Nutrition Book 2024 - Condensed Course PDF

[]{#_Toc19883961.anchor}Preface It is our pleasure to present to you our books. We did as much as we can in order to introduce this book in this format. We hope that this book will be beneficial as a valuable guide for our students. We believe that, this book cannot replace the attending of lectures, seminars and participation in the scientific sessions, and visiting the library to read the most recent journals and text books in order to maximize understanding of Basic Principles of Nutrition. Completeness is a character of ALLAH, so we regret for any defect in this version and we will be very grateful if you can contact and help us to put this book in a better shape. We would like to thank all those who contribute in the production of this book. Contents {#contents.TOCHeading} ======== [Preface ii](#_Toc19883961) [BASICS & PRACTICE OF NUTRITION 1](#basics-practice-of-nutrition) [Introduction 1](#_Toc32447187) [Energy 3](#energy) [Basic food constituents 5](#basic-food-constituents) [Macronutrients 6](#macronutrients) [Micronutrients 21](#_Toc32447191) [Feeding of vulnerable groups 41](#feeding-of-vulnerable-groups) [Malnutrition 51](#malnutrition) [Assessment of nutritional status 60](#section-1) [Dietetics 67](#_Toc19366679) [Medical Nutrition therapy of diabetes 68](#medical-nutrition-therapy-of-diabetes) [Medical nutrition therapy for heart failure 71](#medical-nutrition-therapy-for-heart-failure) [Medical nutrition therapy for hypertension 71](#_Toc32447198) [Medical nutrition therapy guidelines for hyperlipidemia 72](#medical-nutrition-therapy-guidelines-for-hyperlipidemia) [Medical nutrition therapy for renal diseases 73](#medical-nutrition-therapy-for-renal-diseases) [Medical nutrition therapy for liver diseases 73](#_Toc32447201) [Dietary Guidelines for prevention of osteoporosis 74](#_Toc32447202) [Medical nutrition therapy of gout 75](#medical-nutrition-therapy-of-gout) [Medical nutrition therapy for peptic ulcer diseases 76](#medical-nutrition-therapy-for-peptic-ulcer-diseases) [Medical nutrition therapy of cancer 76](#_Toc32447205) [References 82](#references) BASICS & PRACTICE OF NUTRITION ============================== **We are what we eat!** **Definitions** **Nutrition:** the science of the nutrients in foods and their actions within the body. A broader definition includes the study of human behaviors related to food and eating. **Food** is something that we eat and provide nutrients and/or energy necessary for growth, maintenance, repair, proper functions and exercise. **Nutrients:** chemical substances obtained from food and used in the body to provide energy, structural materials, and regulating agents to support growth, maintenance, and repair of the body's tissues. **Essential Nutrients**: nutrients body cannot make or make in insufficient quantities, therefore, must obtain these nutrients from foods "needed from outside the body." **Diet:** is composed of the different foods we eat. **A balanced diet:** is the diet which provides a mixture of foods having all the essential nutrients for *the prevention of deficiency disease.* **Food security:** "when all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food to meet their dietary needs and food preferences for an active and healthy life." **Nutritional well-being** is influenced by the nutrient content of food consumed and its absorption by the body, in relation to other requirements determined by age, sex, level of physical activity and health status, as well as the efficiency of nutrient utilization by the body. Food, health and care are interrelated, and actions affecting one area may have significant consequences on another. **What Is a Healthy Diet?** 1. Fulfills energy needs (macronutrients) 2. Provides sufficient amounts of essential nutrients (micronutrients) **Planning an adequate diet** The most important application of studying the different nutrients is how to utilize this knowledge in properly selecting the variety of foods that would supply us with our nutritional requirements (adequate diet). **Function of food:** Food is essential for body building and repair of tissues as well as maintenance and regulation of tissue functions. - Energy yielding Carbohydrate, Fat, Protiens. - Body building Protein - Protective Vitamins & minerals **Classification of food according to:** I. **Predominant Function:** Energy yielding, Body building, Protective. II. **Macronutrients vs Micronutrients** Macronutrient required in grams (Proteins, Carbs, Fats) Micronutrient required in milligrams or less (Vitamins & Minerals). III. **Organic vs Inorganic** Inorganic (no carbon) water & minerals Organic Carbs, Fats, Protein, Vitamin **Energy** ---------- Energy is not a nutrient. The metabolism of carbohydrates, fats and proteins results in energy production. The average calorific values of proteins, fats and carbohydrates are 4, 9, and 4 kcal/g respectively. Alcohol is another source of energy, providing 7 kcal/g. **Energy is measured in**: - Large calories (kilocalories- Kcal) the amount of heat necessary to raise the temperature of one liter of water by 1oC (from 15-16 °C). - kilojoules (kJ) or mega-joules (1 MJ = 1000 kJ). 1 kcal is equivalent to 4.184 kJ. **Functions of energy:** 1. Performance of mechanical work (physical activity) 2. Functional activity of organs (Metabolism) BMR (basal metabolic rate). 3. Maintenance of body temperature (heat production) 4. Additional energy is required for growth in children, or when recovering from serious illness, or during pregnancy and breastfeeding. **Energy Requirement** **Categories of requirement** 1. Basal (to carry out resting metabolism)---1 kcal/hr/kg 2. Energy required for daily activity 3. Energy required for occupation. i. Physical activity: most important factor. ii. Personal factors: a. Age: The BMR declines with age dt body mass & physical activities. b. Sex: women have a lower BMR than men, in large part because men typically have more lean body mass. c. Body composition and body size: The BMR is high in people who are tall and so have a large surface area. Similarly, the more a person weighs, the more energy is expended on basal metabolism. iii. Growth: The BMR is high in people who are growing  pregnant and lactating women, infants, children, and adolescents. iv. Climate. **Basal Metabolic rate (BMR):** It is the energy expenditure of a fasting individual at complete rest used for activity of vital organs and tissue metabolism and the maintenance of body temperature. BMR represents the largest component of energy expenditure, ranging from 40 to 70 % depending on age, gender, body size and composition. +-----------------------------------------------------------------------+ | [Metric BMR Formula] | | | | \ | | [*Men*: 10 × *weight* (*kg*) + 6.25 × *height* (*cm*) − 5 *x* *age* | | (*y*) + 5]{.math | |.display}\ | | | | \ | | [*Women*: 10 × *weight* (*kg*) + 6.25 × *height* (*cm*) − 5 *x* *age* | | (*y*) − 161]{.math | |.display}\ | +-----------------------------------------------------------------------+ 1. Calculate Basal Metabolic rate (BMR): Use the appropriate equation, inserting your age in years, weight (wt) in kilograms, height (t) in meters. 2. Next, he considers the level of daily physical activity and selects the appropriate PA factor. **Basic food constituents** --------------------------- **Nutrients in Diet** **Macronutrients** **Micronutrients** --------------------------------------------------------------------------------------- -------------------------------------------------------------- Form the bulk of the diet present in quantities of one gram or more in the daily diet Present and needed in small quantities in milligrams or less Energy-Yielding Do not provide energy Carbohydrate, Fat, and Protein Vitamins & Minerals Water: considered a macro-nutrient Although, it does not provide energy **Energy yield of macro-nutrients** **Macronutrient** **Nutrient Energy yield** ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- Carbohydrates 4 Kcal per gram (17 KJ) Proteins 4 Kcal per gram (17 KJ) Fats 9 Kcal per gram (37 KJ) NOTE: Alcohol contributes 7 kcal/g that can be used for energy, but it is not considered a nutrient because it interferes with the body's growth, maintenance, and repair. **In *'Balanced Diet'*,** - Proteins should constitute 10-15% of total daily energy intake. - Fats should constitute 15-30% of total daily energy intake. - Carbohydrates constitute remaining 50-70% of energy. **Recommended Dietary Allowance (RDA):** Is a level of intake corresponding to Mean ± 2 Standard Deviation (SD), which covers requirement of 97.5% of population. ### Macronutrients A- Proteins (key life force) Proteins of the body are inevitably dependent for their formation and maintenance on the proteins of the food. The body needs 20 different amino acids to function. Although they are all important, they are classified into: **[Non essential amino acid:]** 11 of these amino acids are considered nonessential dispensable because they can be synthesized by a healthy body in sufficient amounts. ![](media/image3.png)**[Essential amino acid:]** The 9 amino acids the body cannot make are known as essential indispensable amino acids- they must be obtained from foods and include: tryptophan, lysine, leucine, isoleucine, valine, threonine, phenylalanine, methionine and histidine which is required during periods of growth. **Sources of protein in diet:** - Animal sources: e.g. milk, egg, meat, poultry, fish. - Plant sources: e.g. pulses, cereals, beans, nuts. **Biological value (BV)** Biological value (BV) reflects the similarity in amino acid composition of protein to that of animal tissues; thus, BV indicates what percentage of a dietary protein provides EAAs for the body. A perfect match is *egg protein*, with a value of 100. **High biological value proteins:** - Supply the body with its needs of amino acid (contain all the amino acids) when given in adequate amount. - All animal proteins except gelatin are of high biological value proteins (Animal proteins closely match the human pattern of essential amino acids and considered complete proteins). - **Low (incomplete) biological value proteins:** - They cannot alone support life nor maintain growth. - All plant proteins, except soya beans are of low biological value proteins. **Reference protein** - Is completely utilized by the body because it contains all essential amino acids in optimal amounts for human nutrition. - Ex: Eggs and breast milk. **Limiting Amino Acids:** Amino acids most deficient in proteins of a food item are 'Limiting amino acids' Protein Functions in the Body +-----------------------------------+-----------------------------------+ | 9. **Structural materials** | Proteins form integral parts of | | | most body tissues and provide | | | strength and shape to skin, | | | tendons, membranes, muscles, | | | organs, and bones. | +===================================+===================================+ | 1. **Enzymes** | Proteins facilitate chemical | | | reactions. | +-----------------------------------+-----------------------------------+ | 2. **Hormones** | Proteins regulate body processes. | | | (Some hormones are proteins.) | +-----------------------------------+-----------------------------------+ | 3. **Fluid balance** | Proteins help to maintain the | | | volume and composition of body | | | fluids. | +-----------------------------------+-----------------------------------+ | 4. **Acid-base balance** | Proteins help to maintain the | | | acid-base balance of body fluids | | | by acting as buffers. | +-----------------------------------+-----------------------------------+ | 5. **Transportation** | Proteins transport substances, | | | such as lipids, vitamins, | | | minerals, and oxygen, around the | | | body. | +-----------------------------------+-----------------------------------+ | 6. **Antibodies** | Proteins inactivate foreign | | | invaders, thus protecting the | | | body against diseases. | +-----------------------------------+-----------------------------------+ | 7. **Energy and glucose** | Proteins provide some fuel, and | | | glucose if needed, for the | | | body\'s energy needs. | +-----------------------------------+-----------------------------------+ | 8. **Other** | The protein fibrin creates blood | | | clots; the protein collagen forms | | | scars; the protein opsin | | | participates in vision. | +-----------------------------------+-----------------------------------+ **Recommended dietary allowance for protein:** The best estimate for the amount of protein required for nearly all adults is **0.8 grams of protein per kilogram** of desirable body **Factors affecting protein requirement:** 1. [Growth:] infant and young children optimal growth depends on an adequate dietary protein supply 2. [Physiological state]: as pregnancy and lactation, there is about 925 gram of protein being stored in pregnancy so there is a need for extra allowance. Additional 1.2 g/day of protein is needed in the first trimester, 6.1gm/day in the 2nd trimester and 10.7gm/day body weight in the third trimester of pregnancy, and extra 15 g/day in the first 6 months of lactation. 3. [Pathological states:] as injury, burns and infections as well as convalescence 4. [Physical exercises] 5. [Climate]: loss of nitrogen in hot weather B- Carbohydrates Carbohydrates are mostly plant products in origin and include cereals and cereal products, fruits, vegetables, sugars and syrups. Carbohydrates are the most readily available and easily digested of the \"energy food groups\". It is the cheapest, popular and palatable food group. **The dietary carbohydrate family includes:** - Monosaccharides: single sugars - Disaccharides: sugars composed of pairs of monosaccharides - Polysaccharides: large molecules composed of chains of monosaccharides: - Starch (reserve store of carbs in plants). - Glycogen (reserve store of carbs in the liver). - Fibers. **Functions of carbohydrates:** 1. Meets the body needs for energy. Starch provides an economic and abundant source of energy: 1gm of CHO= 4.1 kcal 2. Spares the burning of protein for energy 3. Complete oxidation of fat for energy 4. Lactose in milk has a laxative effect and help absorption of calcium 5. Provide the body with dietary fibers (see before functions of fibers). **Sources of Carbohydrates:** - Animal: Only glycogen and lactose. - Plant: Grains (rice, wheat, corn) are the richest food source of starch, providing much of the food energy for people all over the world. Sugar, flour in bread, cakes, macaroni, , pulses, potatoes, bananas, dates, honey **Recommended daily intake:** It is recommended that carbohydrates provide about half (50 to 60 %) of the energy requirement. (The remainder comes from fat and protein). A person consuming 2000 kcalories a day should therefore have 1000-1200 kcalories of carbohydrate, or about 250 to 300 grams. **Excessive intake of carbohydrates** obesity. C- Fats - **Lipids:** a family of compounds that includes triglycerides, phospholipids, and sterols. Lipids are characterized by their insolubility in water. - they can supply more energy per gram than carbohydrates can (9 kcal/g). - The lipid family includes triglycerides (fats and oils), phospholipids, and sterols. **The Lipid Family:** - **Saturated fatty acid (SFA):** - A fatty acid carrying the maximum possible number of hydrogen atoms. - Tend to be solid at room temperature - SFA are obtained from animal storage fats and their products, e.g. meat fat, lard, milk, butter, cheese, and cream.. Manufactured margarines contain significant amounts of SFA. - High intakes of SFA LDL cholesterol are associated with atherogenesis and cardiovascular disease. **Rancidity**: ultraviolet rays of light, oxygen and some chemicals can attack double bonds and destroy the structure of PUFA in oils leading to its decomposition and rancidity. - **Unsaturated fatty acid:** a fatty acid that lacks hydrogen atoms and has at least one double bond between carbons (includes monounsaturated and polyunsaturated fatty acids). - **Monounsaturated fatty acids** (MUFA): - MUFA contain only one double bond and are usually liquid (oil) at room temperature. - Dietary MUFA does not raise plasma cholesterol and lowers LDL lipoprotein. - **Polyunsaturated fatty acids (PUFA):** **Essential fatty acids** - Fatty acids that the body requires but cannot make, and so must be obtained from the diet. - Both linolenic acid (the 18-carbon omega-3 fatty acid) and linoleic acid (the 18-carbon omega-6 fatty acid) are essential fatty acids. Arachidonic acid can be obtained from dietary linoleic acid. - Regular consumption of whole grains can also supply enough essential fatty acids. **Functions of essential fatty acids:** - Participate in immune process and vision, - Help form cell membranes and - Aid in the production of hormone-like compounds. - Needed for growth and brain development in infants - Is a polyunsaturated fatty acid in which the closest double bond to the methyl (CH3) end of the carbon chain is three carbons away. - are found in fish and fish oils: salmon, sardins, tuna - soybean oil - Health benefits improved cardiovascular risk factors. ![](media/image8.png) **Functions of fat** 1. Energy source---fat provides 9 kcal per gram. About 40% of energy used by the entire body at rest and during light activity comes from fatty acids. Fats are the main dietary energy source for infants (concentrated source of energy). 2. Storing energy The body\'s ability to store fat is limitless: - Fat cells can increase about 50 times in weight. - If the amount of fat exceeds the ability of the cells to expand, the body can form new fat cells. 3. Insulating and protecting the body: - The layer just beneath the skin insulates against cold weather. - Protects some organs as kidneys from injury. 4. Fat provides essential fatty acids.(see before) 5. Fat is a carrier for fat soluble vitamins A,D,E, and K. 6. palatability by improving taste perception and appearance of food. 7. Some fats are important constituents of cell membranes and can be converted to biologically active compounds such as steroid hormones, interleukins, thromboxanes, and prostaglandins. 8. Cholesterol is converted to bile acids, which are important in digestion. 9. Providing satiety: It is the glycerides in foods that give a full feeling after meal. The fat triggers hormones that cause the stomach to retain foods longer than when we eat CHO or Proteins. **Food sources of fat:** +-----------------------------------+-----------------------------------+ | **Animal fats** | **Vegetable oils** | +===================================+===================================+ | Solid at ordinary temperature | Liquid at ordinary temperature | +-----------------------------------+-----------------------------------+ | Full cream milk, cheese, egg | i. Plant foods: Sesame, Olives, | | yolk, fatty meats, cream, butter | Peanuts, Nuts. | | and Cooking fat (Samna). | | | | ii. prepared oils: from cotton | | | seeds and olives. | | | | | | iii. Margarine | +-----------------------------------+-----------------------------------+ **Dietary needs:**. Many health related agencies recommend a diet containing no more than 25- 30% of energy as fat and maximum of one third of that as saturated fat. Cholesterol should not exceeding 300 mg/day. Roughly speaking, 1 gm/ kg B.W or 20-25% of calories **Deficiency:** A dietary deficiency of essential fatty acids is rare in adult, but it has been observed with the use of prolonged fat-free parentral nutrition and resulted in poor growth and liver abnormalities. In infants, essential fatty acids deficiency causes: - Growth failure - Abnormal scaliness - Erythematous skin lesion - Decreased capillary resistance, increased fragility of red blood cells. - Poor wound healing - Increased susceptibility to infection **Excessive intake** Digestive disturbance cause: diarrhea, distention **Health effects:** Dietary fat and high blood cholesterol play a role in: - Atherosclerosis, and gall bladder stone formation. - Coronary artery diseases - Hypertension - Impaired immune functions - Multiple sclerosis - Some cancers as colon. Breast and prostate ### Micronutrients **Vitamins** Vitamins are complex chemical substances required by the body in very small amounts and cannot be manufactured in the body so they have to be supplied through the diet. **[Types:]** I. **Fat soluble vitamins**: ADEK (vit A, D, E, and K) are not excreted in urine so extra amount stored in the body and can make toxicity. So vitamins deficiency is more common in water soluble than in fat soluble vitamins. II. **Water soluble vitamins:** Vitamin B complex \[thiamine B1, Riboflavin B2, Niacin (nicotinic acid)), pyriden B6, folic acid, cyanocobolamine B12\] and Vitamin C (ascorbic acid). **(1) Fat soluble vitamins** **Vitamin A (Retinol):** (Anti- infectious vitamins), present in the retina. **Functions of vitamin A:** 1. Vision: It is necessary for the synthesis of visual purple responsible for dim light. It has a specialized role in the photochemical basis of vision. 1. Epithelial integrity : It is essential for the maintenance of the structure and function of the epithelial cells lining the cavities and surfaces of the body and regulates differnitiation of epithelial tissues and inhibits its keratinization 2. Supporting reproduction and regulating growth 3. Anti-infection vitamin through maintaining epithelial integrity and immunity competence by enhancing cell mediated and humoral immune response. 4. Control of cellular differnitiation of normal epithelium especially in the respiratory tract so it has a wide ranging immunological and anti-tumour effects 5. Powerful antioxidant. 6. Carbohydrate and lipid metabolism are influenced by vitamin A 7. There is a significant correlation between plasma retinol concentration and blood hemoglobien concentration. It has therefore suggested that vit. A deficiency may be implicated in certain types of anemia. **Sources:** - Animal source: Milk, Butter cream, Liver, Eggs, Fish (cod liver oil) - Plant sources: Darky green leafy vegetables, Fruits, Carrots. **Recommended daily intake:** 2500 I.U./adult (I.U =international unit) +-----------------------------------------------------------------------+ | **Vitamin A deficiency:** | | | | It is estimated that 10 million children are vitamin A deficent. One | | million of these children needlessly die due to infections, go blind, | | or suffer lesser degree of visual impairment every year. | | | | It is the third most frequent nutritional problem after PEM and iron | | deficiency. | | | | **Causes of vitamin A deficiency:** | | | | - Artificial feeding with skimmed milk | | | | - Infections as diarrhea which limit the absorption of Vit. A. | | | | - Fatty infiltration, or damaged liver as in Kwashiorkor. | | | | **The consequences of deficiency of vitamin A are dramatic.** | | | | I. **Ocular Manifestations:** (in sequence) | | | | - **Night blindness:** is the 'First clinical symptom' of Vitamin-A | | deficiency (physiological deficiency appears earlier than | | anatomic changes). | | | | - **'Xerophthalmia' (Dry Eye):** | | | | **Xerophthalmia is most common in children aged 1-3 years** | | | | | | | | - Conjunctival xerosis: is the 'First clinical sign' of Vitamin-A | | deficiency. | | | | - *Bitot spot**:*** are triangular, pearly-white or yellowish, | | foamy spots on bulbar conjunctiva, on either side of cornea | | | | - Corneal xerosis: is a serious manifestation of Vitamin-A | | deficiency | | | | - ![](media/image10.jpeg)Keratomalacia (liquefaction of cornea) is | | a 'grave medical emergency' | | | | II. **Extraocular manifestations of Vitamin A deficiency:** | | | | - Epithelial tissues-skin keratinization occurs in vitamin A | | deficiency, the skin became rough, dry, the sweat and sebaceous | | gland atrophied (follicular hyperkeratosis) | | | | - Growth retardation | | | | - Immunity---vitamin A deficiency results in susceptibility to | | infectious diseases such as diarrhoea and respiratory infections. | | | | - A deficiency of vitamin A can contribute to nutritional | | deficiency anaemia. | | | | - Other features: | | | | | | | | - Increase bladder stones formation | | | | - Keratinizing metaplasia in the middle ear, sinuses, upper | | salivary glands, pancreas | | | | - The mucosal epithelial changes of the bronchi, bronchioles is | | related to pneumonia which is the most common mechanism of death | | in infants of vitamin A deficiency | | | | - Increase incidence of lung cancer | | | | - Neurological manifestations | | | | **Prevention:** | | | | a. Supplementation | | | | b. Food fortification | | | | c. Dietary modification through increase production, availability | | and consumption | | | | **Treatment:** | | | | - The cause should be corrected. | | | | - Vitamin A given in therapeutic doses at once, followed by | | maintenance doses as required. | +-----------------------------------------------------------------------+ **Vitmin D (Anti-rachitic)** Vitamin D is a fat-soluble vitamin that acts as a hormone. It maintains calcium and phosphate homoeostasis and optimises bone health and muscle function. **Vitamin D metabolism** **Vit D occurs mainly in 2 forms:** 1. Vit D2 (ergocalciferol) which found in yeast 2. Vit D3 (cholecalciferol) which found in human skin by exposure to sunlight (cholecalciferol) found in fish liver oil, egg yolk. **Functions of Vit. D:** 1. Promotes absorption of calcium and phosphorus from the intestine. 2. Used in bone formation. 3. Regulate excretion of Ca and Phosphorus in urine. **Sources:** - Dietary sources: (poor), only in foods of animal origin: Milk, butter, salamon, sardine, liver, egg yolk, Fish liver oil (cod liver oil) - Sun ray (Ultra Violet rays): Exposure of the skin to sun. **Recommended daily intake:** Adult 100 I.U, (infant or pregnant woman: 400 I.U.) **Deficiency of vitamin D:** **Leads to Rickets in children and osteomalacia in adults.** Deficiency of vitamin D results in inadequate mineralisation and demineralisation of the skeleton. In adults, deficiency can lead to increased bone turnover and osteoporosis and osteomalacia (porous bone, resulting in bone and muscle pains, and weakness). **Vitamin E** Vitamin E is the collective term given to a group of fat-soluble compounds which have distinct antioxidant activities essential for health. Vitamin E is can be stored within the fatty tissues of animals and humans, so it does not have to be consumed every day. +-----------------------------------+-----------------------------------+ | **Sources** | - The richest dietary sources | | | of vitamin E are edible | | | vegetable oils. | | | | | | - Widely found in food as wheat | | | germ, oil egg and liver. | +===================================+===================================+ | **Functions** | - Prevention of diabetes, | | | cancer, delayed symptoms of | | | Alzhimer disease, enhanced | | | immunological functions | | | | | | - Antioxidant | | | | | | - Improves Vitamin A absorption | +-----------------------------------+-----------------------------------+ | **Deficiency** | It is quite rare in humans. | | | | | | Deficiency Male sterility, fetal | | | death, vision problem and ms | | | weakness. | +-----------------------------------+-----------------------------------+ **Vitamin K** Forms and Sources - K~1~ (Phyloquinone) → Green leafy vegetables, olive and soybean oils - K~2~ (Menaquinone) → formed from intestinal bacterial flora → into blood. (So Antibiotics → ↓ vit. K2, ) It is also found in small amounts in chicken, butter, egg yolks, cheese and fermented soyabeans - K~3~ (Menadione → synthetic "drug" form, used in hospitals Function 1-Important for the coagulation factors (II, VII, IX, X, protein C, S) 2-Important for osteocalcin (a bone-forming protein) Deficiency - ↓ Vit K will cause decreased ability to form clotting factors = ↓ Coagulation (-Prolonged bleeding time (clotting time). - Echymosis → due to fat malabsorption → ↓ vit. K = easy bruising - Hemorrhagic Disease of Newborn **(2) Water soluble vitamins** **Vitamin B1 (Thiamine) anti-beriberi** Function: - Essential for normal metabolism of Carbohydrates. - Thiamine pyrophosphate (TPP) is the coenzyme of Carboxylase, the enzyme concerned with oxidation of pyruvic acid lead to lactic acid. Sources: - Yeast, Germ of Cereals (beans-Nabet-wheat-Belelah- nuts), Pulses, Green leafy vegetable, Eggs. (N.B. refined flour and polished white rice are free from vit B1). - Synthesis by intestinal flora. Recommended daily intake: \- Adult: male : 1.2 mg female: 0.9 mg Intake of high amount during pregnancy and lactation is recommended if diet contain large amount of carbohydrates. **Deficiency of vitamin B1 "Beri-Beri"** Not present in Egypt now but in Far East which depends mainly on polished white rice. **[Etiology of deficiency:]** 1. Inadequate intake. 2. Increased requirement as in pregnancy, lactation and fever. 3. Impaired absorption as in long-continued diarrhea. 4. Impaired utilization as in severe bowel diseases **There were 3 forms of Beri-beri:** - **Dry Beri-Beri:** Peripheral neurologic changes, bilateral, symmertrical, parasthesia of toes, burning of the feet, calf muscle tenderness. - **Infantile beri-beri:** Cardiac failure, aphonia, absent knee tendon reflexes. - **Wet beri-beri:** Odema of the legs and face - Congestive heart failure. **Prevention:** - Health education. - Adding vitamin B1 to rice (enrichment). **Vitamin B2 (Riboflavin)** Function: Act as a coenzyme (in oxidation). Sources: - Diet: Milk, cheese, liver, eggs, meat, grains, pluses. - Synthesis by intestinal flora. Recommended daily intake: - Adult male 1.8 mg - Adult female 1.3 mg - Intake increased in pregnancy and lactation Deficiency: 1. Angular stomatitis. 2. Cheilosis of the lips. 3. Soreness of the tongue. 4. Vascularization of cornea, redness and burning sensation of eyes. 5. Nasolabial seborrhea. 6. Scrotal or vulval dermatitis. **Vitamin B3 NIACIN (Nicotinic acid) or P.P.F.** P.P.F. = Pellagra prevention factor. **Sources:** - Diet: Organ meat (liver), meat, fish, whole meal cereals, pulses, yeast. - Biosynthesis in intestinal flora: from essential amino acids tryptophan (Niacin precursor: 60 mg Tryptophan is converted to 1 mg Niacin in the body). **Function:** Component of coenzyme. **RDA:** - 20 mg for adult male. - 15 mg for adult female Increase doses during pregnancy and lactation. **Deficiency** **Pellagra** (rough skin) 4 "D"s: - Diarrhoea - Dementia - Death - Dermatitis Skin rash in pellagra may appear as pigmented and scaly in areas exposed to sunlight. Esp. neck when it is known as *'Casal's Necklace'*. Pellagra is common in maize eating populations: - Maize poor in Niacin (Limiting amino acid in maize is Tryptophan). - Maize contains antivitamin called 3 acetyl pyridine. Highly endemic in rural areas (when maize was used in past decades). This disease is not present in Egypt now because farmers depends on bread made from mixture of wheat (good source of niacin) and maize and also availability of more nutrient foods. **Treatment:** 300-100 mg orally in divided dose. **Vitamin B5: (Pantothenic acid)** It is found in many foods, so natural deficiency does not occur. It is converted to coenzyme A and is used for the metabolism of fats, carbohydrates and proteins in energy production. It is considered an "anti-stress vitamin", it improves exercise tolerance and is used in treating symptoms of arthritis, allergy and fatigue. It can aid in wound healing and support immune system during infections. **Vitamin B6 (Pyridoxine)** Vitamin B6 acts as a coenzyme in the breakdown and utilization of carbohydrates, fats and proteins. **Function:** Vitamin B6 helps in the production of neurotransmitters, important in fat and protein metabolism, and is important for immune system function in older individuals. **What are the signs of a deficiency?** Vitamin B6 deficiency can lead to nerve damage in the hands and feet. Some symptoms of a vitamin B6 deficiency include dermatitis, cracked and sore lips, inflamed tongue and mouth, confusion, [depression](http://www.drweil.com/drw/u/ART00696/depression-treatment) and [insomnia](http://www.drweil.com/drw/u/ART02004/insomnia). **RDA:** 2 mg **Sources:** Good food sources of vitamin B6 include brewer\'s yeast, bananas, cereal grains, [legumes](http://www.drweil.com/drw/u/ART03206/Cooking-With-Legumes.html), vegetables (especially carrots, spinach and peas), potatoes, milk, cheese, eggs, fish and sunflower seeds. **Vitamin B9 (Folate)** Folate (the form naturally occurring in the body), Folic acid (synthetic form) **Sources:** Widely distributed richest sources: liver, eggs, leafy vegetables, Fortified whole wheat bread. N.B. Folic acid content in food can drop considerably when exposed to heat. **Functions:** - Part of coenzymes THF (tetrahydrofolate) and DHF (dihydrofolate) used in synthesis and repair of DNA and RNA and therefore important in new cell formation - Folate is needed together with B12 for development of red blood cells in bone marrow. - Folate supplements taken 1 month before conception and continued throughout the first trimester of pregnancy can help prevent neural tube defects. **RDA:** Every expectant mother and women \>14yr should be taking daily folic acid supplements 400 micrograms (mcg) per day, and this should increase to 600 mcg during a pregnancy. Women over the age of 14 years: 400 mcg **Deficiency:** - Causes of folate deficiency : - Inadequate intake - Requirements: - Goat's milk (in infants) - Drug induced: antiepileptic drugs, medications used for rheumatoid arthritis, cancer. - Folate deficiency leads to - Megaloblastic anemia and is characterized by large, immature red blood cells. - Deficiency of folate in intrauterine life causes neural tube defects, such as spina bifida and anencephaly Women planning to get pregnant should take folic acid supplements for a full year before conception to reduce the risk of these developments. **Vitamin B12 (Cyanocoblamine)** **Function:** - Synthesis of nucleoproteins. \- Formation of blood (RBCs) in bone marrow. \- Metabolism of nervous system. \- Involved in some enzymatic systems. **Sources:** Only in foods of animal origin as Liver, kidney, meat, fish and milk. **Recommended daily intake:** \- 2 microgarms (Ugm) for adult. \- Increase doses in pregnant and lactating women. **Deficiency:** \- Pernicious anemia (addisonian A) \- Demyelinating neurological lesions. \- Infertility. **Vitamin C (Ascorbic acid, Anti-scurvy factor)** **Functions:** 1. Necessary for the formation of the cement substance of the walls of capillaries. 2. Essential in wound healing. 3. Facilitates absorption of iron. 4. Protects against infection. 5. Prevents hemorrhage. **Sources:** - Fresh green leafy vegetables. - Citrus fruits and juice (Gawava, green pepper, cauliflower, cabbage, tomatoes). **RDA:** - Adult, pregnancy and lactation 30 mg - Child 20 mg **Deficiency of vitamin C Scurvy** Bleeding at any place in the body (lose of tooth, spongy gum, under skin and mucous membrane near joints bleeding). **Causes of Scurvy:** 1. Lack of supplementary vit C 2. High vit. C requirement as in pregnancy, lactation. 3. Low vit. C absorption as in diarrhea, achlorhydria, surgical operations, chronic inflammatory disease. 4. ***Rebound scurvy:*** occurs in neonates exposed to high doses of vitamin C inutero. Sudden deprivation takes place on delivery with appearance of manifestation of scurvy. **Minerals** Minerals are single inorganic elements that are widely distributed in nature. Of the 54 known earth elements, 25 have been shown to be essential to human life. **Classification:** Minerals are classified according to the quantity present in living tissues into: **Calcium** Mineral deposition in bone reaches a peak by 25 years of age. In women after menopause, calcium loss from bone exceeds deposition, leading to progressive demineralization. Osteoporosis with advancing age increases the risk of fractures. \* The adult body contains 1200 gm, 99% of it in bones, there is a dynamic equilibrium between Ca in blood and bone controlled by parathyroid gland. **Functions:** 1. Formation, maintenance of bones (teeth) 2. Essential for blood clotting a. Essential for muscle contractions b. Regulation of neuromuscular transmission c. Important component of enzymes **Sources:** - Milk, Milk products - Fish which eaten as a whole e.g. sardines - Molasses - Fruits & Vegetables, cereals and drinking water **Deficiency:** 1. Rickets in children 2. Osteomalacia in adult 3. Osteoporosis in old age 4. Tetany **Calcium excess may lead to:** 1- Urinary stones 2- Calcification of kidney, other internal organs **Requirements:** - Adults: 500 mg/day - Pregnant and lactating females: 1000 mg/day ![Calcium: How much is enough?](media/image12.jpeg) **Iodine** Iodine is an essential component of the thyroid hormones thyroxine (T~4~) and tri- iodothyronine (T~3~). These hormones are required for normal growth and development of tissues, The body contains 50 mg, 30% of it in the thyroid gland. **Function:** [ ] T3 and T4 formation Large populations are at risk of Iodine deficiency because they live in Iodine-deficient areas. The soil is deficient of Iodine due to high rainfall or floods as in mountainous areas. **Sources:** Vegetables and fruits Seafood (fish) Milk. **Daily requirement:** 100 U gm/day. Increase intake by mouth causes irritation and rash. **Goitrogenic substances** in food (the intake should be increased to 200-300ug/day) are: Onion, Cabbage, Cauliflower, Soya beans. **Deficiency:** Iodine deficiency leads to a wide range of problems collectively known as 'iodine deficiency disorders' (IDD). - **Simple or endemic goiter in adults** - **Cretinism in children: either acquired or congenital.** **Causes of deficiency:** i. Decrease intake of iodine ii. Goitrogenic substance in food as cabbage, cauliflower, onion, turnip, grape and soya beans. **Correction of iodine deficiency:** [Iodized salt] was first successfully used in Switzerland in 1920s. The iodized salt loss its iodine by heating or exposure to the air. It should be added after cooking and should be kept covered all the time. **Iron** The body contains 3-4 gm., 75% of it in the blood. **Functions:** Formation of hemoglobin, myoglobin, certain enzymes. **Sources:** \- Animal: liver, meat, fish, eggs. \- Plant: cereals, pulses, and vegetables, fruits \- Molasses \- Milk is low in iron **Absorption of iron:** Only 10% are absorbed from duodenum. **Factors affecting absorption:** 1. Increase demand as in case of hemorrhage, pregnancy, and growth. 2. Vit C and meat increase the absorption. 3. Phytic acid (in cereals) absorption 4. Fibers and tannin (in tea) absorption 5. Increase calcium in diet absorption 6. Achlorohydria or antacid intake decrease absorption **Iron losses:** 1. Menstruation (loss 30mg per menses) 2. Piles 3. Malaria 4. Any hemorrhage **Deficiency:** Cause hypochromic microcytic anemia. **Requirements:** [ ] Male: 9 mg/Day Female: 27 mg/Day **Flourine** **Function** Mineralization of bone, formation of dental enamel ----------------------- ------------------------------------------------------------------------------------ **Sources** Water, Sea fish, Cheese, Tea **Daily requirement** 1 P.P.M **Deficiency** Dental carries. **Excessive intake:** Dental fluorosis (teeth lose its shiny appearance then become mottled and pitting) Affect bones, tendons and cause pain, stiffness of the back **Zinc** Zinc is a component of various enzymes that help maintain the structural integrity of proteins and regulate gene expression. Zinc deficiency can result in impaired immune responses. Zinc may help prevent the age-related decline in immune system function. Zinc is widely distributed in foods: - Meat, fish and poultry are good sources, and highly bioavailable. - Cereals, milk and milk products are other good sources. - Some nuts are high in zinc, including peanuts, almonds, cashew nuts and sesame seeds. - In general, dark red meat has higher zinc content than white meat and fish. **\ ** **Feeding of vulnerable groups** -------------------------------- Vulnerability has been defined as \"the conditions determined by physical, social, economic, and environmental factors or processes, which increase the susceptibility of individuals or a community to the impact of hazards." Vulnerable groups from the community medicine point of view are groups to be affected to a much greater extent than the general population with nutritional deficiency due to their physiological status. They include: pregnant and lactating women, infants, and growing children and some industrial workers. #### Feeding of pregnant and lactating mothers Pregnant and lactating mothers are considered the most vulnerable because they are liable to develop malnutrition if dietary requirements are not fulfilled, since fetuses share their nutrients with them. Pregnant females during the second and third trimesters and through lactation need extra amount of: - Calories: during pregnancy 300 calories/day extra and during lactation 600 calories/day extra are needed. - Protein: 30% more during pregnancy and lactation / day. - Other nutrients: special attention must be made for iron, folic acid, calcium and vitamin. D. **The important malnutrition diseases that may occur during pregnancy and lactation:** a. Disorders of body weight: - Under-weight if the diet is inadequate. - Obesity due to over nutrition. During pregnancy the mother starts to gain weight at a rate 2 Kg/month from the fourth month of pregnancy. b. Iron deficiency anemia. c. Osteomalasia due to deficient calcium intake. d. Dental caries, Ariboflavinosis and physiological goiter. **Importance of adequate nutrition during pregnancy:** 1. To insure good health of mother. 2. To prevent deficiency diseases of mother. 3. To insure a normal labour. 4. To decrease toxemia of pregnancy, bleeding, uterine inertia, premature labour and perinatal mortality. All these conditions are related to state of nutrition during and before pregnancy. 5. A healthy newborn with good store of different nutrients. This helps in prevention of malnutrition during early childhood. 6. To prepare pregnant women for the long period of lactation. #### Feeding of infants There are many choices concerning feeding of this infant. These are: 1. Breast feeding: with all the benefits and advantages 2. Artificial feeding: Its hazards - Milk born infections of animal or human sources - Hypocalcemia - Liability of overfeeding and obesity - Expensive and may not be available **Breast feeding** There is no doubt that human milk feeding is associated with a significant reduction in morbidity and mortality caused by a number of infective and non-infective disorders. Breast milk is the most adequate, safest and cleanest food for the infant till the age of six months and is considered as a natural adequate diet for the infant and is a hygienic method of protection during the transition to immunologic dependence. Breast feeding is one of the most important influences on children\'s health worldwide providing optimal nutrition for the normal infant during the early months of life. Generally breast milk protects from infection of different organisms, from allergy, from obesity and its sequences later in life. It also secures the psyche of the individual and his/her intellectual performance. The human milk has a high concentration of lactose and relatively low concentrations of fats and proteins in comparison to other species. Its composition varies little in relationship to maternal diet. Human lactation consists of lactogenesis that is controlled by estrogens, prolactin, cortisol and milk ejection that is controlled by oxytocin. **\ ** **Advantages of breast feeding:** 1. Economic advantages 2. Protective value 3. Anti-infective propperties: Ig, bifidus, complements, lysoyzmes, interferon. 4. Anti-allergic : IgA 5. Natural child spacer 6. Psychological and intellectual development 7. Advantages for the mother:contraction of uterus, low cancer, weight loss 8. Prevention of obesity in children 1. **Economic advantages of breast feeding:** Breast milk is cheap cost almost nothing. The mother who largely depend on vegetable protein should change her diet to milk containing high biological value protein. 2. **Protective value of breast milk:** The protection afforded by breast milk to the infant is the outcome of many factors related to milk constituents both quantitatively and qualitatively. - **Milk composition has the ideal composition for the infant:** - **Proteins:** can be completely digested, absorbed and metabolized and is considered as a \[reference protein\]. Human milk has a unique combination of amino acids necessary for this period of life. The higher content of cystine amino acid and the low content of aromatic amino acid are suitable for the metabolic peculiarities of the new born. Furthermore cystine, which is especially important for brain development is relatively more in human milk. - **Fats:** are rich in linoleic acid which is important for human brain development and improve the digestability. The greater content of glycerol esters which is important for haematopoesis. Cholesterol content of human milk is higher than in cow\'s milk and this is important for the rapid brain growth and formation of nerve tissues as well as for extensive mylinization process that goes on during pregnancy and in the synthesis of bile salts. Human milk contains a specific lipase synthesized by the breast so that the digestion of milk fat begins long before it reaches the small intestine of the infant. - **Carbohydrates:** are mainly in the form of beta lactose which is favorable for the synthesis of the galactolipids important for the growing brain and enhances calcium absorbtion. It is metabilozed to galactose and glucose so needed for synthesis of galactolipid which is important for brain growth. - **Minerals and electrolytes:** 3. **Anti-infective properties of the breast milk:** - Breast milk is always clean and safe and has a specific anti-infective properties related to enzymes, immunoglobulins and cellular factors. - Immunoglobulin: breast milk contains IgA, IgM, and IgD. The most important of these is IgA which has a concentration in breast milk higher than in mother\'s serum indicating active secretion. It is resistant to gastric acidity and it is not absorbed. It acts in the intestine against a group of bacteria and viruses notably E-Coli, Poliovirus 1,2,3, Rota virus and many other enteroviruses. - The bifidus factor: this is a nitrogen containing carbohydrate that promote growth of lactobacillus bifidus which inhibits growth of E-coli. Lactobacillus bifidus dominates the bacterial flora and produces lactic acid which discourages the growth of enteric pathogens. - Lactoferrin: an iron binding protein which deprives E-coli from iron and thus inhibits its growth and help the action of IgA on E-coli. \[iron preparation given by mouth neutralize the effect of lacoferrin and would encourage the colonization of the gut with E-coli. - Lysozymes: produced by breast milk macrophages and present in high concentration in breast milk. It lyses bacterial cell wall of E-coli, Salmonella and various viruses. - The activated complement together with lysozymes act on the cell wall of bacteria - Interferon: inhibits viral replication - Cellular factor: macrophages through phagocytosis The breast milk antimicrobial activity appear to be effective in milk stored for 24 hours or even longer when refrigerated. Some of these factors are stable to boiling. 4. **Anti-allergic properties of breast milk:** Breast-fed babies had a lower incidence of atopic dermatitis, allergic rhinitis, food allergy, asthma and secretory otitis media and various forms of allergy. This property appears to be related to the presence of IgA which prevents the adsorption of antigen on the mucosal cells of the gut villi, thus preventing the escape of antigen into blood and protects against atopic diseases. 5. **Natural child spacer:** It may not be a highly reliable method by itself. It has to be too frequent and exclusive. 6. **Breast feeding and psychological& intellectual development:** Breast feeding is important to establish the emotional bond and interrelationship between mother and child and facilitate adequate mental, social and emotional development and contributes to the emotional stability, personal adjustment of the baby, security and comfort to the infant and satisfactory experience for the mother. 7. **Breast feeding and benefits for the mother:** - Sucking stimulates the secretion of oxytocin from the posterior lobe of pitutary causing uterine contraction so enhancing uterine involution and limiting post-partum bleeding. - It has been mentioned that the incidence of cancer breast is less among mothers who breast-fed their infants. - As lactation proceedes the accumulated fat is converted into energy in the milk. 8. **Breast feeding and prevention of obesity:** The latest part of breast feed is rich in lipids and proteins which satisfy baby and so over-feeding is prevented. This guard against obesity early in life. Colostrum: Immediately after delivery and for the first few days (2-3 days) the breast secretes a yellowish sticky fluid which is colostrum. The amount secreted daily is not large. It contains much more IgA, lactoferrin and white blood cells than breast milk and is of great importance for the infant defense mechanism against neonatal infections. **Promotion of Breast feeding:** 1. Prenatal and post-partum education and frequent mother-baby contact 2. One-on-One advice about breast feeding technique 3. Demand feeding and rooming in 4. Avoidance of bottle supplements and early follows up after delivery 5. Maternity leave: delayed return to employment 6. Good advice about common problems as sore nipples, positioning 7. Sensitize and educate health professionals and community 8. Prepare mothers for labors and breast feeding 9. Avoid pre- and post-lacteal feeds 10. Give colostrum to all new-bornes 11. Use fresh expressed milk for premature or low-birth weight infants 12. Stop free samples and handouts of formula feeding literature 13. Avoid unnecessary separation of mother and infant 14. Avoid routine episotomies and unnecessary sedation 15. -Assist mother with section or episotomy in positioning 16. Maintain contact between mother and infant including sick or LBW 17. Establish support groups of local experienced mothers, specialists. 18. Maternal confidence and family support **Deficiency diseases of infants:** 1. Rickets 2. Iron deficiency anemia 3. Marasmus at the end of the 1st year of life. *\ * #### Feeding of preschool children The energy requirement of a child aged one year is about 1000 cal/day. After the age of one year, his energy needs can be computed by adding 100 cal for every year of life, thus a child aged 5 years needs 1500 cal/day. **Deficiency diseases of childhood:** 1. Protein energy malnutrition 2. Iron deficiency anemia 3. Rickets 4. Airboflavinosis and vitamin A deficiency. **Food and nutrition for children and young people** Childhood and adolescence are periods of rapid physical, social, cognitive and behavioral change. Optimal nutrition during childhood and adolescence is essential for the maintenance of growth and good health. The dietary requirements of children and young people are different to those of adults and are constantly changing as individuals grow and develop. Establishing good nutrition and physical activity patterns in childhood contributes to good health throughout life. The values, habits and behaviors developed during this period often influence behaviors in adulthood. In addition there is emerging evidence that health during childhood and adolescence impacts on health during adulthood. **The guidelines are as follows.** 1\. Eat a variety of foods from the four major food groups each day: - vegetables and fruit, including different colours and textures - breads and cereals, increasing wholegrain products as children increase in age - milk and milk products or suitable alternatives, preferably reduced or low-fat ,lean meat, poultry, fish, shellfish, eggs, legumes, nuts and seeds. 2\. Eat enough for activity, growth and to maintain a healthy body size. 3\. Prepare foods or choose pre-prepared foods, snacks and drinks that are: low in fat, especially saturated fat, low in sugar, especially added sugar, low in salt (if using salt, use iodised salt). 4\. Drink plenty of water during the day. Include low-fat milk every day, but limit drinks such as fruit juice, sports drinks. limit coffee or tea. 5\. Eat meals with family as often as possible and Encourage children to be involved in shopping, preparing, cooking and storing food in ways to ensure food safety. 8\. Be physically active by taking part in regular physical activity, aiming for 60 minutes or more daily, and spend less than two hours a day in front of television, computers and gaming. #### Nutrition in elderly (geriatric) people Health and nutritional status in older people is influenced by the naturally occurring ageing process and the cumulative effects of exposure to various risk factors and determinants of health throughout the life span since infancy. Older persons are particularly vulnerable to malnutrition. Moreover, attempts to provide them with adequate nutrition encounter many practical problems, as their nutritional requirements are not well defined and basal metabolic rate and lean body mass decline with age, where energy requirement per kilogram of body weight is reduced. The process of ageing also affects other nutrient needs. **[Causes of malnutrition in geriatric populations:]** - Poor oral health, ill-fitting dentures and dry mouth can result in limited dietary variety, lower nutrient intakes and a decreased enjoyment of food. - Changes in taste and smell may affect food selection, food preparation methods, dietary variety and nutrient intakes. - A lack of food knowledge and practical cooking skills, and/or a change in the ability to cook and prepare food, may result in limited dietary variety and lower nutrient intakes. - Medications may alter food intake and may cause reactions that interfere with normal nutrient metabolism and requirements. - Social isolation is associated with increased nutritional risk. Sharing meals with family or friends may increase the amount and variety of food consumed. - Affordability: Low Socioeconomic status and limited money may mean older people cannot respond to their needs and may not be able to access safe and healthy food, physical activity opportunities and social networks. - Accessibility: Older people with adequate income may still be at risk of food insecurity if they experience difficulty accessing a variety of healthy food, and preparing and eating meals. [**Good nutrition:**] Dietary changes seem to affect risk-factor levels throughout life and may have an even greater impact in older people. - Modest reductions in saturated intake - Reductions in salt intake, which would reduce blood pressure and cholesterol concentrations. - Increasing consumption of fruit and vegetables by one to two servings daily could cut cardiovascular risk by 30%. Good nutrition in older people is associated with: - preventing malnutrition - supporting physical function - reducing the risk of chronic disease - supporting mental health - Preventing disability. **Older adults are at risk for under-nutrition due to dietary, economic, psychosocial, and physiological factors**: **1. Dietary intake** - Little or no appetite - Problems with eating or swallowing. - Eating inadequate servings of nutrients. - Eating fewer than two meals a day. **2. Limited income** may cause restriction in the number of meals eaten per day or dietary quality of meals eaten. **3. Isolation** - Older adults who live alone may lose desire to cook because of loneliness. [^^](http://consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more#ref7) - Appetite of widows decreases. - Difficulty cooking due to disabilities. - Lack of access to transportation to buy food. **4. Chronic Illness** - Chronic conditions can affect intake - Disability can hinder ability to prepare or ingest food - Depression can cause decreased appetite. - Poor oral health (e.g., cavities, gum disease, and missing teeth) and xerostomia, or dry mouth, impairs ability to lubricate, masticate, and swallow food. - Antidepressants, antihypertensives, and bronchodilators can contribute to xerostomia (dry mouth). **5. Physiological changes** - Decrease in lean body mass and redistribution of fat around internal organs lead to decreased caloric requirements. - Change in taste (from medications, nutrient deficiencies, or tastebud atrophy) can also alter nutritional status - Eating inadequate servings of nutrients. - Eating fewer than two meals a day Food Guide Pyramid for geriatric **\ ** **Malnutrition** ---------------- **Malnutrition** refers to all deviations from adequate nutrition, including *under-nutrition, over-nutrition* and specific deficiencies (or excesses) of essential nutrients such as vitamins and minerals. **Food insecurity:** when people lack secure access to sufficient amounts of safe nutritious food for normal growth and development, and an active and healthy life. **Classification of malnutrition:** **The double burden of malnutrition (DBMN)** - The coexistence of undernutrition and overnutrition (in many developing countries). - DBMN may manifest within the community, household or individual. **The consequences of malnutrition:** - Compromised immune function and impaired wound healing. - Contribute significantly to morbidity and mortality. - Increases health care costs by prolonging hospital length of stay due to the increased probability of medical complications **In general, malnutrition has four basic stages:** - [In the first stage], decreases in nutrient intake (e.g. poor diet, eating difficulty) or excessive losses (e.g. chronic diarrhea, abnormal bleeding, large draining wounds) limit nutrient availability. - [In the second stage], nutrient stores are depleted as nutrients are required to meet metabolic demands. - [In the third stage,] metabolic or biochemical changes occur, leading to marginal malnutrition. - [In the fourth stage,] deficiency symptoms appeared. In this last stage, referred to as clinical or symptomatic malnutrition, cell or tissue damage is present and nutrient deficiencies are manifest by specific, observable symptoms. **Prevalence and distribution of malnutrition** - Malnutrition is common in low-income groups in developing countries and is strongly associated with poverty. - UNICEF estimates that about 10% of children in the world are wasted today. Only about 1-3% are wasted as a result of an emergency. (around 19 million severely malnourished children). - Stunting is much more common than wasting, affecting an estimated 32 % of children worldwide. The higher prevalence of stunting is due to chronic poverty, which has a long-term effect on children's growth, and affects large proportions of the population in developing countries. - The combination of wasting and stunting mean an estimated 146 million children are *underweight* (individuals who are too light for their age as a result of stunting and/or wasting) worldwide. This is mainly due to stunting rather than wasting. - Underweight prevalence among children in rural areas is almost double that of children in urban areas. - Of the under-nourished children in the world, more than half are found in South and Central Asia. Nutritional supplementation is required in those patients who cannot eat enough. It is necessary to provide nutritional support for all severely malnourished patients on admission to hospital, moderately malnourished patients who, because of their physical illness, are not expected to eat for 3-5 days, and normally malnourished patients not expected to eat for 7-10 days. External rather than parental nutrition should always be used if the GIT is functioning normally. A polymeric diet with whole-protein and fat can be used except in patients with severely GIT function who may require pre-digested, i.e. elemental diet. The aim of any regimen is to achieve a positive nitrogen balance, which can usually be obtained by giving 3-5 g of nitrogen in excess. **Causes of malnutrition:** Problems of malnutrition mostly occur in the less technically developed or politically unstable countries. The causes of malnutrition are multifarious and are multidimensional: **[I-Failure to take the proper quantity, and quality of foods to meet individual requirements:]** 1. Economic: Poverty especially with misdistribution of wealth and with inflation 2. Food shortage 3. Psychologic (anorexia nervosa) 4. Cultural food practices as some taboos and habits 5. Inability to obtain, prepare and serve foods (handicapping, elderly) 6. Iatrogeneic, anorexiants 7. Educational ignorance of food selection and preparation 8. Dizasters 9. Infections **[II Defective absorption:]** 1. Chronic diarrhea 2. Malabsorption syndrome 3. Intestinal parasitism 4. Protein losing entropathy 5. Antacids **[III Impaired metabolism of nutrients:]** 1. Hereditary and acquired biochemical disorder 2. prematurity and infection **[IV Increased needs for foods:]** 1. Growth, pregnancy and lactation 2. Physical work and exercise 3. Chronic febrile state (infection) 4. increased metabolism as in hyperthyroidism 3. Nausea and vomiting ![Image result for causes of malnutrition](media/image15.png) **Interactions of malnutrition and infections:** Malnutrition increases the risk of infection and infectious diseases. Infection worsens nutritional status. Malnutrition Infection: - Malnutrition affects a variety of immune and disease resistance mechanism. - It leads to poor wound healing - It decreases the protective bowel secretions Infection Malnutrition: - Infection can lead to anorexia - It increases metabolism - It leads to malabsorption - Due to some dietary taboos during infections - Increase losses from stools, vomitus and tissues The consequences depend on the previous nutritional status, nature of infectious agents and diet during the recovery period. **Who is most vulnerable to malnutrition?** The population groups most nutritionally vulnerable in emergencies can be categorized according to their: - Physiological vulnerability - Geographical vulnerability - Political vulnerability - Internal displacement and refugee status In terms of **physiological vulnerability**, the most vulnerable are those with increased nutrient needs and those with reduced appetite. They include: - low birthweight babies - 0-24-month-old children - pregnant and lactating women - older people, the disabled and people with chronic illness - people living with HIV and AIDS (PLWHA) **Forms of malnutrition (undernutrition):** - Acute malnutrition (wasting) - Chronic malnutrition (stunting) - Micronutrient deficiencies. **Acute malnutrition** A drastic deterioration of nutritional status in a short time can lead to *acute malnutrition* or *wasting* (individuals too thin for their height). This form of malnutrition poses more severe health risks than chronic malnutrition and leads to weight loss and specific micronutrient deficiencies in both children and adults. This causes bodily functions to be impaired, especially resistance to disease. In its severe form acute malnutrition can lead to death. Increased levels of acute malnutrition in a population result in increased illness and death. These consequences often characterize nutrition emergencies and *famine* situations. - **Clinical forms of acute malnutrition** - - - **Clinical features of severe acute malnutrition (SAM)** +-----------------------+-----------------------+-----------------------+ | | ***Kwashiorkor*** | ***Marasmus*** | +=======================+=======================+=======================+ | **Caused by** | Protein deficiency | Deficiency of all | | | | nutrients "Balanced | | | | malnutrition" | +-----------------------+-----------------------+-----------------------+ | **Growth failure** | Present | Present | +-----------------------+-----------------------+-----------------------+ | **Edema** | Present (Bilateral, | Absent | | | pitting) | | +-----------------------+-----------------------+-----------------------+ | **Hair changes** | Common: | Normal hair | +-----------------------+-----------------------+-----------------------+ | **Face** | Moon face (dt edema) | Senile facies | +-----------------------+-----------------------+-----------------------+ | **Look** | Lethargic | Alert & irritable | +-----------------------+-----------------------+-----------------------+ | **Skin changes** | Dermatosis, flaky | Thin skin, hanging in | | | paints (atrophy, | loose folds "old | | | cracked, peeling) | man's appearance | +-----------------------+-----------------------+-----------------------+ | **Muscle wasting** | Mild or absent (may | Sever muscle wasting | | | be masked by edema) | | +-----------------------+-----------------------+-----------------------+ | **Subcutaneous fat** | Reduced but present | Absent | +-----------------------+-----------------------+-----------------------+ | **Fatty infiltration | Present | Absent | | of liver** | | | +-----------------------+-----------------------+-----------------------+ | **Appetite** | Poor | Good | +-----------------------+-----------------------+-----------------------+ | **Anemia** | Severe (sometimes) | Less severe | +-----------------------+-----------------------+-----------------------+ | **Dehydration & | | | | Electrolyte imbalance | | | | frequent infection in | | | | both** | | | +-----------------------+-----------------------+-----------------------+ **Chronic malnutrition** Chronic malnutrition occurs over the long-term and is caused by insufficient intake of some nutrients and affects nearly 800 million people worldwide. Children under the age of five are particularly affected. Frequent infections can also slow down growth and lead to *stunting* where an individual is too short for his/her age. - The short-term implications of chronic malnutrition in children include growth faltering and weight loss with associated micronutrient deficiencies. In adults, it can lead to weight loss and various micronutrient deficiencies which all lead to poor health. Chronic malnutrition also makes people more susceptible to disease and infection. - The longer-term effects of chronic malnutrition are associated with impaired physical and mental development in children. Stunted women are more likely to have *low birth weight* babies (of less than 2.5 kg.) whose health can already be compromised at birth. These consequences increase the demands on medical, public health and food assistance in crisis situations. Poor nutrition is a constraint to recovery and development in the medium- to long-term as well, and perpetuates poverty. **Prevention of malnutrition and food insecurity:** **Prevention of malnutrition and food insecurity:** I. **At the individual/family level:** - Nutritional education on healthy eating habits, adequate feeding, healthy food choices, food preparation. - Promotion of breast feeding II. **At the community level:** - Health promotion & nutrition education. - Socioeconomic development - Environmental sanitation: The sanitation barrier stops infectious diarrhea, which is a perpetrator of malnutrition. - Prevention & control of infectious diseases: e.g. diarrheal, acute respiratory diseases. - Improve status of women: Hunger disproportionately affects females more so than males (they are 'expected' to eat less than men). - Screening for malnutrition III. **At the national level:** - Agricultural development: agricultural/food production. - Control food pricing and increasing market availability. - Nutrition intervention programs: - **Supplementation:** - Supplementation refers to the addition of pharmaceutical preparations of nutrients---capsules, tablets, or syrups---to the diet. - Supplementation has been used for iron deficiency anemia in the form of syrup or tablets. Usually this starts as treatment and is maintained as a preventive measure. - In the case of Vitamin A deficiency both low and high dose repeat supplementation programs have been used in various locations worldwide. - **Food Fortification:** - *Food fortification:* Is a public health, measure where nutrients are added to food (in relatively small quantities), to maintain/improve the quality of diet of a group, community or a population. - Is highly effective for preventing micronutrient deficiencies. - Food Fortification is an example of 'Primary Level of Prevention' - Examples of Food Fortification: Iodization of salt, Vitamin A and Vitamin D, Fluoridation of water. - Criteria for food fortification: - Vehicle to be fortified must be consumed regularly in diet by populations - Amount of nutrient added must not cause deficiency or toxicity in consumers - On addition of nutrient, there should be no change in taste, odour, consistency or appearance - Cost of fortification must be affordable by consumers - **Immunization**: Most infectious diseases of childhood potentiate malnutrition. IV. **At the international level:** International collaboration---The UN World Food Program, and several agenices such as FAO, WHO and UNICEF work for improving the nutrition in underdeveloped countries, and to provide emergency nutrition during disasters. **Assessment of nutritional status** ------------------------------------ **Nutritional assessment** is the interpretation of anthropometric, biochemical (laboratory), clinical and dietary data to determine whether a person or groups of people are well nourished or malnourished (over-nourished or under-nourished). **Nutrition screening:** the use of nutrition assessment techniques to identify people who are malnourished or are at risk for malnutrition. **Methods for the assessment of nutritional status:** I. **Nutrition assessment at the individual and group levels: ABCD** A. **Anthropometric measurements:** The word anthropometry comes from two words: Anthropo means 'human' and metry means 'measurement'. - Nutritional anthropometry is concerned with the measures of variation of physical dimensions and growth composition. These measurements deviate from normal when malnutrition is present in any individual. - Then these measurements compared with normal growth curves to detect any deviations. **Height** This is measured with the child or adult in a standing position (usually children who are two years old or more). **Weight** A weighing sling (spring balance), also called the '**Salter Scale**' is used for measuring the weight of children under two years old, to the nearest 0.1 kg. In adults and children over two years a beam balance is used and the measurement is also to the nearest 0.1 kg +-----------------------------------------------------------------------+ | Converting measurements to indices | | | | An index is a combination of two measurements or one measurement plus | | the person's age. | | | | **Weight-for-age** is an index used in growth monitoring for | | assessing children who may be underweight. | | | | **Height-for age:** | | | | - Is an index used for assessing **stunting** (chronic malnutrition | | in children). | | | | - **Stunting** is defined as a low height for age of the child | | compared to the standard child of the same age. | | | | **Weight-for-height:** | | | | - Is an index used for assessing **wasting** (acute malnutrition). | | | | - **Wasting** is defined as a low weight for the height of the | | child compared to the standard child of the same height. | | | | **Body mass index** is the weight in kilograms divided by their | | height in meters squared | | | | \ | | [\$\$BMI\\ = \\ \\frac{weight\\ (kg)}{{\\lbrack height\\ | | (m)\\rbrack}\^{2}}\$\$]{.math.display}\ | +-----------------------------------------------------------------------+ **Skin fold thickness:** It is the only simple method in measuring body fat. The sites, which are frequently used, are over triceps and inferior angle of the scapula. **Mid Upper Arm Circumference (MUAC):** It is used to detect early protein caloric deficiency. It should be taken at the site of mid upper arm with a flexible steel or fiber glass tape. **Head chest ratio:** They are equal at about 6 months of age. Then the chest grows more rapidly so, between 6months and 5years a chest/head circumference ratio of less than one may be due to failure to develop or wasting of muscles and fat of the chest wall. (can be used as an indicator of protein caloric malnutrition of early childhood) **Waist circumference & Waist hip ratio** Used to assess adiposity which is related to visceral fat. B. **Biochemical assessment** C. **Clinical assessment** - Biophysical methods: As radiological examination, cytological tests as buccal smears. D. **Dietary assessment** **Food records:** Completed at the time of each meal/snack for 1-day or multiple (3-7) days. Dietary Records Utilizing New Technologies: Cellular phones and personal digital assistants  Photograph or text meals and snacks  Software to identify foods and estimate quantities and calories. **Recalls** - **Dietary history:** Obtained by interview with individuals and record detailed data in a questionnaire form. It's disadvantages is that it takes long time - **24-Hour Dietary Recall** Guided interview in which the food consumed in the previous 24 hours period are described in detail. +-----------------------------------+-----------------------------------+ | | | +-----------------------------------+-----------------------------------+ | - Easy to do, little training, | - Useful for individual | | inexpensive, quick | assessment of usual diet? | | | | | - Unusual & restaurant foods | - Require multiple assessments | | | | | - Recent memory | - Some underestimation | | | | | - Diet not altered by method | - Open-ended | | | | | - If interviewer administered | - If interviewer administered | | -- literacy not an issue | bias? | +-----------------------------------+-----------------------------------+ - **Food Frequency Questionnaire (FFQ)** +-----------------------------------+-----------------------------------+ | | | +-----------------------------------+-----------------------------------+ | - Indicates usual intake over a | - Semi-quantitative | | period of time typically past | | | year | - Memory (recall bias?) | | | | | - Commonly used | - Doesn't include infrequently | | | eaten foods | | - Relatively easy, quick | | | | - Underestimation | | - Diet not altered by method | | +-----------------------------------+-----------------------------------+ II. **Nutrition assessment at the National levels** A. **The food balance sheet technique:** It is indirect method of nutrition assessment. It aims to determine the individual share from different foods, assuming that the available foods are distributed equally among the people. To reach this, it goes through the following: 1. The different foods are divided into 11 groups: +-----------------------+-----------------------+-----------------------+ | 1. Cereals | 5. Vegetables | 9. Milk | | | | | | 2. Starchy roots and | 6. Fruits | 10. Eggs | | tubers | | | | | 7. Meat and poultry | 11. Oils, fat | | 3. Sugars | | | | | 8. Fish | | | 4. legumes and | | | | pulses | | | +-----------------------+-----------------------+-----------------------+ 2. The local production of the foods in each group is calculated and added to it the amounts imported or obtained as a gift or donation. 3. The amounts exported or not used for person's diet (used in agriculture, fed to animals, used in industry or wasted are subtracted from the above value. The difference represents the amount actually eaten by the people and is called the balance. 4. The balance is divided by 365 then by the mid-year population to get the individual chare from each food group (the average diet). Total food consumption = (food produced locally + food imported) - food exported \ [\$\$Total\\ food\\ consumption\\ per\\ capita\\ per\\ day\\ = \\ \\frac{\\text{Total\\ food\\ consumption}}{Mid\\ year\\ population\\ \\times \\ 365}\$\$]{.math.display}\ This is done for every calendar year separately by the ministry of agriculture and published by the FAO. **[Advantages:]** 1. It shows the pattern of food consumption in the country. 2. By comparing the average food consumption in successive years, we can determine the trend of food consumption whether it is improving or not. 3. Comparison of food consumption in different countries. 4. By the use of food composition tables we can determine the nutritive value of the average food consumption and this help to plan the nutritional policy for the nation. **[Disadvantages:]** 1. This method assumes that the available food is distributed equally among people and this never happens as many factors determine food consumption (economic state, food habits, etc.). 2. The nutrition requirements are not the same in all the people as they differ according to age, sex and physiological state. **Pattern of food consumption in Egypt** The characteristic food balance sheet for Egypt: 1. A very high consumption of cereal foods, mainly those made into bread (wheat, maize and millet). 2. A very low consumption of animal foods (meat, fish, milk and eggs). 3. A moderate consumption of vegetables and fruits. 4. Somehow low consumption of legumes mainly in the form of beans and lentils. 5. Somehow low consumption of fats and oils. **From the above pattern we can expect that:** a. The excessive energy derived mainly from cereals leads to overweight or even obesity among Egyptians. b. Protein deficiency must be expected because of low consumption of animal proteins (high biological value), and most proteins come from cereals (low biological value). Protein deficiency more likely to occur in growing children, pregnant and lactating females. c. As most of iron comes from cereals, then most of it is unabsorbed owing to presence of phytic acid, phytates, and phosphates on cereals. Thus we expect high prevalence of anemia among Egyptians. d. Diseases like beri-beri and scurvy are unlikely to be present in Egypt, because cereals supply more than enough vitamin B1 and fruits mainly and vegetables to some extent supply vitamin C. A. **Vital statistics** - Infant mortality is a sensitive indicator of hygienic conditions in a community, and reported to be high in countries where malnutrition is common. - Neonatal mortality - Perinatal mortality - Under five mortality - Diarrhoea: malnutrition is a primary cause of diarrhoea. So statistics on diarrhoea is a valuable index of malnutrition. - Measles: Its mortality and severity is much worse in malnourished communities. - Tuberculosis: Malnutrition affects the incidence and mortality from TB. - Anemia, rickets, PEM **\ ** []{#_Toc19366679.anchor}**Dietetics** Dietetics means practical application of the principles of nutrition; it includes the planning of meals for the well and the sick. In some diseases, the patient can be kept on the usual diet, while in others, the diet is modified into\" therapeutic diet\" with the following objectives: 1. Suit manifestations of the disease as in pyrexia, or diarrhea 2. Meet the particular dietary needs of the case as restriction of protein or fat. 3. Help saturation of the tissue reserves and restoration of physiological functioning that contribute to body resistance and improve prognosis. 4. Compensate for any existing or expected deficiency. The rapidly increasing worldwide prevalence of chronic diseases such as diabetes mellitus, hypertension and hyperlipidaemia as a result of population's progress to adopt an unhealthy eating pattern and sedentary lifestyle has led to a significant proportion of mortality and morbidity. Hence, dietary component remains the cornerstone in chronic disease management for people who suffer from chronic diseases as well as for those who are at risk of developing diseases, apart from medication and physical activity. **Medical nutrition therapy (MNT):** - Refers to the dietary management of patients with diet-related medical conditions in the form of assessment, education and counseling and recommendation of special nutrition supplements, in order to improve the patient's overall health status and to reduce healthcare cost involved in disease management. - is considered as an integral part in chronic disease management as part of the evidence-based clinical practice guidelines. **\ ** ### Medical Nutrition therapy of diabetes Type 2 diabetes is the more common form of diabetes, mainly occurring in elder persons and is associated with obesity among the population. In view of this, medical nutrition therapy should emphasize on: Type 1 diabetes: the main effort should be directed towards dietary manipulation and insulin therapy to improve glycemic control. *Nutrition intervention for type 1 diabetes*: insulin therapy should be integrated into an individual's dietary and physical activity pattern. Individuals using rapid-acting insulin by injection or an insulin pump should adjust the meal and snack insulin doses based on the carbohydrate content of the meals and snacks. For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept consistent with respect to time and amount. Type 2 diabetes: gradual weight loss (0.25 to 1.0kg/week) for overweight people via diet and lifestyle modifications. Also, diet plan should be tailored to individual preference, physical activity level, cultural and ethnic practices; and dietary habits. Special attention on dietary requirements should be paid to patients with diabetes during their sick days, travel, exercise; pregnancy and lactation for female patients as well as youth and elderly persons. **[Calories]** should be tailored to the needs of the patient. The overweight diabetic patient is started on a reducing diet of approximately 1000-1600 Kcal daily. The lean patient is put on isocaloric diet. **[Carbohydrate (CHO)]:** Unrefined CHO are [fiber] rich rather than simple sugars which is slowly absorbed preventing rapid swings in blood glucose. So eating an apple is better than drinking the same amount of CHO as apple juice. Dietary fiber intake should be increased, concentrating on soluble fibers as [pulses and fruits]. Dietary fibers may also promote satiety and [assist weight loss] (30 g fiber/day is recommended). **[Fat:]** should be reduced to less than 30% of the total energy intake. - - - - [**Protein***:*] - For individuals with diabetes and normal renal function, there is sufficient evidence to suggest that usual protein intake 15-20% of energy should be modified. - In individuals with type 2 diabetes, ingested protein can increase insulin response without increasing plasma glucose concentrations. Therefore, protein should not be used to treat acute or prevent night time hypoglycaemia. - High protein diets are not recommended as a method for weight loss at this time: - The long term effects of protein intake \>20% of calories on diabetes management and its complications are unknown. - Although such diets may produce short-term weight loss and improved glycemia, it has not been established that these benefits are maintained long term, and long term effects on kidney function for persons with diabetes are unknown. **[Salt:]** Should be limited to \

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