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Nutrients

  1. Macronutrients -
    1. Proteins
    2. Fats
    3. Carbohydrates
  2. Micronutrients -
    1. Vitamins
    2. Minerals

Macronutrients

Energy/ gram

%age requirement in balanced diet

Protein

4 cal/gm

7-15

Carbohydrate

4 cal/ gm

65-80

Fat

9 cal/ gm

10-30

 

Recommended Energy requirement:-Revised Guidelines for the Indian Population

Adult male:- Ref. Body Wt: 60 Kg

  1. For light work : 2320 K Cal
  2. Moderate work: 2730 K Cal
  3. Heavy Work : 3490 K Cal
Adult female:- Ref. Body Wt: 55 Kg
  1. For light work : 1900 K Cal
  2. Moderate work: 2230 K Cal
  3. Heavy Work : 2850 K Cal
Extra Energy:-
  1. Pregnancy : 2nd & 3rd Trimester + 350 K Cal
  2. Lactation : First 6 Months  + 600  K Cal
  3. Lactation : 6-12 Months +520 K Cal


Recommended Daily Energy and protein intake

 

Group

Energy

Protein

Infancy

0-6 months

7-12 months

 

92 Kcal /kg/day

80 kcal/kg/day

2.3 g /kg/day (0-3 months)

1.8 g/kg/day (3-6 months)

1.65 g/kg/day (6-9 months)

1.5 g/kg/day (9-12 months)

Pregnancy

+ 350

+15 g/day

Lactation

First 6 months

6-12 months

 

+600

+520

 

+25 g/day

  1. Proteins:
    1. Important Points
      1. constitute 20 % of body wt
      2. 9 Essential amino acids (EAA): Methionine, Threonine, Tryptophan, Valine, Isoleucine, Leucine, Phenylalanine, histidine and Lysine.
      3. Foods containing all EAA: Milk, meat, egg, cheese, fish and fowl.
      4. Reference Protein: Egg
      5. Main source of proteins in Indian diet: Cereals and pulses.
      6. Limiting amino acid in cereals: lysine and Threonine
                                                       Pulses: Methionine
      7. Protein efficiency ratio :- Is the weight gain per unit volume of protein consumed.
      8. Digestible coefficient of proetins:- is the % of N2 retained out of N2 absorbed from the diet.
      9. Biological value of proetins:- the % of N2 absorbed in the body from proteins consumed.
      10. Best method to compare the protein quality is by Biological value.
      11. In calculating the protein quality, 1 gm of protein is assumed to be equivalent to 6.25 gms of Nitrogen.
      12. Net protein utilization (NPU):
        Biological value X Digestibility co-efficient      (AIIMS Nov’08)
                                    100

        NPU= Nitrogen retained by body x 100
                            Nitrogen intake
        Proportion of ingested protein that is retained in the body under specific conditions for the
        maintenance and growth of tissue.
        NPU for egg: 96 and NPU for pulses: 65
        More complete expression of protein quality than amino acid score.
        NPU for Indian diet varies b/w 50-80.
      13. Amino Acid Score:
        measure of concentration of amino acid in test protein.
        =  No. of mg of one Amino acid per gm of protein x 100
        No. of mg of the same amino acid per gram of egg protein
        1. Amino acid score for starch: 50-60 and for animal foods: 70-80.
      14. Assessment of protein quantity by Protein Energy Ratio:
        Protein Energy Ratio/ percentage= Energy from protein X 100
                                                                
        Total energy in diet
        What % of energy value is supplied by protein content
      15. Assessment of Protein Nutrition status
        1. Serum albumin concentration > 3.5 g/dl (normal)
                                                      1.5 g/dl –mild malnutrition
                                                      < 3 g/dl- severe malnutrition
        2. Mid-arm circumference
        3. Creatinine Height Index
        4.  Total Body Nitrogen
      16. Protein requirement

Group

Protein Required
(Gms/Kg)

Group

Protein Requirement
(Gms/Kg)

InFants

0-3 Months

3-6 ``

6-9 ``

9-12 ``

 

2.30

1.80

1.65

1.50

AdolesCent

10-12

13-15

16-18

 

1.83

1.56

1.35

Children

1-3 years

4-6

6-9

 

1.24

1.10

0.90

Pregnancy

 

 

Lactation

1.00 (+15 GMS)

 

 

1.00 (+ 25 GMS)

  1. Protein energy malnutrition (PEM)
    1. Incidence in preschool children is around 1-2%. Affects weaklings and children in the first year of life.
    2. Gomez classification: It compares the weight of a child with a normal child of the same age. The ‘normal’ reference child is in the 50th percentile of Boston standards. It is as follows:
      1. 90 – 110% of normal: normal nutritional status
      2. 75 – 89% of normal: 1st degree, mild malnutrition
      3. 60 – 74% of normal: 2nd degree, moderate malnutrition
      4. Under 60% of normal: 3rd degree, severe malnutrition
    3. Mclaren’s classification: it uses height as the measuring criteria
      1. 93% height for expected age – Normal
      2. 80 – 93% height for expected age – Short
      3. < 80% height for expected age – Dwarf
    4. Water low’s classification: it combines height for age (H/A) and weight for height (W/H)
      1. H/A (Stunting)                  W/H (Wasting)
      2. Normal >=95%                Normal >90%
      3. Mild – 87.5 – 95%             Mild – 80 – 90%
      4. Moderate – 80 – 87.5%     Moderate – 70 – 80%
      5. Severe - <80%                 Severe - <70%

W/H →
H/A

> Mean-2SD

< Mean-2SD

> Mean-2SD

Normal

Wasted

<Mean-2SD

Stunted

Wasted & stunted

  1. Childhood Nutritional Indicators
    1. Stunting (Height for age): 2SD below the mean of the population are considered stunted. Indicates chronic malnutrition; also known as indicator of duration of malnutrition.
    2. Wasting (weight for height): 2SD below the mean of the reference population are considered wasted; indicates acute or recent malnutrition; also known as indicator of severity of malnutrition.
    3. Underweight: indicates both acute and chronic malnutrition.
    4. NFHS III: children <3 yrs: Stunted: 44.9%; Wasted: 22.9%; Underweight: 40.4%.
    5. Common to both acute & chronic malnutrition is Weight for age.
  2. Rapid Assessment of Malnutrition
    1. Bangle test: 4cm diameter.
    2. Quac stick: Measures malnutrition by comparing MAC with height.
    3. Shakir’s tape: useful field instrument for 1-5 yrs ( MAC remains practically unchanged during this period.
  1. PEM Clinical Features:-

Features

Marasmus

Kwashiorkor

Clinical (Always present)

 

 

Muscle wasting

Obvious

Sometimes hidden by fat & oedma

Oedma

None

Present mainly in lower limb, face

Mental changes

Quite & apathetic

Irritable , moaning, apathetic

Fat wasting

Severe loss of sub

cutaneous fat

Fat often retained but not firm

Weight for height

Very Low

Low but masked by oedma

 
 
  1. Mid arm circumference
  1. Can’t be used before the age of 1 year.
  2. Between 1-5 years it hardly varies.
  3. 13.5 cm or more: normal, 12.5-13.5 cm indicates mild- moderate malnutrition and below 12.5 cm, severe malnutrition.
  4. Shakir’s TAPE is used to measure mid-aim circumference. Q
  1. Fats
    1. Fatty acids
      1. Saturated: Lauric, Palmitic and Stearic acid (LPS)
      2. Unsaturated: MUFA (monounsaturated fatty acid) e.g. Oleic acid.
        1. PUFA (polyunsaturated fatty acid) e.g. Linolenic acid and α-linolenic acid
        2. PUFA are found in vegetable oil.
      3. Coconut and palm oil : high Percentage of saturated FA
      4. Fish oil (animal oil) : PUFA and MUFA.
      5. Invisible fat: Rice : 3%, wheat: 3%, jowar 4% and bajara 6.5%.
      6. Ideal fat: ratio of PUFA/saturated FA=0.8-1.0
         
        Linoleic/ α-linolenic(n-6/n3)=5-10 in total diet.
      7. Cereal based diet: to ensure balance of FA→ ↑ intake α-linolenic acid and ↓ Linoleic acid. (↑W3, ↓ W6)
Fats Saturated FA MUFA PUFA
Coconut oil 92 6 2
Palm oil 46 44 10
Ground nut oil 19 50 31
Safflower oil 10 15 75
Sunflower oil 8 27 65
Com oil 8 27 65
Soya bean oil 14 24 62
Butter 60 37 3
Margarine 25 25 50
 
  1. Hydrogenation:
  1. Unsaturated fatty acid→ saturated FA and EFA content is reduced
  2. Liquid oil→ semi-solid or solid fat .
  3. Vanaspati ghee lacks in fat soluble vitamins.
  4. It is fortified with 2500 IU of Vit a and 175 IU of Vit D per 100 gm.
  1. Trans Fatty Acids:
  1. Geometric isomers of cis- unsaturated fatty acids.
  2. Partial hydrogenation : increases shelf life of PUFAs
  1. Creates trans-FA
  2. Removes critical double bond in EFA
  1. Trans FAs→ plasma lipid profile more atherogenic than saturated FA
  2. ↓ HDL cholesterol and doesn’t elevate LDL cholesterol.
  3. Years are needed to flush them from body.
  1. Refined oil:
  1. Treatment with alkali to remove free FA and rancid material.
  2. No change in the content of unsaturated FA
  3. It improves quality and taste and increases cost.
  1. Choice of cooking oil
  1. A variety of cooking oils are to be chosen instead of one.
  2. Mixture of two or more oils with different composition: equal mixture of PUFA rich sunflower oil, Safflower oil or corn oil with MUFA rich groundnut oil, supplemented with occasional use of mustard oil for adequate intake of omega 3 PUFA.
  3. Rice bran oil with sunflower oil, canola oil and sesame oil.
  4. Mustard oil contains erucic acid which is detrimental to health.

 

Extra Edge: 

Foods rich in α- linolenic acid(n3):  wheat, bajara, black gram, lobia, rajmah, soyabean, green leafy Vegetables, fenugreek and mustard seeds and fish .

  1. Carbohydrate
    1. Three main sources:
      1. starch,
      2. sugars
      3. cellulose.
      4. Carbohydrate reserve (glycogen) of human adult is 500 g.
      5. Dietary Fibre
      6. Non-starch polysaccharide: cellulose and non-cellulose
      7. Two types: Insoluble fibres ; cellulose, hemi-cellulose and lignin Soluble fibres: pectins, gums and mucilages.
      8. Resistant to digestion
      9. Absorbs water and increases the stool bulk.
      10. Intestinal bacteria cause emulsification of fibres, softens the stool and make the passage easy.
      11. Reduces intestinal transit time of food and reduces chances of putrefaction and formation of gases and toxic substances.
      12. Reduces incidence of cancer stomach, colon and CHD.
      13. Binds to bile salts, reduces their re-absorption and reduces cholesterol level.
      14. Gums and pectins reduce post prandial glucose levels.
      15. Fenugreek seeds contain 40% gum and thus effective in reducing blood glucose and cholesterol
      16. Fibres have no metabolic effect
      17. They decrease absorption of vitamins and minerals like iron and zinc.
      18. Recommended daily intake 40 gm.
      19. Indian diet: 50-100 gm / day.
  2. Types
    1. High fibres (>10 g/100gm); wheat, maize, jowar, bajra, ragi, pulses and fenugreek
    2. Medium ( 1-10 g/100gm); rice, vegetables, fruits, coconut, seasam, almond and dates
    3. Low (<1 g/100gm) refined and processed sugar
    4. Nil: sugar, fat & oil, milk and meat.
  3.  Vitamin A :
    1 IU of vitamin A  = 0.3 microgram of retinol
    = 0.55 microgram of retinol palmitate
    1. Sources of vitamin A
      1. Animal food: liver, eggs, butter, cheese, whole milk, fish and meat.
         
        Halibut liver oil is the richest source of vitamin A (900,000 RE ) followed by cod liver oil, ox liver margarine
      2. Plant foods: Green leafy vegetables. Darker the leaves, more is the carotene content.
         
        Green and yellow fruits and vegetables; papaya, mango, pumpkin, carrots.
      3. Most important carotenoid is beta-carotene.
         
        Fortified foods: vanaspati, margarine and milk.
        A normal person has vit A reserves for 6-9 months.
    2. Vitamin A Deficiency: prevalence in India is 6.01% in children  < 6 year of age.
  1. Night blindness is caused first due to lack of Vit A
  2. Conjunctival Xerosis: first clinical sign to appear.
  3. Bitot’s spots are indicative of vitamin A deficiency in children not in adults.
  4. Corneal Xerosis
  5. Keratomalacia is one of the major causes of blindness in India.
  6. Vitamin a deficiency disorders :-  (xerophthalmia)
    1. Refers to all ocular manifestations of vitamin A deficiency.
    2. Most common in children aged 1-3 years.
  7. WHO classification of xerophthalmia:
    1. Primary changes:        
  • X1A     Conjunctival xerosis
  • X1B     Bitot’s spots
    • X2       Corneal xerosis
    • X3A     Corneal ulceration / Keratomalacia <1/3
    • X3B     Corneal ulceration / Keratomalacia >1/3
  1. Secondary changes:  
  • XN   Night blindness (1st symptom)
    • XF    Fundal changes
    • XS    Corneal scarring        
  1. Prevention & Control
  2. Short-term action:
  • Treatment- Administer 2 lakh IU orally on 2 successive days & repeat after 4 weeks if needed (WHO guideline is immediate dosing, with the same dose repeated next day & the after 2 weeks) Q
  • Prophylactic- For children <1year – 1 lakh IU
    • For children >1 year- 2 lakh IU every 6 months. Q       
  1. Medium-term action:
  • Fortification of foods such as vanaspati ghee and toned milk
  • Remember : 2500 IU of Vit A and  175 IU of Vit D is present in dalda
  1. Long-term action:
  • Change in nutritional habits with inclusion of vitamin A rich foods.
  • Breast feeding for as long as possible
  • Immunization against infectious diseases such as measles
  • Prompt treatment of diarrhea and other associated infections.
  1. Assessment of vitamin A deficiency:
    1. Surveys are done in preschool children between 6 months to 6 years.
    2. Prevalence criteria for determination of xerophthalmia problem  Q
Criteria Prevalence in population at risk (6 months -6 years
Night blindness
Bitot’s spot
Corneal xerosis/corneal ulceration/keratomalacia
Corneal ulcer
Serum retinol (less than 10 mcg/dl)
 
>1%
>0.5% 
> 0.01%
>0.05% 
>5%
  1. Daily intake of Vitamin A recommended by ICMR
Group Retinol (mcg)
Adult: Man
Women
Pregnancy
Lactation
600
600
600
950
Infants 350
Children: 1-6 years
               7-12 years
400
600
Adolescent 600

d. Intake values recommended by ICMR

  Folate requirement per day Vitamin B12 requirement per day
Healthy adult 100 mcg 1 mcg
Pregnancy 400 mcg 1.5 mcg

Lactation

150 mcg 1.5 mcg
Children 100 mcg 0.2 mcg
  1. Vitamins & their deficiency diseases
Vitamins
Chemical name Deficiency
A
Retinol
Xerophthalmia, VADDs
B1
Thiamine
Beriberi, Wernicke’s Korsakoff psychosis
B2
Roboflavin
Ariboflavinosis (cheilosis, glossitis, stomatitis)
B3
Niacin
Pellagra (diarrhea, dermatitis, dementia& death), Casal’s necklace
B5
Pantothenic Acid
Burning feet syndrome (Grierson Gopalan syndrome)
B6
Pyridoxine, Pyridoxal
Anemia
B7
Biotin
Dermatitis, Entritis
B9
Folic acid
Megaloblastic anemia, Neural tube defects
B12
Cyanocobalamin
Megaloblastic anemia
C
 
Ascorbic acid
 
Scurvy
D
Cholecalciferol
Rickets & osteomalacia
 
E
Tocopherol
Hemolytic anemia in newborns
K
Menaquinone, Phylloquinone
Hemorrhagic disease of newborn




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