Nutrition

Dr.M.Manivasagam, Professor
Rajah Muthiah Medical College & Hospital
Annamalai University
 Nutrition
• The process by which the organism utilizes food
• National nutrition week – 1st – 7th Sept
• Energy – Carbohydrates and Fats
• Body building – Protein
• Protective foods – Vitamins & Minerals
 Energy
• Food – Supplies energy for physical activity and metabolic
needs
• Nutrients – for maintaining growth and repair or worn out /
ageing tissues
• Calories – heat required to raise the temperature of 1 gm of
water from 14.5 to 15.5 C
• Caloric requirement –
– 1 – 10 kg – 100 kcal / kg / day
– 11 – 20 kg – 1000 + 50 kcal / kg / day
– > 20 kg – 1500 + 20 kcal / kg / day
– Simple formula – till one year 1000 kcal, add 100 kcal for every
year from then.
 Carbohydrates
• Provide energy, taste, preserve foods
• Types
– Monosaccharides – glucose
– Disaccharides – sucrose
– Polysaccharides – glycogen
• Glucose
– Fuel for brain and muscle
– Converted to glycogen, stored in liver and muscles
• 55 – 60% of total calories
 Fiber
• Constituent of plant cell wall
• Contribute to the bulk and very little to the energy of food
• Includes cellulose, pectins, gums, lignins
• Water holding capacity, bile binding capacity, growth of
normal intestine microflora
• Lowers cholesterol and limit glucose absorption
• Softening of stools and acceleration of intestinal time
• High fiber can cause reduced bioavailability of minerals,
flatulency and decreased appetite
 Protein
• Second most abundant substance in body
• 24 amino acid, 8 essential AA
• Helps the child to grow and formation of body fluids
• Requirement – 1.5 gm / kg / day
• Complete protein – contain all the Essential AA
• Reference protein : provides amino acid pattern
close to tissue protein - EGG
 Fat
• Concentrated source of energy
• Triglycerides (fats & oils) phospholipids (lecithin), sterols (cholesterol)
• Saturated FA – Animal source except coconut oil
• Unsaturated FA – Essential FA
• Visible and non visible fats
• Omega 6 FA
– Linoleic / Arachidonic acid
– Defi – skin changes
• Omega 6 FA
– Linolenic / Eicosapentanoic acid
– Defi – neurological and visual symptoms
 Minerals
• Small inorganic elements
• Calcium, Phosphorous, Sodium, Chloride, Magnesium,
• Trace elements
– Essential – iron, iodine, zinc, selenium, copper, molybdenum
– Probably essential – manganese, silicon, nickel, boron
– Potentially toxic – fluorine, lead, cadmium, mercury, arsenic
 Periods of growth
• Prenatal period
– Ovum – 0 – 14 days
– Embryo – 14 days to 9 weeks
– Fetus – 9 weeks to birth
• Perinatal period
– 22 weeks to 7 days after birth
• Postnatal period
– Newborn first 4 weeks after birth
– Infancy – first year
– Toddler – 1 – 3 year
– Preschool – 3 – 5 years
– School child – 6 – 10 years (girls), 6 – 12 years (boys)
 Periods of growth – contd..
• Adolescence
– Early Adolescence : 10 – 13 years
– Middle Adolescence : 14 – 16 years
– Late Adolescence : 17 – 20 year
 Assessment of Growth
• Anthropometry
• Assessment of Tissue growth
• Bone age
• Dental Age
• Biochemical & Histological
 Parameters – age dependent
• Weight
• Length / height
• Head circumference
• Chest circumference
• Mid arm circumference
• Skin fold thickness
• Upper segment – lower segment ratio
• Arm span
• Mid parental height
 Parameters – age independent
• Bangle test
• Shakir’s tape
• Quack stick
• Body mass index
• Ponderal index
 Low birth weight
• Low Birth weight - < 2500 gms
• Very LBW - < 1500 gms
• Extremely LBW - < 1000 gms
Classification for weight – GOMEZ
Wt / age in % Grade of malnutrition

>90 Normal

76 – 90 I

61 – 75 II

<60 III
 Classification for weight – WELCOME
TRUST

60-80% Edema + Kwarshiorkor

60-80% - Under wt

<60 - Marasmus

<60 Edema + m.k

Classification for weight - IAP
>80% Normal

71-80% Grade I

61-70% Grade II

51-60% Grade III

<50% Grade IV
 Classification of PEM by Height

ht/age water low mc laren v.rao

Normal >95 >93 >90

Iostunting / short 90-95 80-93 80-90

IIo stunting 85-90 - -

IIIo stunting/dwarf <85 <80 <80

 Classification – Contd..
Wt/ht Water low Mc laren

Normal >90 >90

IO mild (wasting) 80-90 85-90

IIo mod (wasting) 70-80 75-85

IIIo sev (wasting) <70 <75

 Weight for Height
• Acute malnutrition :
– Height for age is normal
– Weight for age is low
• Chronic Malnutrition :
– Height for age and weight for age are low
 Bone age / Skeletal Maturity
• Appearance & Fusion of Various Epiphyseal centres
• Radiological examination of Wrist and elbow
 Primary Dentition
Eruption Sequence
Central Incisors 6 – 7 months
Lateral Incisors 8 – 9 months
Canine 16 – 18 months
First molar 12 – 14 months
Second molar 20 – 24 months
Completion of enamel formation
Central Incisors 1 ½ months
Lateral Incisors 2 ½ months
Canine 9 months
First molar 6 months
Second molar 11 months
Permanent Dentition – Eruption Sequence
Central Incisors 7 – 8 years
Lateral Incisors 8 – 9 years
Canine 11 – 12 years
First Premolar 10 – 11 years
Second Premolar 10 – 12 years
First molar 6 – 7 years
Second molar 12 – 13 years
Third molor 17 years +
Permanent Dentition – Completion of
Enamel formation
Central Incisors 4 – 5 years
Lateral Incisors 4 – 5 years
Canine 6 – 7 years
First Premolar 5 – 6 years
Second Premolar 6 – 7 years
First molar 2 ½ - 3 ½ years
Second molar 7 – 8 years
 Protein Energy Malnutrition
• PEM is a range of pathological conditions arising from lack
on varying proportions of protein and calories, more
frequently in infants and young children commonly
associated with infections
• Spectrum of PEM
– Kwashiorkar
– Marasmus
– Marasmic Kwashiorkar
– Prekwashiorkar
– Nutritional dwarfism
– Underweight
– Invisible PEM
 Kwashiorkar
• Disease of first child when the second child has
displaced the 1st one from the breast
• Classical features – Apathy, Miserable, stunted
growth, edema, hepatomegaly, tremors, hair & Skin
changes
 Marasmus
• Active, alert, good appetite, later becomes irritable
• Wasting – child becomes skin and bone
– Grade I – axilla and groin
– Grade II – Buttocks & thigh
– Grade III – Chest & Abdomen
– Grade IV – Buccal pad of fat
 Others
• Marasmic Kwashiorkar – Marasmic child develops edema
• Prekwashiorkar – Poor nutritional status with some features
of Kwashiorkor but no edema
• Nutritional dwarfism – prolonged PEM starting early in life –
remain for number of year
• Underweight - Malnourished child with no features of
kwashiorkor or marasmus
• Invisible PEM – 6 – 24 months, looks normal, too small for
age and poor resistance to infection
 Etiology of PEM
• Conditioning influences – LBW / Infections
• Cultural practices – Food fads / method of cooking /
Alcoholism
• Socio economic factors – poverty / Illiteracy / lack of
knowledge regarding nutritional value of food
• Food production & intake
– abrupt withdrawal of breast milk
– Delayed and inadequate weaning
– Lack of food supplementation for target group
 Etiology of PEM – Contd..
• Availability and utilization of health / other services
– Lack of health education
– Nutritional surveillance
– Nutritional rehabilitation
– Primary health care
– Immunization
– Early diagnosis
– Prompt treatment
– Referral services
 Clinical feature of PEM
• Growth retardation – Weight loss, wasting, stunting
• Hepatomegaly – fatty infiltration
• Hair changes – Flag sign
• Skin changes – Flaky paint dermatoses
• Mucosal changes – Vitamin deficiencies, bacterial infections
• Bleeding / purpuric changes
• Edema – moon face, effusion into serous cavities
• Mental changes – irritability and apathy
• Tremors – seen during treatment
 Clinical signs
• Decreased protein – Kwashiorkor
• Decreased calories – Marasmus

• Acute – Marasmus
• Chronic – Kwashiorkor

• Adaptation – Marasums
• Dysadaptation – Kwashiorkor
 Management of PEM
• Assessment – History, Anthropometry
• Classification – Wellcome trust and IAP
• Investigation
– Sr.Albumin
– Urinary urea & Creatinine
– Urinary Hydroxyproline
– Sr. essential amino acid index
– Peripheral smear
– Liver biopsy
 Management of Acute emergency
• Hypothermia
• Hypoglycemia
• Specific infection
• Dehydration & electrolyte disturbances
• Chronic renal failure
• Anemia
• Vitamin & Mineral supplements
 Restoration / Nutritional Management

• ORS → Milk → Family pot feeding

• High energy milk
• Cereal milk
• 150 – 200 calories / kg / day
• 3 – 4 gms / kg / day
 Diff b/n Marasmus & Kwashiorkor
Marasmus Kwashiorkor
Age <1 1–3
Edema None Lower legs or generalized

Wasting Gross loss of Hidden

subcutaneous fat, skin and
bone
Muscle wasting Obvious Hidden

Growth retardation Obvious Obvious

Mental change Quite Irritable, moaning,

apathetic
Appetite Good Poor

Diarrhea Present present

 Diff b/n Marasmus & Kwashiorkor
Marasmus Kwashiorkor
Hair change Seldom Often diffuse depigmentation occasional
flanky paint or enamel dermatosis

Sr. Albumin Usually Normal Low

Urinary Urea / gm Usually Normal Low
creatinine
Urinary Hydroxyproline / gm Low Low
Creatinine
Sr. Essential amino acid Low Low

Anemia Uncommon Common

Liver biopsy Normal or atrophic Fatty changes
 Poor prognosis in PEM
• Age <6 month – 12 months
• Deficit in Wt / Ht > 30%, Wt/ age > 40%
• Stupor or coma
• Severe infection
• Petechiae / hemorrhagic tendencies
• Signs of CCF / resp. difficulty
• Total serum protein < 3 gm / dl, Sr.Albumin < 2gm%
• Severe anemia with clinical signs of hypoxia
• Increased serum bilirubin level, increased transaminase levels
• Extensive exudative or exfolliative cutaneous lesions
• Hypoglycemia /hypothermia
• In serum protein electrophoresis low gamma globulin fraction
• Low Sr. phospholipids and total lipids
 Food Values
• 1 cup – 100 ml or 100 gms
• 1 teas spoon – 5 ml or 5 gm
• 1 table spoon – 15 ml or 15 gm (3 teas spoon)
• 1 tumbler – 200 ml (2 cup)
 Food item Protein gms Kilocalories
Iddy – one 2 50
Puri – two 2 50
Wheat chappati 1 2 50
Bread slice 1 2 50
Dosai 2 50
Uppma 1 cup 6 250
Ragi 6 tsp 2 100
Cooked dhal 1 tsp 0.5 15
Bengal gram 1 18
powder 1 tsp
Cane sugar 1 tsp 0 20
 Food item Protein gms Kilocalories
Brown sugar 1 tsp 0 15
Honey 1 tsp 0 15
Rasam 1 cup 0 20
Coconut water 1 cup 1.4 24
Coffee 100 ml 1.4 60
Butter milk 100 ml 0.8 15
Butter 100 gm - 729
Ragi 100 gm 7.3 328
Rice 100 gm (Par boiled) 6.4 346
Wheat 100 gm 11.8 346
 Food item Protein gms Kilocalories
Wheat bread 100 gm 7.8 245
Bengal gram roasted 100 22.5 369
gm
Black gram Dhal 100 gm 24 347
Green gram dhal 100 gm 24.5 348
Red gram dhal 100 gm 22.3 335
Tomato 100 gm 1.4 21
Egg Hen 1 6 8
Biscut 1 0.5 25
Papadam 1 0.5 25
Banana 1 0.6 50
 Food item Protein gms Kilocalories
Spinach 100 gm 2 26
Cow’s milk 200 ml 6 120
Curd 30 ml 1 20
Papaya ripe 100 gm 0.6 32
Ground nut 100 seeds
9 200
 6 gms of Protein
• 1 egg • 1 ounce (30 ml) meat / fish
• 2 cup milk • 50 groundnuts
• 3 idlis • 15 cashewnuts
• 3 chappatis • 3 cup cooked rice
• 3 dosas • 6 tsp bengal gram
• 6 puris
• 12 tsp cooked dal
• 18 tsp ragi
Thank you