laboratory tests
that measure the levels of thyroxine
(T4),triiodothyronine (T3) and thyroid stimulating
hormone (TSH).

105. Treatment:
•Regular use of iodized table salt.
•Administration of multivitamin tablets containing at
least 250 µg of iodine to pregnant women.
•In case of hypothyroidism, daily oral administration
of thyroxine.

106. IRON
Iron is an essential mineral that is a component
of hemoglobin, the red pigment of red blood cells
(RBC), responsible for the transport of oxygen in the
blood. It is also involved in cellular respiration as a
component of the enzyme complex cytochrome P450.
Iron deficiency is characterized by a sharp fall in
hemoglobin levels.

107. Deficiency Symptoms:
•Anemia
•Exhaustion
•Shortness of breath
•Restless leg syndrome
•Headache
•Anxiety
•Hair loss

108. Diagnosis:
Clinical examination can give indications that the
patient is suffering from iron deficiency. A complete blood
count (CBC) revealing sub-optimal levels of hemoglobin
(<7-8 g/dl) is a confirmatory test. The level of iron stores
can be assessed by a ferritin test. The total iron-binding
capacity (TIBC) indirectly measures the levels
of transferrin, a protein that iron attaches itself to help in
moving around in the blood.
Treatment:
The standard treatment for iron deficiency is oral
supplementation with iron. This should be taken on an
empty stomach. As vitamin C increases the absorption of
iron, the iron tablet can be taken with a glass of orange or
lime juice.

109. MAGNESIUM
Magnesium is a very important mineral that is
an essential co-factor for many enzyme-catalyzed
biochemical reactions in the body. It is required for normal
functioning of the musculoskeletal, nervous, and immune
systems.
Deficiency Symptoms:
•Since magnesium deficiency can occur in conjunction
with calcium and potassium deficiency, the latter should
be kept in mind while assessing the symptoms.
•Muscle cramps and spasms
•Irregular heart-beats (arrhythmia)
•Weakness

110. Cont;
•Seizures
•Confusion
•Anxiety
•Twitching
Diagnosis:
Magnesium testing should be considered when the
levels of calcium and potassium are persistently low, or
when there are deficiency symptoms. A test result
indicating low magnesium level signifies either
inadequate dietary intake or excessive excretion.
Therefore, the corresponding diseases impacting these
parameters should be kept in mind in the differential
diagnosis.

111. Treatment:
Magnesium supplementation remains the mainstay
of treatment. Magnesium salts of oxalate or
gluconate can be administered orally. In case of severe
deficiency, parenteral route may be considered with
regular monitoring.

112. MANGANESE
Manganese is a micronutrient that is a component of
several enzyme complexes and helps in various metabolic
functions. It is required for the metabolism of carbohydrates,
amino acids, and cholesterol, and in the formation of bones,
connective tissues, sex hormones and clotting factors. It also
helps to maintain normal brain function and blood sugar
levels. It facilitates calcium absorption and wound healing. It
also has an antioxidant function.

113. Deficiency Symptoms:
•Impaired growth
•Impaired reproductive function
•Impaired glucose tolerance
•Skeletal abnormalities
•Altered carbohydrate and lipid metabolism

114. Diagnosis:
Manganese deficiency can be detected by testing the
blood or serum. The analysis is carried out using an
automated equipment such as an inductively coupled
plasma-mass spectrometer.
Treatment:
Treatment relies upon oral multivitamin / mineral
supplementation.

115. PHOSPHOROUS
Phosphorus is a very important mineral that is essential
for the development and maintenance of teeth and bones. It
is the second most abundant mineral in the human body and
is essential for making proteins for the growth, maintenance,
and repair of cells and tissues. It is also required for muscle
contraction and nerve impulse conduction. It is an essential
component of deoxyribonucleic acid (DNA) and ribonucleic
acid (RNA), and adenosine triphosphate (ATP).

116. Deficiency symptoms:
• Excessive fatigue / weakness
• Loss of appetite
• Irritability
• Numb / burning / tingling sensation in extremities
• Diffuse bone pain
• Joint pain / swelling / stiffness
• Susceptibility to dental cavities
• Brittle hair and nails

117. Diagnosis:
A diagnosis is based on a blood test if the physician
suspects that there is a deficiency, or in conjunction with
abnormal levels of calcium. The test provides information
about the phosphorus level status in the blood, but in order
to diagnose the underlying disease condition, other tests
are warranted.
Treatment:
Phosphorus deficiency can be treated by taking
adequate amounts (recommended daily allowance of 1200
mg for adults, both male and female, and 800 mg for
children) in the form of supplements and multivitamins.

118. POTASSIUM
Potassium is essential for the proper functioning of
cells, tissues and organs. Being an electrolyte,
potassium, along with sodium, is required
for maintaining the membrane potential of cells, as well
as regulation of acid-base balance in the body. It is
essential for the electrical activity of the heart and is also
involved in skeletal and smooth muscle contraction and
for optimal nerve activity.

119. Deficiency Symptoms:
•Hypertension
•Congestive heart failure
•Nausea and vomiting
•Tingling and numbness
•Abdominal cramps and bloating
•Constipation
•Cardiac arrhythmia
•Muscle cramps, fatigue and weakness
•Depression and other mood changes

120. Diagnosis:
Abnormalities in potassium levels can be
determined by a blood test. This can detect both
potassium deficiency (hypokalemia) and potassium
elevation (hyperkalemia). This test is especially used to
monitor kidney failure patients undergoing
hemodialysis.
Treatment:
Potassium supplementation is recommended only
under medical supervision. Children, especially should
not be given potassium supplementation until
prescribed by a medical practitioner. Generally, these
supplements are available as potassium salts of acetate,
gluconate, bicarbonate, citrate, and chloride.

121. SELENIUM
Selenium is a trace element and is required in small
amounts for maintenance of health. As an essential
component of enzymes, it acts as an antioxidant and
catalyzes the production of active thyroid hormones. It
is also required in the maintenance of optimal immune
functions.

122. Deficiency Symptoms:
•Memory lapses / sluggish memory and difficulty
concentrating
•Lowered immunity (increased susceptibility to
infections)
•Hair fall
•Discoloration of skin and nails
•Tiredness and fatigue
•Infertility / recurrent miscarriage
•Poor wound healing

123. Cont;
Diagnosis:
A definitive diagnosis can be made based on a blood
test, which measures the level of selenium in the blood.
Treatment:
Selenium deficiency can be corrected by selenium
supplementation, which is available in combination as
multivitamin / multimineral formulations, or by itself in
the form of selenomethionine or as sodium
selenite or sodium selenate. Importantly, the bio-
availability of selenomethionine is much higher (~90%)
than the selenite or selenate forms.

124. SODIUM
Sodium is an essential element of the human body
and the most common form of it is table salt (sodium
chloride). Sodium is required for regulating blood
pressure and for maintaining fluid balance. It is also
essential for nerve impulse conduction and muscle
contraction.

125. Deficiency Symptoms:
Sodium deficiency leads to lowering of the level of
sodium in the blood (hyponatremia), which occurs in
certain disease conditions like kidney failure and in some
types of cancer. The main symptoms of sodium
deficiency are given below:
•Fatigue and lethargy
•Confusion
•Muscle cramps / spasms
•Headache
•Nausea and vomiting
•Dizziness,Seizure and coma (in severe cases)

126. Diagnosis:
Sodium deficiency can be suspected if the patient
presents with prolonged vomiting or profuse sweating.
However, a definitive diagnosis can only be made
based upon a blood test that measures the level of
sodium ions (Na+) in the serum.
Treatment:
Treatment usually involves adjustment in diet and
lifestyle. In severe cases of hyponatremia, fluids and
electrolytes need to be administered intravenously.
Medications may also be needed to treat the underlying
cause of hyponatremia as well as to manage the
symptoms.

127. ZINC
Zinc is an important trace element that is required for
optimal immune function, growth and repair, hormone
production, wound healing, and acts as an antioxidant.
Deficiency Symptoms:
• Impaired neurological function
• Impaired immunity
• Growth retardation
• Food allergy
• Diarrhea
• Gastrointestinal problems (abdominal pain, diarrhea,
anorexia, glossitis)
• Skin problems (alopecia, dermatitis, acne, stomatitis)
• Hormone imbalances

128. Diagnosis:
Zinc deficiency can be diagnosed by conducting a blood
test, which measures its level in the serum or plasma. The
test is important because zinc is not stored in the body and
can fluctuate with time, so it must be measured directly as
and when required.
Treatment:
Zinc deficiency can be treated by multivitamin
supplements in which the element may be present as
gluconate, acetate or sulfate.

129. In many
parts of the world where
drinking water contains
excessive amounts of
fluorine (3-5mg/L),
endemic fluorosis has been
observed.

130. • It occurs when excess fluoride is
ingested during the years of tooth
calcification – first 7 years of life
• Characterized by molting of dental
enamel which has been reported
above 1.5mg/L intake
• Fluorosis seen on the incisors of
upper jaw

131. • Associated with life time
daily intake of 3-6mg/L or
more
• Heavy deposition of
fluoride in skeleton
• Crippling occurs leading to
disability

132. PREVENTION:
• Changing the water sources
• Chemical defluorination
• Preventing use of fluoridated toothpaste
• Fluoride supplements not prescribed for children
consuming fluoridated water

133. • It is a paralyzing disease of
human and animals it also
referred to as neurolathyrism as
it affects the nervous system.
• lathyrus sativus is commonly
known as ‘khesari dhal’, a good
source of protein but its toxins
affects the nerves
• the toxin present in lathyrus seed
has been identified as beta oxalyl
amino alanine (BOAA) which has
blood brain barrier
LATHYRISM

135. • It is an eating disorder
characterized by
immoderate food
restriction,
inappropriate eating
habits or rituals,
obsession with having
a thin figure, and an
irrational fear of
weight gain, as well as
a distorted body self-
perception.

136. • Bulimia nervosa is an eating
disorder characterized by binge
eating and purging, or consuming a
large amount of food in a short
amount of time followed by an
attempt to rid oneself of the food
consumed (purging), typically
by vomiting, taking
a laxative, diuretic, or stimulant,
and/or excessive exercise, because
of an extensive concern for body
weight.

137. CONCLUSION
Nutrition disorders are diseases that occur when a
person’s dietary intake does not contain the right amount
of nutrients for healthy functioning, or when a person
cannot correctly absorb nutrients from food. Nutritional
deficiency occurs when the body is not getting enough
nutrients such as vitamins and minerals. A well balanced
diet is required for the normal growth and development of
an individual.

138. THANKYOU