An introduction for students of

Second Edition

Lecturer
Department of Food Technology and Nutritional Science

Santosh, Tangail-1902.

First Edition October, 2008

Second Edition April, 2009
All rights reserved by the Students of FTNS, MBSTU.
Dedicated to
Newborn LBW baby whose need better care and nutrition.
Preface to the second Edition
Nutrition plays an important role in normal growth and development and more so in the
prevention and treatment of various communicable and life style diseases. This introduction to
the HUMAN NUTRITION AND DIETETICS is intended, in the first place, for the use of
students of Food Technology and Nutritional Sciences. It incorporates all the basic needs of
normal nutrition including infants, children, adolescent, adults, pregnant, lactation as well as
geriatric nutrition. An effective diet plan should be taking into considerations the tastes, eating
patterns, cultural patterns and nutritional needs of the individuals. This edition especially
introduces the basic human needs and dietary guidelines for nourishment and betterment of
health.
I am greatly indebted to Dr.K.M.Formuzul Haque for his encouragement and advice and
cordially acknowledged to all my colleagues for their help in the writing this book. I am
extremely grateful to my family members and all team leaders of study groups especially Rochi,
Razon, Shawon, Modumita, Hannan, Setu, Shamoli, Nazmul, Jahangir, Fazlu, Shakat Riaz for
their enthusiastic support.
I am thankful to all the students of the FTNS department, MBSTU, for their wholehearted
support and cooperation.
April, 2009.
A.K.Obidul Huq

Chapter-1: Introduction to Human Nutrition and Dietetics

Human Nutrition
Human nutrition is the scientific discipline that deals with nutrition in man. In particular it is
concerned with the nutritional requirements, food consumption, food habits, the nutritive value
of foods and diets, the relationship between diet and health, and with research in these fields.
Dietetics
Dietetics is the subjects which deals with general diet menu designed for individual (infant,
children, adolescence, adult, pregnant, lactation, old age) who require normal diet and who
require extensive modified diet (therapeutic diet).
Therapeutic Diet
Therapeutic diet is that component of treatment of an individual with an acute or chronic
disease which includes or involves modification food intake. In addition pre-mature birth
inherited metabolic disorders (Galactosamia) temporary infection use of some medication needs
dietary modification.
Classification of Therapeutic Diet
According to function, Therapeutic diet is classified into 4 groups:
1. Primary Therapy: Here diet is the only way to treat the disease. e. g. NIDDM (Non
Insulin Dependent Diabetes Mellitus). Carbohydrate modification is used Noncomplicated obesity. Inherent metabolic disease Galactosamia, vitamin A deficiency,
Iron deficiency anemia, Iodine deficiency problem.
2. Integral Therapy: It is used in conjunction with therapeutic agents. i.e. here both diet
and medicine is required, e.g. Atherosclerosis, IDDM.
3. Adjunct therapy: Here diet helps but not an integral part, e.g. hypertension. Na may
be restricted, but medicine is must. Ulcer irritating foods should be avoids but
medicine is essential.
4. Supportive Therapy: Medical treatment is the only way to treat the disease, but a good
diet helps to recovery fast, e.g. bone fracture after surgery diet.

Purpose of Diet Therapy:

3

1. To bring about change in body weight, whenever necessary.

Obese (normal) underweight
2. To maintain in good nutritional status.
3. To correct nutrient deficiency that may occur.
4. To adjust food intake to bodies ability to metabolize the nutrient.
e.g. Carbohydrate in diabetes mellitus.
Dietitian: Dietitian is a person who translates the science of nutrition into practice in furnishing
the best possible nourishment of the people.
Dietitian works in:
1. Hospital
2. Education institution (#. Research #. Teaching)
3. School going children diet
3. Primary private clinic (RD=Registered Dietitian)
4. Industries lunch
5. Business center
6. Community service agencies
7. Govt. agencies.
Types of Dietitian:
According to activities of works, dietitian are 4 types.
1. Therapeutic Type: He/she is a member of health core team in a hospital. He/she meets a
medical stuff and discuss procedures for implementing diet orders.
Physician: Disease diagnosis and for this patient Give medicine and suggest proper
diet.
Suppose 2000 kcal diet and 30g high quality protein, low fat. Dietitian will be
prepare this diet chart and supply it to the kitchen.

2. Clinical Dietitian: He/she works in a private clinic. They provide diet for non
hospitalized subjects. The subjects are either refered by physician or they come by
themselves (knowledgeable person). The clinical dietitian note their history of food
intake, family history of disease, disease record if any, if need ask for blood/stool/urine
examination and then prepare diet chart accordingly.
3. Research Dietitian: He/she works in medical centre, research centre, university. They
perform human metabolic studies to different subject according to problem, provide diet
analyze nutrients from blood given and from food stuff and stool and urine collected for
24 hours and finally from the experimental results, dietitian prepare diet chart for
specific disease/condition.
4. Administrative Dietitian
They work in food department (policy making govt.). They supervise/ advice person
involved with food formulation policy better nutritional food production or import for a
nation. Also helps in food cost accounting.
Role of dietitian:
1. Dietitian has an important role especially planning the diet of a convalescing patient
plan a diet as per the doctors diet prescription.
2. Prepare the patient mentally to accept the modified diet.
3. Plan the diet and make it more appetizing and appealing.
4. Enlightens and motivate the patient as per the needs regarding the technical and
scientific aspects governing the diet.
Factors to be considered in planning or preparing a diet chart:
1. The subjects/patients ht, wt, BP, body frame, physical activity, complication to be noted.
2. Recent blood/stool/urine analysis report if available should be checked. If needed ask
the subjects to analysis blood/stool/urine and bring the report.
3. Family history of disease to be known.
4. The diet chart should be nutritionally adequate, but should full with in limits and
therapy (i.e. consider disease condition and modify diet accordingly. e.g. diet for
5.
6.
7.
8.

atherosclerosis, prepare diet.

Take food intake history and identity deficiency or excess nutrient excess.
For patient history and duration of disease to be known.
Subject economic condition o be known.
Take care of individuals liking and disliking.

9. Consider a) Religious and cultural preferences.

5

b) Family background and status.

c) Methods of food preparation.
d) Eat all persons at a time or separately.
10. Whether patient / subject has basic knowledge on nutrition, nutrient rich
food stuff,

best cooking process, children / pregnant / lactating mothers

should give more food etc.

11. Psychological influence illness usually changes persons behaviors fear,

worry ness,

insecurity, frustration, change patients behavior which affect food intake.

12. Also appearance of food, glass, plate, trays etc. should determine food intake.
13. Also same food preparation everyday and same procedure.
14. Consider age and physical condition children / elderly
15. Suggest food items such a way that can fulfill has / her requirement and at the same time he/
she can digest the food, chew the food, able to metabolize the food.
16. Consider season available of food in particular season especially in case of fruits and
vegetables.
17. Consider location availability of food by his /her surroundings e.g. do not advice sea fish
who lives far from sea.
18. Diet chart should include varieties of food within same group (e.g. carbohydrate group,
protein group, fat group).
19. Consider duration of the diet. If it is for 1-2 weeks and if the diet is deficient in one /two
nutrient (e.g. CA, P) than it is ok, but if the diet is for long time than provide the required
nutrient even by supplementation.
20. Total diet for 24 hour should be divided into at least 3 times / frequent small meal (5/6) is
better.
21. The diet should be acceptable and understandable by the subject.
22. Modified diet according to subject / patient improvement
6

Balanced Diet: A balanced diet is defined as one which contains a variety of foods in such
quantities and proportions that the need for energy, protein and all nutrients are adequately
meet, for maintaining health, vitality and general well-being and also makes a small provision
of extra nutrients to withstand short duration of weakness.
Balanced diet - a diet containing all the nutrients needed by the body to function well. This is
attained by eating the right combination of foods in proper quantities. Generally, a nutritious
and well balanced diet is composed of a variety of foods selected from the three basic food
groups:
A balance diet is one which contains all the food constituents in proper proportions to
Meet the energy and nutritional requirements of the individual.
The GO or energy -rich foods, the GROW or body-building foods and GLOW or bodyregulating foods.
Factors to be considered:
1. Nutritive values of the food items
2. Age, sex, body weight, height
3. Physiological and pathological conditions , e.g. sickness/ lactation
4. Physiological activities and profession, e.g. sedentary , moderate, mild activity
5. Socioeconomic status
6. Cost and availability of foods
7. Food habits , food choices
8. Religion and customs
9. Climates
10.

BMR ( Basal Metabolic Rate )

Importance of balance diet: A balanced diet is an accepted meal to safeguard a population

from nutritional deficiencies. It has got the following importance:

1. It contains energy yielding, body buildings and protective foods in correct proportions
and every individual is assured of obtaining the requirement of all the nutrients.

2. It also makes a small provision of extra nutrients to withstand short duration of leanness.
3. It facilitates development of an analytical and chemical approach to food and diet.
4. It is designed to prevent under and over nutrition of the community
7

5. At present the concept of important of dietary fibre has been incorporated in the
formulation of balance diet which protects the population from many diseases like colon
cancer, diabetes, CHD etc.

6. As it is designed by taking economic condition, religion, personal likings and disliking,

food availability into considerations, it provides total protection from the community for
which it is constructive.

********************

Chapter-2: History of Nutrition.

Definition and Concept of Nutrition
"To eat is a necessity, but to eat intelligently is an art."La Rochefoucauld
Nutrition means the taking in and use of food and other nourishing material by the body.
Nutrition is a three part process.
First, food or drink is consumed.
Second, the body breaks down the food or drink into nutrients and
Third, the nutrients travel through the bloodstream to different parts of the body where they are
used as "fuel" and for many other purposes.
To give the body proper nutrition, a person has to eat and drink enough of the foods that contain
key nutrients.
Nutrition, by definition, is the way our bodies take in and use food. Foods that are great sources
of nutrition are called nutrients. Nutrients can be defined as chemical substance present in
foods which produce energy. There are six different types of nutrients, such as carbohydrates,
fats, proteins, vitamins, minerals and water.

Nutrients give us energy, growth, help repair body tissues, and regulate body functions.
Therefore each nutrient can be vital to your health.
In a more limited sense, the process by which the living tissues take up, from the blood,
matters necessary either for their repair or for the performance of their healthy
functions.
In the broadest sense, a process or series of processes by which the living organism as a
whole (or its component parts or organs) is maintained in its normal condition of life
and growth.
Finally we can say that Nutrition is the process whereby living organisms utilize food
for maintenance of life, growth, the normal functioning of organs and tissues and the
production of energy.
History of Nutrition
The imperative of preserving the historical records of science has long been appreciated
by scholars in many fields (e.g. Medicine, chemistry, mathematics, physics, and, more
recently, nuclear physics and biochemistry). Medicine and chemistry conspicuously have
led the way in building impressive centers of history. The science of nutrition had no
center of history until 1975, when Vanderbilt University created "An Accessible Archives
of Human Experience in Nutrition", consisting of an extensive collection of monographs
on the history of nutrition, 15th century-20th century, and an archive of the personal
papers of nutrition scientists.
This collection was formalized as a result of the initial major gift by Dr. W. Henry
Sebrell, Jr. of his papers and those of Dr. Joseph Goldberger. Vanderbilt's History of
Nutrition Collection and Archives has grown significantly since 1975 and has attained
national and international recognition.
This collection is maintained in the Special Collections of the Eskind Biomedical
Library. It represents the efforts and contributions of many individuals during the last
three decades plus the encouraging support of the Medical Center's administration and
of the major nutrition science society, the American Institute of Nutrition (AIN).
Beri-beri: "The first clinical descriptions of beriberi were by Dutch physicians, Bontius
(1642) and Nicolaas Tulp (1652). Tulp treated a young Dutchman who was brought back
9

to Holland from the East Indies suffering from what the natives of the Indies called
beriberi or "the lameness." Tulp's description of beriberi was a detailed one, but he had
no clues that it was a deitary deficiency disease. This discovery came more than two
hundred years later.
The early history of nutrition may be conveniently following head-lines
1. Chemical nature of plant foods and animal tissues
2. Respiration and Energy output in human subjects
3. Feeding Experiments
4. Observations on the treatment of certain diseases in human beings by changing diet.

Chapter-3: Composition of Human Body

Health: Health is a state of complete physical, mental and social wellbeing and not merely
absence of disease or infirmity so that each citizen can lead a socially and economically
productive life.
New philosophy of health:
Health is fundamental human right
Health is integral part of development
Health involves individual , state or international responsibility
10

 Health is essence of productive life.

Dimensions of Health
Four major dimensions of health included in the WHO definition of healthPhysical, Mental, Social and Spiritual
Besides these many more may be cited- emotional, vocational, political, philosophical, cultural,
socioeconomic, environmental, educational, nutritional, preventive and curative
Guidelines for Good Health
The guidelines for good health are given bellow:
1. Maintain regularity in your routine.
2. Eat as much natural food as you can.
3. Consume seasonal foods as far as possible.
4. Eat well but do not overeat.
5. Avoid excessive salt and spices.
6. Avoid too much sweet, especially sugar.
7. Eat foods which contain carbohydrate, especially starch and fiber.
8. Avoid food that contain large amount of cholesterol and saturated fat.
9. Measure own weight regularly and maintain ideal weight.
10. Avoid eating the same kind of food all the time. Eat a variety of food.
Composition of Human Body
The human body is divided into three compartments,
Body cell mass, 55 percent;
Extra cellular supporting tissue, 30 percent;
Body fat, 15 percent.
The body cell mass is made up of cellular components such as muscle, body organs (viscera,
liver, brain, etc.) and blood. It comprises the parts of the body that are involved in body
metabolism, body functioning, body work and so on.
The extracellular supporting tissue consists of two parts:
11

The skeleton and

Other supporting structures.
The extracellular fluid (for example, the blood plasma supporting the blood cells) and the
skeleton and other supporting structures
Body fat is nearly all present beneath the skin (subcutaneous fat) and around body organs such
as the intestine and heart. It serves in part as an energy reserve. Small quantities are present in
the walls of body cells or in nerves.
A common determination is to estimate lean body mass (LBM) or the fat-free mass of the body.
These measures vary from the very simple to the very difficult. The simpler ones are of course
less precise.
Anthropometry using weight, height, skin fold thickness and body circumferences is relatively
easy and very cheap to undertake, and does provide some estimate of LBM and body
composition.
In contrast, methods using, for example, bioelectrical impedance, computerized axial
tomography (CAT scans) and nuclear magnetic resonance require expensive apparatus and
highly trained staff.
The fluid in the cells (intracellular fluid) has mainly potassium ions, and the
extracellular fluid is mainly a solution of sodium chloride. Both also have other ions.
Total body water can be estimated using different methods including dilution techniques
to measure, for example, plasma volume.
Body fat is estimated using different methods. Because a large portion of adipose tissue
is present beneath the skin, it can be estimated by using a skin fold caliper to measure
skin fold thickness in different sites .
Another method is to weigh the person both in air and under water using a special
apparatus and tank. This method really provides an estimate of body density.
Body composition is much influenced by nutrition. The two extremes are the wasting of
nutritional marasmus and starvation and the overweight of obesity.
Body composition differs between the genders and, perhaps only slightly, among races.
12

African Americans have been shown to have heavier skeletons than whites of the same
body build in the United States. In females pregnancy and lactation influence body
composition.
The body composition of children is influenced by their age and growth. Disturbances of
growth resulting from nutritional deficiencies influence body composition, including the
eventual size of the body and of body organs.

******************

Chapter-4: Concept on RDA of the Nutrients for Human Life Cycle

Recommended Allowances and Requirements: Recommended daily allowances (RDAs) for

protein, vitamins and minerals are estimated with an extra safety margin to ensure that the
whole populations needs are covered. Allowance for a nutrient is a value estimated to cover the
needs of 97% of the population. This value is calculated by estimating a mean + 2 SD) or the
observed requirements in a group of Individuals.
RDAs may vary from country to country according to levels of intake intended to be achieved.
Requirement for a particular nutrient or energy, on the other hand, is the amount necessary to
ensure normal physiological functions, and to prevent occurrence of symptoms of deficiency.

RDA (Recommended dietary allowance)

13

RDA is the levels of intake of essential nutrients consider being adequate to meet the known the
nutritional needs of practically all healthy persons.
RDAs are categorized

For both sexes,

For different age group,

For pregnancy and lactation, and

Sometimes for different kinds of physical work.

RDA as have usually been calculated

On the basis of a certain physique (`reference man or woman`, etc), and

On assumptions concerning the level of activity.

History of RDA: The RDA was developed during World War 2 by Lydia J.ROBERTS, Hazel
K. Stiebeling and Helen S. Mitohell under the auspices of the Nation Research Council.

The Nation Research Council determined a set of dietary standards were needed, especially
given the possibility that rations would be needed during the war. The standards would be used
for overseas population who might need food relief. Roberts, Stiedeling, and Mitchell surveyed
all available data, created a tentative set of allowances, and submitted them to experts for
review. The final set of allowances was accepted in 1941. The allowances were meant to provide
superior nutrition for civilians and military personnel, so they included a `margin of safety. `
The RDA was established by the food and Nutrition Board of the (US) National Academy of
Sciences. In 1997 at the suggestion of the Institute of Medicine of the National Academy RDA
become one part of a broader set of dietary guidelines called the Dietary Reference Intake used
by the United States and Canada.
Factors Affecting RDA
The nutrition requirements are affected by several factors such as:
Age- (infant, adolescent, aged). Infants require more per kilo gram of body weight that
adolescents, since their metabolic rate is much faster than that of adolescents.
Sex- (male of female) adolescent girls require more iron that adolescent boys in order to
replace the iron lost during menstruation every month.
14

 Body size- (height, weight, surface area, stature). A tall heavily built man needs more
calories than a small-stature man, since his bob surface area is more than that of the latter.
Physiological state- (pregnancy, lactation). A pregnant woman requires more nutrition food
than an ordinary adult woman, since she has to meet the additional nutritional requirements
of the growing fetus.
Type of work- (sedentary, moderate, heavy). A sedentary worker requires less calories than a
heavy worker, since the former expends less energy than the latter during work.
The RDA may then be considered as The Nutrition Yardstick

Uses of RDA: They are mainly used:

As a basis for all feeding programs such as school-lunch programmers.

To interpret food consumption records.
To evaluate the adequacy of food supplies in relation to nutritional needs.
To establish guidelines for public food assistance programmers
To develop and evaluate new food products developed by the food industry.
To establish guidelines for labeling of food from the nutritional standpoint, and most

important.
To develop nutrition education programmers

When studying RDA, it must be remembered that an excess for all nutrients except energy has
been given. To be on the save size, some people may consume excess of these, but it must be
borne in mind that not all nutrients are well tolerated if taken in excess of RDA e.g. vitamins A
and D are stored in the body and may toxic effects unlike water soluble vitamins B and C, which
if consumed in excess of the requirements will be excreted by the body. Also an excess of energy
intake daily, however small, can result in overweight and lead to obesity in the long run.
With regard to body requirements, the concept of bioavailability has emerged recently.
Bioavailability means ho much of the nutrient that is ingested actually gets digested and is
absorbed across the intestines. This amount is the amount which is actually made available to
the body for further use. When considering the requirement of any nutrient, this important
aspect has to be taken into account. Several studies in this regard are being carried out. This
idea is being developed and soon we will become familiar with it as more data and knowledge is
generated in the coming years.
Reference Daily Intake: (RDI) is the daily dietary intake level of a nutrient considered
sufficient to meet requirements of nearly all healthy individuals in each life stage and gender
group.
15

The RDI is used to determine the Recommended Daily Value (RDV) which is printed on food
labels in the U.S and Canada. RDI is the current status of RDA.
RDI is based on the Dietary Reference Intake (DRI)
They are intended to serve as nutrition guidance to the general public and health professionals.
USES:

i. Food labels.
ii. Composition of diets for schools, prisons, hospitals or nursing homes.
iii. Industry developing new food stuffs.
iv. Healthcare policy makers and public health officials.

RNI (Recommended Nutrient Intake): is the level of dietary intake thought to be sufficiently
high to meet the requirements of almost all individuals in a group with specified characteristics.
RNI takes into account individual variability. Of necessary, the RNI exceeds the requirement of
almost all individuals (Health and Welfare Canada, 1983)
The presence of experts from the Food and Agriculture Organization/World Health Organization
(FAO/WHO) and the United States should provide valuable input of experiences from all over
the world and from the country with the most advanced research in nutrient requirements.
It was believed that a situational analysis of the currently available RDAs in the Southeast Asian
region could provide useful input for the workshop discussions. This overview attempts to
collate and analyze the RDAs in the region for commonalities and differences and to highlight
specific and special features. It is hoped that this paper will serve as background information
for further deliberations during the workshop and discussion sessions.
For this purpose, RDAs currently in use in the following six Southeast Asian countries were
obtained for the review: Indonesia,1 Malaysia,2 Philippines,3 Singapore,4 Thailand,5 and
Vietnam.6 In addition, recommendations from WHO/FAO7-9 as well as RDAs used in the United
States10 were included for comparison. Brunei Darussalam uses a combination of several
RDAs, especially the Malaysian and British RDAs. Recommendations for the most relevant
nutrients in the region-namely, energy, protein, calcium, iron, vitamin A, thiamin, riboflavin,
folate, vitamin B2, vitamin B12, vitamin C (ascorbic acid), and iodine-are tabulated and
compared for the different countries and according to age.

16

Documentation of the RDAs received were incomplete in most cases, where only the nutrients
tabulated were received by the author. The development process or steps and the rationale for
the levels of the various recommendations were thus unclear. Some of these aspects, especially
with regard to current and future developments in the review of national RDAs, are reported
herein by the representatives from various countries.
General Comparisons: The various RDAs have widely differing years of implementation; the
oldest is the Malaysian RDA, which was introduced in 1975. Most of the RDAs were introduced
in the late 1980s or early 1990s. The Vietnamese RDA was adopted by various sectors in the
country and was formally signed by the Minister of Health in September 1996. Indonesia also
has high political backing of the RDA, which was officially released as a decree of the Minister
of Health in 1994. Several versions of the WHO RDA for specific nutrients are used in this
review. The nutrients listed differ widely, but the core group of nutrients is similar; the most
common ones are energy, protein, calcium, iron, thiamin, riboflavin, niacin, vitamin A, folate,
vitamin B2, vitamin B12, and vitamin C. Thailand and the United States also listed requirements
for several other micronutrients.
The different RDAs adopted different age groupings, especially from adolescents onward.
Indonesia, Malaysia, Philippines, and Thailand refer to adults from 20 years onward;
Singapore, Vietnam, the United States, and WHO use 18 years and above. In the RDAs for the
United States and Indonesia (female), requirements for adults over 50 years old are separately
listed; requirements for adults over 60 years of age are separately listed for Indonesia (male),
Singapore, Thailand, and Vietnam. For Malaysia and the Philippines, a cutoff of 70 years is
used for older adults. With the exception of Malaysia and Vietnam, the median weight and
height for each age group in the RDAs are given.
Comparison of RDAs is complicated by the use of different body weights in different countries.
Body weights used in the US RDA are the highest for all age groups in all countries studied.
WHO uses a wide range of body weights for each age group. Among the Southeast Asian
countries, body weights used also differ considerably for all age groups.
Nutrient Levels: Estimated nutrient levels in the USDA Food Guide at the 2,000-calorie level,
as well as the nutrient intake levels recommended by the Institute of Medicine for females 19-30
years of age.
Nutrient

USDA
17

ICM Recommendations for

Food Guide

Females 19 to 30

Protein, g

91

RDA: 56

Protein, % kcal

18

AMDR: 10-35

Carbohydrate, g

271

RDA: 130

Carbohydrate, % kcal

55

AMDR: 45-65

Total fat, g

65

Total fat, % kcal

29

AMDR: 20-35

Saturated fat, g

17

Saturated fat, % kcal

7.8

As Low As Possible

Monounsaturated fat, g

24

Monounsaturated fat, % kcal

11

Polyunsaturated fat, g

20

Polyunsaturated fat, % kcal

9.0

Linoleic acid, g

18

AI: 12

Alpha-linolenic acid, g

1.7

AI: 1.1

Cholesterol, mg

230

As Low As Possible

Total dietary fiber, g

31

AI: 28

Potassium, mg

4,044

AI: 4,700

Sodium, mg

1,779

AI: 1,500, UL: <2,300

Calcium, mg

1,316

AI: 1,000

Magnesium, mg

380

RDA: 310

Copper, mg

1.5

RDA: 0.9

Iron, mg

18

RDA: 18

1,740

RDA: 700

Zinc, mg

14

RDA: 8

Thiamin, mg

2.0

RDA: 1.1

Riboflavin, mg

2.8

RDA: 1.1

Niacin equivalents, mg

22

RDA: 14

Vitamin B6, mg

2.4

RDA: 1.3

Phosphorus, mg

18

Vitamin B12, g

8.3

RDA: 2.4

Vitamin C

155

RDA: 75

Vitamin E (AT)

9.5

RDA: 15.0

1,052

RDA: 700

Vitamin A, g (RAE)

RDA = Recommended Dietary Allowance; AI = Adequate Intake; AMDR = Acceptable

Macronutrient Distribution Range; UL = Upper Limit; AT = mg d--tocopherol; RAE = Retinol
Activity Equivalents

List of RDA of nutrients in Bangladesh

Name of Moi

Fibe

Calor

Prote

Lipi

Carbo

Calc

Iro

Cerat

Vit

Vit

Vit

the food

ie

in

hydrat

ium

enoid

B-1

B-2

stur
e

Rice

12.

Wheat

6
12.

349

8.5

.6

77.4

10

2.8

.27

.12

1.2

346

11.8

1.5

71.2

41

4.9

64

.45

.12

Pulse

8
10

2.3

345

28.2

.6

56.6

90

6.3

120

.39

.41

GLV

92

27

2.2

.2

4.2

164

10

1275

.02

.36

64

2.2

0
1052

.04

.04

.03

.03

10

Colored

85

1.2

57

1.2

.2

12.7

27

vegeta
Potato

74.

.4

97

1.6

.6

22.6

11

.7

0
.03

Fruits

7
81.

5.2

51

.9

.3

11.2

10

1.4

100

.21

.09

21

Fish

7
53.

273

21.8

19.4

2.9

180

2.1

0
24

Meat

7
72.

109

25.9

.6

25

.14

Kilojoule (KJ): A Joule is the energy expended when one kilogram is moved one meter by a
force of one Newton. This is the standard unit of energy used in human energetic. Because
19

Nutritionists are concerned with large amounts of energy, they conventionally use kilojoules
(KJ=103J) or mega joules (MJ=106J)
One KCa1 is equivalent to 4.184KJ.
Physical Activity Level (PAL): PAL means the total energy requirement for a 24 hour period. It
is calculated by the expression:
The total energy required for 24 hours
-------------------------------------------------------The basal metabolic rate over 24 hours
Definition of Energy Requirement: The energy requirement, of an individual is the level of
energy intake from food that will balance energy expenditure when the individual has a body
size and composition, and level of physical activity, consistent with long-term good health; and
that will allow for maintenance of economically necessary and socially desirable physical
activity. In children and pregnant or lactating women the energy requirement includes the
energy needs associated with the deposition of tissues or the serration of milk at rates consistent
with good health.

Requirement estimates refer to needs persisting over moderate periods of time. The
corresponding intakes may be referred to as habitual or usual to distinguish them from
intakes on a particular day.

It is not necessary that, these amounts must be consumed each day. For a given level of
body weight, physical activity and appropriate growth rate, there is only one level of
intake at which energy balance can ho achieved. If the Intake is above or below the
requirement, a change in body energy storage occurs unless energy expenditure is
correspondingly attested.

Components of Energy Requirements:

Energy needs are determined by energy expenditure and estimates of requirements should be
based on measurements of energy expenditure. However, because of the difficulty of obtaining
such information sometimes the only feasible approach is to estimate requirements from
measurements of habitual intake compatible with a steady state and appropriate body
composition and levels of activity.
The components of energy requirements are:
20

1. Basal Metabolic Rate (BMR)

2. Activity level
3. Metabolic Response to Food
4. The Fourth component of energy requirement is the energy cost of growth which includes two
components: a) the energy value of the tissues formed, and b) the energy cost of synthesizing
them.
BMR (Basal metabolic rate)
The metabolic rate at basal condition of the body is called BMR. In the majority of cases the
largest component of energy expenditure is the basal metabolic rate (BMR). The BMR is
determined principally by body size, body composition and age. The BMR per unit of weight
varies with age; it is higher in children than in elderly. The BMR per unit of weight varies with
also weight; it is higher in short and light individuals than in tall and heavy ones.

Physical Activity
Some activities are essential for the individual and the community and can be considered as
economic activities which arc lifesustaining. These activities are designated as occupational
activities.
Some activities are also considered essential for physical and intellectual wellbeing of the
individual , household or group which are called discretionary activities
PAL Level
Young Men

Light

Moderate

1.7 X BMR

Young Women 1.7 X BMR

2.7 X BMR
2.2 X BMR

Heavy
3.8 X BMR
2.8 X BMR

Metabolic Response to Food

The metabolic activities of the body are stimulated after absorption of food with the result that
the heat production increases. The increase in metabolism after ingestion of food is called
specific dynamic action (SPA) of foods. The increased oxygen uptake (specific dynamic action)
depends on the nutrient composition of food consumed, for proteins it is higher than that, for fat
21

and carbohydrates. The greater the energy demand of an individual the greater will be the
energy expenditure in digesting, absorbing and sorting the ingested nutrients.
Growth
The energy cost of growth includes two components: the energy value of the tissue or product
formed and the energy cost of synthesizing it. The total cost depends on the composition of the
product.

Energy Requirements of Adults

Energy requirements of adults are determined from body weight and levels of physical activity,
as defined by the BMR factor. Values of BMR factors appropriate for different levels of physical
activity are:

Average Daily Energy Requirement of Adults Expressed as a PAL Values

Activity levels

Male

Female

Light

1.55

1.56

Moderate

1.78

1.64

Heavy

2.10

1.82

Energy Requirements of Adolescents:

Because of the variable timing of adolescent growth spurt, it is recommended that estimates of
requirements should be based on weight rather than age, provided that the age is within the
acceptable range of weight for height.
Energy Requirements of Infants and Children
The calculation of energy requirements of children is done in two stages:
First- the requirement per Kg is obtained according to the age range and then this is multiplied
either by the actual body weight or by the median weight for age.
Daily Average Energy Requirements for Infants and Children aged 3 Months to 10 Years:
22

Age Range and Sex

Median Weight
(Kg)

Energy Requirements

Kcal / Kg Kcal / day

3-6 Months

7.0

100

700

Sexes

6-9 Months

8.5

95

810

Com-

9-12 Months

9.5

100

950

11.0

105

1150

13.5

100

1350

3-5 Years

16.5

95

1550

Boys

20.5

90

1850

7-10 Years

27.0

78

2100

Girls

20.5

85

1750

27

67

1800

-Bined 1-2 Years

2-3 Years

5-7 Years

5-7 Years

7-10 Years

Energy Cost of Pregnancy and Lactation:

Energy needs increase from the first to the third trimester during pregnancy. During early
stages the pregnant woman is able to store energy for use later. Therefore, only a single figure is
given for the extra amount of energy needed per day throughout pregnancy.
In lactation it is assumed that part of the extra energy requirement for mi1k production is met
from the fat Stores laid down during pregnancy.

Daily Average Extra Energy Requirements during Pregnancy and Lactation

Pregnancy

Lactation

Full Activity

: 285 Kcal / day

First 6 months

Reduced Activity

: 200 Kcal / day

After 6 months : 500 Kcal

23

: 500 Kcal

Chapter-5: Nutrition in Maternal and Child Health (MCH)

Under nutrition is associated with adverse human outcomes, premature death being the most
serious. The relative risks of infection increase exponentially as stunting prevalence increases,
such that malnutrition is

associated with an estimated 2.8 million child deaths each year, or

51% of child deaths in nine low-income Asian countries including Bangladesh. Childhood
malnutrition in Asia is greater than anywhere else. One in every three Preschool children in
Asia is stunted, and in the countries of South Asia, such as BANGLADESH and India, this
proportion is as high as one out of every two children. Seventy percent of the worlds
malnourished children reside in the region. Malnutrition occurs at all stages of the life cycle
(Fig-1).

Maternal health and nutritional status in Bangladesh:

In Bangladesh, the poor maternal nutrition status throughout their life cycle is indicated by low
BMI, low weight gain during pregnancy and low birth weight of their babies. Fewer than half
(45.4%) of mothers are acutely malnourished (BMI <18.5). The average weight and height of
24

non-pregnant women range from 39-41kg and 147-148cms respectively indicating prevailing
under nutrition among them. During pregnancy, mothers weight gain is only 4.7kg in rural
areas and 5.7kg in urban areas and in most instances they lose about 1 kg or each childbirth.
Social discrimination favouring male more than female, physical and mental tress, interfamily
food distribution favouring the male adult and the male child, food taboos, inadequate intake of
nutrients and micronutrients during pregnancy is the main causes of the problem.

5.1

Nutrition in Pregnancy

Nutritional status during pregnancy is extremely important. Not only does dietary intake
influence pregnancy outcome for both mother and child, but it also has a direct impact on future
lactation performance. The nutritional requirements of pregnant women are increased in
comparison with those of non-pregnant women, although not by as much as once believed.
During pregnancy, a number of metabolic and functional adaptations occur, particularly in
mechanisms for energy utilization. While the notion that a pregnant woman should "eat for two"
might be a useful educational analogy in cases where dietary intake needs to be increased, it is
nevertheless an exaggeration. Healthy well nourished mothers can go through pregnancy
without a significant increase in their dietary intake.
Pregnancy is a physiological, biochemical and hormonal changing condition. During this
physiological changes nutritional requirements of a pregnant women increase due to;
Rapid growth of the fetus
Development of the placenta
Enlargement of maternal tissue namely the breast and uterine tissue
Increase in maternal circulating blood volume
Formation of amniotic fluid
Storage reserves for mineralization of the skeletal and bone structure of the fetus and
tooth buds.
Weight gain in pregnancy
Pre-pregnancy weight is very important for healthy outcome. Recommendations for weight
during pregnancy should be individualized according to pregnancy body mass index (BMI)
(weight/height square or kg/m2) to improve pregnancy outcome, avoid excessive maternal
postpartum weight retention, and reduce risk of adult chronic disease in the child. Prenatal
25

weight gain within the Institute of Medicine (IOM) recommended ranges is associated with
better pregnancy (see Table 1), but many women do not gain within these ranges.

Table 1: Weight gain Recommendations for Pregnancy

Pre-pregnancy weight
category

Recommended wt gain

Wt gain per wk after 12

weeks

Kg.

Pounds

BMI <19.8

12.5 18.0

28 40

BMI of 19.8 to 26.0

11.5 16.0

25 35

0.5 kg (~ 1 lb.)

BMI >26.0 to 29.0

7.0 11.5

15 25

0.4 kg

BMI >29.0

At least 7.0

15

0.3 kg

Source: Institute of Medicine (IOM), Nutrition during pregnancy, 1990.

Figure A: Components of weight gain in pregnancy: later weight gain ensures healthier birth
weight (Source: Hytten (1970) Maternal physiological adjustments. NAS, Wash. DC)
The timing of prenatal weight gain is also important. Many investigators agree that weight gain
in the second and third trimester is of greater importance for ensuring fetal growth than weight
gain during the first trimester. Examination of the components of a womans weight gain during
pregnancy supports the importance of later weight gain. Weight gained earlier in pregnancy
26

primarily contributes to maternal reserves, and is secondarily due to the growth of placenta,
breasts, uterus and increased amniotic and extra cellular fluids. Not until after twenty weeks
does the fetus begin to increase dramatically in size.

Sl
no

Items

Kg

Breasts

0.4

Fat

3.5

Placenta

0.6

Fetus (baby)

3.4

Amniotic fluid

0.6

Uterus (increase)

1.0

Blood vol. (increase)

1.5

extra cellular fluid

1.5

Total weight gain should be 12.5 kgs (expected increase).

Maternal Age and Pregnancy Outcome:
Maternal Age is very important in pregnancy outcome and the early health of children. It is
considered best for women to start having children in their early twenties and to stop at about
35 years or soon after. Very young mothers have problems not only their own health but with
that of their children well. The recent increase in teenage pregnancies provided some
opportunity to study the problem of childbearing at too early an age, but more investigation is
required, particularly in developing countries, because the mother may well still be growing
towards her final mature status and the nutritional and metabolic stress of pregnancy and
lactation will be exceptionally severe. There by, once the baby born faces grave difficulties
irrespective of nutritional status, there is more likelihood of low birth weight children, of
stillbirths and neonatal deaths among the children of mothers who are younger than 20 years.
The lower the age, the greater is the probability of difficulty. Studies on this issue indicated that
the optimal time for beginning child bearing is 22 to 23 years.
High maternal age, too is of important in this respect and especially in the developing world, a
woman having her first child in her early thirties is at special risk. Obstetrical complications
are greater and risks of stillbirth, of immunity and pre maturity are also higher, women who
27

continue child bearing into their late thirties or forties are also at risk as are their children.
Congenital malformations increase with birth order, both having separate, demonstrable effect.

Nutritional Requirement:
All nutrients are important during pregnancy but the nutrients needing the greatest increase are
protein, calcium, phosphorus, magnesium and folic acid.
TABLE-A: Safe levels of intake of selected nutrients for active women of reproductive age

Condition

Weight

Energy Protein Iron

Vitamin A

Vitamin C Folate

(kg)

(kcal)

(g)

(mg)

(g retinol)

(mg)

(g)

2 210

49

24-48

500

30

170

Not pregnant or 55
lactating
Pregnant

55

2 410

56

38-76

600

30

420

Lactating

55

2 710

69

13 26

850

30

270

Calorie Requirement:
According to ICMR Nutrition expert group recommended extra allowance of 150kcal/day during
1st trimester and 350kcal/day in the last 2 trimester.
Protein Requirement:
The requirement of protein in pregnancy is increased by about 30% over the normal. According
to ICMR Nutrition expert group recommended extra allowance of 14g/day.
Mineral Requirement:
Among the minerals, those involved in building skeleton-calcium, phosphorus and magnesiumare in great demand during pregnancy, and increases of about 50% are recommended. The body
conserves iron even more than usual during pregnancy. Menstruation ceases, iron absorption
increases, and the hormones of the pregnancy raise the concentration of iron in the blood. Thus
28

a woman theoretically needs no more iron during pregnancy than she has needed all along. But
most women minimal iron stores and the demands of pregnancy deplete them to the deficiency
point. Thus almost all pregnant women are advised to take an iron supplement throughout
pregnancy and for two or three months after delivery.

Vitamin Requirement:
The pregnant woman needs extra amount of folic acid. It is due to the great increase in her
blood volume. It is often advisable for the physician to prescribe folic acid as a supplement. The
vitamin needed in the next highest amount is other B vitamins associated with the manufacture
of red blood cell-vitamin B12.
Diet for Pregnant women:
The food selected for emphasis should normally those in the milk, meat and vegetable
categories. Because caloric needs increase less than nutrient needs, the pregnant woman must
select food high nutrient density. For most women, appropriate choices include food like milk,
cheese, lean meats, eggs, liver, dark-green vegetables and legumes, whole-grain breads and
cereals. For vitamin C-rich food such as broccoli or add a second, fair vitamin C source, such
as tomatoes.
Guidelines of a Balance Diet for Pregnant Woman
1. About 10% calories should derive from proteins and remaining from fat and
carbohydrate according to calculate references.
2. Good quality protein such as milk, meat, fish, eggs and cheese should be added to diet.
3. Additional requirement of protein for vegetarians may be obtained from a combination
of whole-grains, legumes and nuts.
4. Liberal amount of fresh fruits and flesh fruit juices are recommended from which extra
amount of vitamin C found.
5. Vitamin A rich food such as liver, egg yolk, butter, dark green and yellow vegetables and
fruits should be added.
6. Vitamin D rich food such as butter, egg-yolk, liver, fish liver oil should be added.
7. Dairy product should be included for the fulfillment of Ca requirement.
8. 30-60 mg additional elemental iron should be provided as supplementation.
9. 0.5 mg of folic acid to all women in the 2nd half of the pregnancy should be given.
10. Sometimes Ca tablet is recommended by the physician.
29

Bangladesh: Food taboos / misconceptions during pregnancy

Food items

Reasons for Restriction

Consequences

Fear of the epilepsy of

Protien

A). Fish
1). Cirrhina mrigala
(Mrigel fish)

the new born

2). Wallago attu

The baby will have

(Boal fish)

Protein

bigger mouth

3). Mastacemles armatus

Reason for foetus will

Protien

(Bain fish)

cramble inside the mother belly

B). Coconut (including

The eyes of the new born

Green coconut water)

C). Cucumber
(both varieties)
D). Duck egg

will look like coconut white

New born skin will be
scrachy

Fat, mineral
Carbohydrate
Vitamins
and minerals

the new born will have

Protien

harsh voice like duck

E). Twin banana or
any other fruits

There will be twin babies

born

Less intake
of CHO,vit

and minerals
F). Chicken egg

The baby will be chicken hearted

5.2
30

Protien

Nutrition in Lactation

Lactating mothers will lose their body-weight postpartum if they do not compensate with
additional food intake. For women who exclusively breastfeed their children, the average energy
costs for milk production are 595 kcal per day at 0-2 months post partum and 670 K. Cal per
day at 3-8 months. Energy needs are lower for women who partially breast feed, depending on
the extent to which supplementary foods are given to the child. Studies in developing countries
have consistently shown that energy in take during lactation is considerably lower than
recommended. In Bangladesh, production of mothers milk is limited by poor nutritional status
and concentration of nutrients is milk declined with infants age. The effect of lactation on
postpartum body-weight is controversial; some studies have not found any association, some
reported postpartum weight gain and many studies have shown a significant weight loss of
lactating mothers after postpartum period
Lactating mother's nutritional requirement should meet (1) her own daily needs (2) provide
enough nutrients for the growing infant and (3) furnish for the energy for the mechanics of milk
production. In every society there are some preference, belief, ideas and interests about food
intake of lactating mother. Traditionally these beliefs are inseparable from social, cultural and
religious factors of our country. It is recognized that all these factors are deeply involved in all
the affairs of human health and sickness. Irrespective of rural and urban areas, majority of our
people lack of knowledge of nutrition.
LACTATION
The process of formation and secretion of milk in the alveoli of breast and its expulsion
from mammary gland is called lactation.
Phages of Lactation:
Lactation include 4 phases1.

Mammogenesis:

It means development of breast. Female sexual hormones at puberty act on "the stromal
tissues, alveoli and ducts of the breast and influenced its development. Estrogen

31

causes development of stoma and duct system. Progesterone is responsible for the
development of lobule and alveoli.
2. Lacto genesis:
It means synthesis of milk. It is initiated by the prolactin and is continued by the GH,
thyroxin and ACTH. This three hormones form a modified solution of carbohydrate,
protein and fat etc.
3. Lactopoesis:
Continuation of lacto-genesis by maintaining the secretion of leutotropic hormone (LTH)
is called lactopoesis.
4. Ejection of Milk:
When baby sucks the breast, stimulation from nipple passes to hypothalamus which
stimulates posterior pituitary to secrete oxytocin. The oxytocin contracts the muscle fibre
(myoepithelial cells) of alveoli and duct repeatedly and initiate the ejection of milk.
Role of Hormones on Lactation (Mammary gland):
1.

Estrogen: Responsible for the development of stroma & duct system of the breast.

2. Progesterone: Responsible for the development of lobule & alveoli of the breast.
3.

Prolactin: i. Final development of breast.

ii. Synthesis and secretion of milk.

4. Oxytocin:
i.

Contraction of myoepithelial cells of breast.

ii. Ejection of milk.

iii. Contraction of uterus during parturation
5. Growth Hormone:
It is essential for overall development of breast.
6.

Thyroid hormone:

Helps in the development of breast and lactation by increasing the metabolism,

7. ACTH: It helps in development of breast.
Regulation of Lacto genesis
32

Immediately after the baby is born, the sudden loss of both estrogen and progesterone
secretion by the placenta now allows the lactogenic effect of the prolactin from the
mother's pituitary gland.
Over the next 1 to 7 days the breast begins to secret copious quantities of milk instead of
colostrum,

Areola

Nipple
Adipose tissue
Lactiferous duct
Lactiferous sinus
lampullai
Lobules and alveoli
Fig. The Breast & its Mammary Gland.
33

The secretion of milk requires an adequate secretion of most of the mothers other hormone
as well, are growth hormore, cortisol and parathyroid hormone. These hormones are
necessary to provide the amino acids, fatty acids, glucose and calcium that are required for
milk formation.
Low level of Estrogen & Progesterone > Anterior Pituitary - Prolactin
Breast > Milk scertion.

Process in milk secretion

It is the process by which the milk is ejected or 'let down' from the alveoli to the duct
before the baby can obtain it. The process is caused by a combined neurogenic and
hormonal reflex involving the posterior pituitary hormone oxytocin.
When the baby suckles the breast or when cries for milk, sensory impulse are
transmitted through somatic nerves from the nipples to the spinal cord and then to the
hypothalamus, there causing oxytocin secretion at the same time that they cause
prolactin secretion. Oxytocin then carried via blood to the breast, where it causes
contraction of the myoepithelial cells that surround the outer walls of the/alveoli, and
initiates the ejection of milk.
Composition of colostrums and milk (Units are weight per deciliter.)

34

Component

Human colostrum

Human Milk

Cows' Milk

Water, g

88

88

Lactose, g
Protein, g
Casein,
Ratio
Fats
Linoleic acid

5.3
2.7

6.8
1.2
1.2

5.0
3.3
3.1

2.9

Sodium, mg
Potassium, mg
Chlorid, mg
Magnesium, mg
Phosphorus, mg
Iron, mg
Vit. A, ug
Vit. D, ug
Thiamine ug
Riboflavin, ng
Nicotinic acid, jig
Ascorbic acid, ug

92
55
117
4
14
0.092
89

3.8
8.3%
of fat
15
55
43
4
15
0.152
53
0.032
16
43
172
4.32

3.7
1.6%
of fat
58
138
103
12
100
0.102
34
0.062
42
157
85
1.62

15
30
75
4.42

Nutritional Requirement (RDA) for Lactating Mother:

During lactation mothers requirement of different nutrient is increased. The extra nutrient is
mainly required for the production of milk. Lactating woman produce 800-850ml of milk daily,
this is equivalent of 600 kcal. With 80% efficiency in converting food energy into milk, a mother
needs an additional 750 kcal daily. The RDA table suggests that 500-550 kcal come from added
food, assuming the rest will come from the stores of fat her body accumulated during pregnancy
for that purpose. Calcium, phosphorus, magnesium and protein needs continue to be high
because these nutrients are secreted into the milk for the baby. Folic acid requirement is lower
in lactation than in pregnancy because the mothers blood volume declines.
Table: RDA for lactating mother
Group

Lactation

Energy

Prot

Fa

Iron

I2

VitA

VitB1

VitB2

Niaci

Folat

VitC

(Kcal)

(g)

(mg)

(g)

(g)

(mg)

(mg)

(mg)

2710

69

(g)
60

76

200

850

1.8

1.7

(mg)
18.2

(g)
270

30

Diet for lactating mother:

35

Logically, because the mother is making milk, she needs to consume something that resembles it
in composition. The obvious choice is cows milk. Basically, nutritious food should make up the
reminder of the needed kcal increases. As the breast milk is a fluid, the mothers fluid intake
should be liberal. A mother should need to drink between six and eight glasses of liquids daily.
Gu idelines for Nutritional Management
The diet during lactation is based on th e general diet f o r health by adults and should
include choices f r o m the four food groups in the m i n i m u m amounts listed in below
Table 1 foods may be taken in greater amounts or other food added to supply sufficient,
calories to meet individual needs.
M a n y fo od metabolites are excreted in breast m i l k and may cause gastrointestinal
distress in the baby. Onions, garlic, spicy foods, chocolate, and cola should
generally be consumed in moderation. Food metabolites usually appeal' in breast
m ilk w it hi n four lo six hours following ingestion. Alcoholic beverages may be
permitted in moderate a m o u n t s .
Provided that individual caloric requirements are met, a general diet with
emphasis on dairy products can meet nutrient needs for all essential nutrients
except iron. Supplemental iron may be recommended.
Women who strictly exclude animal products from their diets should receive v i t a m i n
B 1 2 supplementation. In f an t s exclusively breast f e d by these vegetarian-diet mothers
have been shown to exhib it str ik i ng dysf un c t i on of the hematopoietic and centra!
nervous systems unless the mother and/or child receives vitamin B^ supplementation.

T A B L E -1:

Recommended Minimum Daily Intake from the Four Food Groups for
Lactating Women

Food groups

Minimum Daily Amount

Milk and Milk products

4 servings or equivalent

Meat and protein equivalent

6-8 servings or equivalent

Fruits and vegetables

4 servings including a dark green or dark yellow

vegetables and citrus fruits or juice

Grains

4 servings
36

Fluids

6-8 servings

Food taboos during lactation in Bangladesh:

Food items
1. Colostrum

Reason for restriction

Consequences

Toxic or harmful milk

Less immunity and devoid

Getting more nutritious milk

2. Vegetables
3. Beef
4. Citrus fruits

Indigestion and sometimes Sutica.

Will develop the character of cow
Will delay healing process

Fewer intakes of vitamins

Less protein intake
Less intake of vitamin C and
Delayed healing process

Food taboos/misconception during lactation of the world:

1. India: pumpkin, duck egg and green vegetables are restricted during confinement period.
Nutrition requirement but intake decreases.
2. Thailand: restriction about two weeks after delivery regarding beef and certain vegetables.
3. Malaysia:
i). Among Orang asli tribe children fish and fish fliet and salt are restricted.
ii). Among Malre women restriction of certain fruits and vegetables for
40 days.
4. Korea: Seaweeds and soup and rice are only eaten.

5.3. Nutrition in Infancy & Childhood

Infancy is the period which spans from birth to one year of life, is a rapid growth period. The
rapid growth and metabolism of the infant, they demand ample supplies of the growth and
energy nutrients. Because they are small, babies need smaller total amount of these nutrients
37

than adults do; but as a percentage of the body weight, babies need over twice as much of most
nutrients. By the end of the first six months after birth a child nearly doubles his birth weight
and by one year he triples it. During this period a child begins to crawl, babble, sit and some
may even walk. Girls are generally quicker in these aspects than boys.
An infant grows rapidly in the first year of life. Hence energy requirements are very high. ICMR
recommends an intake of 120 cal/kg body weight in the first six months and 100 cal/kg body
weights in the next six months. Rapid growth also demands higher intake of protein. Simple
easily digestible protein ideally supplied through breast milk is recommended. The ICMR has
recommended a protein intake of 2.3- 1.8g/kg body weight in the first months and 1.8-1.5g/kg
body weight in the next six months.
Diet for infant:
Breastfeeding should begin as soon after birth as possible. Colostrum, the first milk produced by
the breasts after birth, provides important protection against infection as well as nutrients for
the growing infant. To insure adequate breast milk production and growth of the infant,
Breastfeeding should be "on demand. Breast milk alone is sufficient for an infant from birth
through four to six months of age. Breastfeeding should continue as long as possible (2-3 years)
to provide continued protection from illness and important nutrients for growth and
development.
The mature breast milk has the following properties which fulfill the entire requirement of the
infant. They are;
1. Human milk provides all nutrients in right proportion as needed for the rate of growth of
the infant and in easily digestible forms.
2. The possibility of contamination in breast feeding is less.
3. The protein present in breast milk is easily digestible.
4. Fat in breast milk comprises of PUFA especially linoleic acid and alpha linoleic acid
which is very much needed for child growth.
5. Fat soluble and water soluble vitamin are in good amounts but their concentration
depends largely on mothers diet.
6. Among minerals, the sodium concentration is low which supports the new born infants
kidney to deal with sodium easily. Iron content though low in breast milk, is well
38

absorbed. Calcium and phosphorus though lower than other milk are fulfilled by the
ample intake of the milk.
7. Human milk contain specific immunological factor such as lymphocytes. These help in
the production of immunoglobin A (IgA).
8. Breast milk contains anti-body that can protect the infant against infection and has antiallergic properties too.
It also helps to create a strong emotional bond between the mother and the child and gives the
feeling of security and warmth
DIET FOR INFANTS ( UP TO ONE YEAR OF AGE)
0-5 months

: Exclusive breast- feeding on demand

: No water
: No honey
: No bottle milk

5-6 months

6-9 months

: Continue breast feeding

Cereals- rice

= twice a day

Mashed banana, papaya, mango = once a day

Cooked mashed potato, carrot, pumpkin = once a day

Feed

= 3-4 times /day

Continue breast feeding, increase all the above mentioned

foods

= twice a day

: Add khichri (rice + dal) or mashed chappati= twice a day

:

Wheat to be introduced after 8 months

= twice a day

Washed dal

=2-3 spoons

Mashed vegetables

= twice a day
39

Mashed fruit

= once a day

Feed

= 4-5 times /day

9 months -1 year : Continue breast feeding, feed family food

rice /chappati/khichri

=3 times /day

: washed dal
:

= twice a day

Mashed cooked vegetables

= twice a day

: Mashed fruit

= once a day

= 6-7 times/ day

Feed

Breast feeding: Breast feeding is a method of feeding of an infant directly from the human
breast. This is the best and most natural way of feeding the infant. Exclusively breastfeeding or
giving nothing but breast milk to infants from birth is recommended up to 6 months.
Breast Milk - the ideal food for the infant because it is biologically complete , easily digested
and assimilated, and can support satisfactory growth and development for the first 6 months of
life without the need for other foods. After 6 months, breast milk is not sufficient to sustain
growth of the infant. Breast milk, especially colostrums contains antibodies that helps protect
the infant from infections.
Virtually all children benefit from breastfeeding, regardless of where they live. Breast milk has
all the nutrients babies need to stay healthy and grow. It protects them from diarrhea and acute
respiratory infections - two leading causes of infant death. It stimulates their immune systems
and response to vaccinations. It contains hundreds of health-enhancing antibodies and enzymes.
It requires no mixing, sterilization or equipment. And it is always the right temperature.
Children who are breastfed have lower rates of childhood cancers, including leukaemia and
lymphoma. They are less susceptible to pneumonia, asthma, allergies, childhood diabetes,
gastrointestinal illnesses and infections that can damage their hearing. Studies suggest that
breastfeeding is good for neurological development.
And breastfeeding offers a benefit that cannot be measured: a natural opportunity to
communicate love at the very beginning of a childs life. Breastfeeding provides hours of
40

closeness and nurturing every day, laying the foundation for a caring and trusting relationship
between mother and child.
Advantage of breast feeding
B = Best for baby
R = Reduces allergy
E = Economical
A = Antibodies
S = Stool inoffensive
T = Temperature in correct stage
F = Fresh
E = Emotional bonding between mother and child
E = easy
D = Digest easily
I = immediately available
N = Nutritional balance
G = Gastrointesterities greatly reduces
Breast feeding is successful when:

The baby suckles frequently

The mother wants to breast feed and is confident in her ability to do so.

COMPLEMENTARY FEEDING (WEANING) is the process of expanding the diet to include

food and drinks other than breast milk (Complementary feeding (weaning) and the
Complementary feeding (weaning) Diet, DoH, 1994).
Complementary feeding (weaning) is a time of nutritional vulnerability. It represents a period
of dietary transition just when nutritional requirements for growth and brain development are
41

high. A nutritionally adequate complementary feeding (weaning) diet is essential for achieving
optimum growth in the first year. Growth in the first year influences both the wellbeing of the
child and the long term health of the adult.
There are important nutritional and developmental reasons for introducing solid foods.
Nutritional
After about six months of age, breast milk alone cannot meet an infants energy
requirements.
Both stores of iron and zinc are likely to be depleted by six months, these minerals must
then be supplied in the diet.
Developmental
Introduction of different tastes and textures promotes biting and chewing skills.
Chewing improves the mouth and tongue co-ordination which is important for speech
development.
Failure to introduce different textures and tastes by 6-7 months can results in their
rejection later.
Proper Age of Complementary feeding (weaning): Complementary feeding (weaning) is a
gradual process which does not start at a given age or weight. Current guideline states:
The majority of infants should not be given solid foods before the age of four months
and a mixed diet should be offered by the age of six months
Practical Points about Complementary feeding (weaning)
A mothers attitude is important because a relaxed approach; a peaceful atmosphere is required
and television and family noise are rarely helpful.
Safety should be emphasized from the start because of the risk of choking; infants must never be
left alone.
If choking occurs:
1. Place the infant face down along forearm or lap
2. The head should be supported, but tipped below chest
3. Tap firmly between shoulders
Complementary feeding (weaning) is messy and mothers need to be prepared for this.
42

Utensils should be appropriate.

Food should not be forced on a baby.

The process of reducing milk feeds should be gradual.

Initially drop one milk feed during the day.

By eight month a second milk feed may be dropped.

Suitable first complementary feeding (weaning) foods include vegetables and fruit purees, nonwheat cereals, unsweetened yoghurt. The quantity, consistency, flavour, potential allerginicity
and preparation of first foods all need to be considered.
First complementary feeding (weaning) foods should be bland and smooth, but once food is
accepted from a spoon, introduction to a variety of different taste should be encouraged.
Allergenicity: Infants are most vulnerable to the initiation of food allergy in the first months of
life and the risk of allergy is greatly increased by family history of atopic disease such as
eczema and asthma. For these at risk infants, potential food allergens should be avoided until
at least six month of age.
Common food allergens include:
Cows milk, Eggs, Citrus fruits, Nuts, Wheat, Fish etc.
A vegetarian complementary feeding (weaning) diet is little different from any other in the first
weeks and suitable first foods are the same, i.e. pureed fruits and vegetables, baby rice and
gluten free cereals. As complementary feeding (weaning) progresses, nutrients at potential risks
of insufficiency include energy, iron, good quality protein and vitamin D.
General advice can be given as follows:
Energy:
Maintain breast-milk throughout the first year.
Include energy dense foods, e.g. nut butter, ground nut and cheese, regularly
Use less bulky and low fiber vegetables.
Iron:
Give iron rich foods daily and give vitamin C rich fruits, vegetables.
Avoid giving tea or excessive quantities of whole cereals which may inhibits iron
absorption.
43

Protein:
Include a variety of cereals, pulses and dairy products to achieve a good protein intake
Vitamins:
Vegetarians mother who are breast feeding should receive vitamin D supplements

Checklist for an adequate complementary feeding (weaning) foods or diets

1. Foods from each groups daily
2. 600 ml breast milk or infant formula milk daily
3. Vitamins drops if exclusively breast-fed after six months, or any dietary restriction
4. Iron rich foods
5. Vitamin C rich foods at meal time
6. Limited use of high fibre foods
7. Restricted use of low fat foods
8. Three meals and two snacks from around nine months.

plementary feediGuidelines for comng (weaning):

1 Breastfeeding alone is normally sufficient until an infant is 4-6 months of age.

2

From 4-6 months, soft foods should be added gradually to the diet.
3 When foods are first introduced they should be mashed smoothly; by about nine
months, foods can be finely chopped; by two years, most children can manage adult
foods.

4 From six months to two years, a child should be fed four to six small meals each day in
addition to breastfeeding.
5

After six months, an infant should be eating body-building, energy and protective

foods plus breast milk every day.

6 Food for young children, once prepared, should never be stored without refrigeration
for more than two hours.
44

7 The hands of both mother and child should be washed before handling food.
8. Use a clean cup and spoon for feeding young children never use feeding bottles.
Recommended complementary feeding (weaning) food:
The complementary feeding (weaning) process should be gradual. It should start with some soft
foods like mashed banana, mashed potatoes or other tubers.
Suggested introductory food includes;
1. Low-sugar rusks or unsweetened ground rice in milk.
2. Mashed cooked vegetables, such as carrots and potatoes.
3. Mashed cooked meat and fish with unsalted gravy
4. Mashed fruits like banana and fresh orange juice
5. Cooked egg-yolk
Gradually more carbohydrate foods (e.g. starchy vegetables, cereal products, rice, bread and
fruits) and less fatty foods should be offered as the child approaches 2 years of age. A variety of
protein food should be offered including plant proteins such as beans, pulses and Soya products.
And animal protein also be included (e.g. meat, fish, dairy products and egg).

Nutrition of Children
Although the nutritional needs of children are similar to those of the adults; i.e. energy, protein,
mineral elements and vitamins, yet they differ from those of the adults in three respects;
1. Their energy requirement per unit of weight is higher than that of the adults
2. Their food should contain a higher proportion of tissue-building materials, namely
proteins and mineral elements as well as vitamins than that of adults.
3. Their diet should be made up of foods which are suitable to the digestive abilities of any
given age.
Nutritional requirement of children:

45

In the second year and the through the years of child hood the muscle development is more and
boons begin to lengthen although the skeletal growth is slower. During this period the child
needs less calories but more proteins and minerals for growth. Teething continues from infancy
to early childhood. The specific nutrients on which we have to give more emphasis are protein,
calcium and iron. Vitamins especially C and A are required for growth and development of
tissues.
Diet for children
During the year 1 to 3 the emphasis need to give more on proteins, minerals and vitamins. If
supplementation of the diet has been done carefully then the child is consuming 3-meal pattern
diet but without heavy spices, oils and fats. So also all bran and coarse cereals must be avoided.
It is necessary in case of some toddlers who dislike milk to fed them with curds o milk solids in
mashed potatoes, soups, custards or puddings. On the other hand some toddlers who may drink
more milk than required may exclude some solid food in the diet. For such children food and
mealtimes may be made more attractive so that acceptance of food is readily accomplished.
It must be emphasized here that refined sweets and fried foods must be totally avoided. A variety
of foods must be offered in smaller amounts to provide key nutrients.
The mother may encourage some degree of food choice and self-feeding so that eating can be
pleasant and positive mans of development. The preschool children (3 to 6 years) demand a lot
of variety in foods. Sometimes he may gorge himself, at other times appear disinterested in food.
He generally refers single foods with simple flavors rather than complicated foods and dishes
such as heavily spiced curries. The child appears to be interested in the texture, color and form
of the food. His need is so identify each food on the basis of its characteristics and name it.
Finger foods such as raw fruit and vegetables cut in finger size are much acceptable in this age
group. Milk is less preferred by the pre-schoolers. The emphasis of the diet should be on the
quantity and quality. If a child is given smaller servings, a great number of them may be
consumed. As they prefer to do things by themselves, they should be given opportunity to do so.

*****************************

Chapter- 6: Nutrition in Adolescents

46

The adolescent period is characterized by the onset of puberty which is the final growth spurt of
childhood. Malnutrition of children varies widely. Boys tend to mature later than girls. This
fluctuation in the development accounts for the wide differences in metabolic rates, in
requirement of food in scholastic capacity. The body changes in girl and boys are the result of
the hormonal changes that regulate the development of sex characteristics. This different in
growth pattern also emerges as a difference in other aspects such as in the case of girls there is
an increase in the accumulation of subcutaneous fat, especially around the pelvic region. Boys
although slow in growth, beat the girls in height and weight science they put on more muscle
mass and there is growth of the long bones.
Nutritional Requirement of Adolescents
olescent: The adolescent period is characterized by heavy demands of calories and proteins.
The appetite of the child increases and he tends to consume more carbohydrate foods and fewer
protein foods. The need for calcium and iron support bone and muscle growth continues. In case
of girls menstrual iron losses may predispose her to simple iron deficiency anemia. Her needs
for iron are more than those of boys of similar age. Since rate of metabolism is high the need for
iodine is also increased. This nutrient must be taken care of in the areas lacking adequate iodine
in soil and therefore in foods. It can easily be supplied through use of iodized salt. The B
vitamins are required in the greater amount by boys than girls to meet the extra demands of
energy and muscle tissue development. Intakes of vitamin C and A be low due to improper habits
of eating snacks. It is necessary to take more care of girls than the boys, who may be vulnerable
to malnourishment. If the physical activity of the girl does not match her intake may result in
excessive fat deposit. Secondly, if she is figure-conscious she may follow some crash diets which
will predispose her to malnutrition. The hazard of such diets can be gauged from the fact that
her body is preparing for motherhood which in conditions of undernourishment or malnutrition
can spell danger for the future mother.
Table 3: Simple food exchange list for adolescent boy and girl
(16-18 years old)
Energy Requirement:

2820 kcal;

Protein:

53 g
47

Food group

No. ofexchanges

Protein (g)

Energy (kcal)

___________________________________________________________________
1. Milk

20.2

400

2. Legumes and pulse

12.0

200

3. Flesh food

10.0

100

4. Vegetable A

5. Vegetable B

100

6. Fruit

200

7. Cereal

12

24

1200

8. Fat

400

9. Sugar

50 g

200

________________________________________________________________
Total

66.0

2800

Chapter- 7: Geriatric Nutrition

Nutrition of Elderly People:
The people whose age 65 years or above are considering as old people. Changes in organ
function that often occur with aging. Some of the most significant changes occur in digestive
system, once such change is painful deterioration of the gums and subsequent loss of teeth. The
sense of taste and smell may also be altered, reducing the pleasure of eating. The stomachs
secretion of hydrochloride acid and enzymes decreases, as do the secretion of digestive juices by
the pancreas and small intestine. Muscles of the GI tract weaken with reduced use. Food moves
slowly through GI tract and constipation may become a problem.
The heart and blood vessels also age, become weaker, and the arteries become less flexible. The
decreases in blood flow through the kidneys makes them gradually less efficient at removing
48

wastes and maintaining the bloods normal composition. Visual impairment that occurs with
aging can make it difficult for the older person to shop foods and prepare them. Hearing loss is
also common. As the metabolic rate slows with age, the older person may not have the same
strength and energy he had when he was younger. Furthermore because the elderly are more
likely to have chronic diseases, they are also likely to be taking prescription drug over long
periods of time. And this increase the risk of drug related malnutrition.
During aging the bones show osteoporosis changes because of deficiency of calcium, protein,
vitamins, minerals and hormones. Osteomalacia is also common, particularly in women
confined in doors with deficient intake of vitamin D. The process of aging can be retarded by
maintaining a strong cardiovascular and respiratory system. Exercise, regular and active
enough to increase heart beat and respiration rate is one of the keys to good health in later year.

Nutritional Requirement of Elderly People:

Calorie:
The lower metabolic rate in the elderly reduces calorie requirement. A retired life, arthritis and
angina reduce physical activities to minimum. Calories should therefore restrict to ombat any
tendency to obesity. On the other hand, if there is loss of weight, adequate calories should be
supplied to regain normal weight. Average figures for people 75 and older are 2050kcal/day for
the man and 1600kcal/day for the woman.
Carbohydrate:
Science the caloric requirement of adults is lowered, it is necessary to control the intake of
carbohydrate especially the simple sugar. Consumption of complex carbohydrate can be
49

encouraged to include food such as whole grain, cereals, potatoes and dried legumes in the diet.
These foods should supply about 40 to 45% of the total caloric requirement. About 5 to 10% of
the total energy requirement may come from simple sugar.
Protein:
The rate of protein synthesis decreases every year as age advances. No new tissue is formed
except that there is maintenance of worn out tissues. The requirement for dietary protein
decreases by about 30%. It is necessary to supply protein at about 15-20% of the caloric
requirement. This applies to people who have good health and do not suffer from any problems.
Older person suffering from gastro-intestinal problems, infection or changed metabolic
efficiency as a result of disease or medication should increase their protein intake appropriately.
The daily protein intake should be at least 1.0 to 1.4 g/kg body weight.
Fat:
It is necessary to consume fat comprising about 10-15% of the total calorie intake. This is
because many adults are prone to heart disease for which this preventive measure needs to b
paid attention to. Serum cholesterol levels increase after the age of 50 years. Therefore one
should completely avoid foods containing high levels of cholesterol such as egg yolk, whole
milk, organ meats etc. Adequate use of PUFA, less or no fried foods and trimmings of all visible
fats from meats would minimize the intake of saturated fats. Vegetable oil is recommended to
take which helps fulfill essential fatty acid requirements and to reduce cholesterol level.
Vitamins:
The requirements for these are similar to adults. However, due to the normal aging process the
ability to store fat soluble vitamins decreases. The problem of vitamin deficiency in the old may
stem from inadequate intake rather than from increased need. The need for the fat soluble
vitamins especially A and D may be met easily through the diet but their absorption and storage
may be hampered due to lack of dietary fat, inadequate bile secretion, use of laxatives and
antibiotics and/or pancreatic insufficiency. Special attention need to be given to vitamin D
science bone decalcification is very common in the later years. If its requirement is not met
through the diet, supplements may have to be given. Other fat soluble vitamins may be supplied
through diet. Older people may require supplementation of B vitamins especially thiamine,
50

pyridoxine, cyano-cobalamine and folic acid because their daily food intake is decreased, hence
the decrease intake of dietary vitamins has to be compensated by external supplementation with
vitamins. The increased needs for these vitamins may be due to less efficient absorption or
altered metabolism and excretion resulting not only from physiological change but also from
certain medications on drug interaction. Adequate vitamins intakes can be ensured by including
foods from each of the food groups. And special emphasis should bee given to fruits and
vegetables groups. If the diet consumed does not provide adequate amount of vitamins, a
multivitamin tablet providing daily requirement of different vitamins should be given.
Minerals:
Special attention needs to b given to two main minerals, iron and calcium, since these may be
lacking in poor diets and may need to be supplemented. The requirement of iron for women may
be higher than that of men until they attain menopause. But after completion of menopause their
requirement for iron is similar to that of men. Absorption of calcium decreases with age
resulting in osteoporosis and fragile bones with fracture easily. Calcium is also important for
maintaining health of the oral tissues.
Fluid:
The importance of adequate fluid intake so as to maintain the volume of urine excreted at
minimum of 1.5 liters. They should drink about 6 to 8 glass of fluid like water, juice etc. a day.
Fiber:
Fiber recommendation for the general population should be stressed to the older citizens as
well: increase the use of fruits, vegetables, legumes and whole grain cereals. The fiber
consumption helps to avoid constipation and reduce cholesterol level of the body.
Guidelines for meal planning:
1. Consider the food likes and dislikes of the individual. Learn essential food dishes
acceptable to the person. For example, milk may be disliked as beverage but well
accepted in curd, custards, and puddings and so on.
51

2. Use fried foods, rich desserts, highly seasoned foods, and strongly flavored vegetables
3.

with discretion and according to the patients tolerance.

If chewing is difficult, adjust the meals to include finely minced or chopped meats, soft

breads, fruits and vegetables.

4. Serve four or five small meals when the appetite is poor.
5. Breakfast is the meal most enjoyed by many older persons, and every effort should be
made to provide pleasing variety.
6. Dinner at noon rather than in the evening is preferred by some.
7. If coffee and tea produce insomnia, they should be restricted to meals early in the day.
8. Encourage a liberal fluid intake daily. Adjust the fiber content of the diet if composition
is a problem.

Table 4: Simple food exchange list for an Old Man (60-80 Years)
Age: 65 years
Requirements
Energy-1757 kcal
Protein 55 g
Food group

No. of exchanges

Protein (g)

Energy (kcal)

1. Milk

20.

400

2. Legumes and pulses

12.0

200

5.0

50

3. Flesh food
4. Vegetable A

5. Vegetable B

100

6. Fruit

100

7. Cereal

12.0

600

8. Fat

200

25 g

100

9. Sugar

52

Total

49

1750

NUTRITIONAL REQUIREMENTS IN NORMAL SITUATION FOR ALL GROUPS

Average individual energy requirements and safe levels of intake for various nutrients
Sex
age

& Energy
(Kcal)

Prot

Fa

Iron

Iodi

VitA

VitB1

VitB2

Niaci

Folat

VitC

(g)

(mg)

(g)

(g)

(mg)

(mg)

(mg)

(mg)

(g)

group
(g)
Children
6-12m
950
14
21
50
1-3 y
1350
22
30 13
70
3-5 y
1600
26
35 14
90
5-7 y
1820
30
40 19
90
7-10 y
1900
34
42 23
120
Boys
10-12 y 2120
48
47 23
150
12-14 y 2250
59
50 36
150
14-16 y 2650
70
59 36
150
16-18 y 2770
81
59 23
150
Girls
10-12 y 1905
49
42 23
150
12-14 y 1955
59
43 40
150
14-16 y 2030
64
45 40
150
16-18 y 2060
63
46 48
150
Men-active
18-60 y 2895
55
64 23
150
> 60 y
2020
55
45 23
150
Women-active (non pregnant or non lactating)
18-60 y 2210
49
49 48
150
53

350
400
400
400
400

0.6
0.9
1.1
1.2
1.4

0.5
0.8
1.0
1.1
1.3

5.4
9.0
10.5
12.1
14.5

32
50
50
76
102

20
20
20
20
20

500
600
600
600

1.7
1.8
1.9
1.9

1.6
1.7
1.8
1.8

17.2
19.1
19.7
20.3

102
170
170
200

20
30
30
30

500
600
550
500

1.5
1.6
1.6
1.4

1.4
1.5
1.5
1.4

15.5
16.4
15.8
15.2

102
170
170
170

20
30
30
30

600
600

1.9
1.9

1.8
1.8

19.8
19.8

200
200

30
30

500

1.4

1.3

14.5

170

30

> 60 y
Pregna

1835
2410

49
56

41
54

19
76

150
175

500
600

1.4
1.6

1.3
1.5

14.5
16.8

170
420

30
30

nt
Lactati

2710

69

60

76

200

850

1.8

1.7

18.2

270

30

ng

Safe levels of intake are the levels that maintain health and nutrient stores in almost all
healthey individuals within a group.

Chapter-8 Primary Nutritional Diseases

Primary Nutritional Diseases
Major nutritional deficiency diseases are-->

Protein-Energy Malnutrition (PEM)

Vitamin A Deficiency Disorders (VADD)

Nutritional anemia (esp. Iron)

Iodine Deficiency Disorders (IDD)

Vitamin A Deficiency Disorders (VADD)

VADD :

VADD is a comprehensive term that covers all the effects of the deficiency state,

including those on health, survival and vision. VAD is the underlying cause of xeropthalmia.
Vitamin A requirements
Retinol Equivalents (RE) per day
( 1 RE = 1 g retinol)
Child

1-6 years

400 RE

Adult

Women

500 RE

Men

600 RE

Pregnancy

600 RE
(FAO/WHO, 1983)
54

Major food sources

Dark green leafy vegetables
Yellow fruits
Carrots
Palm oils
Liver and liver oils
Functions
Vision (night, day, colour)
Epithelial cell integrity against infections
Immune response
Haemopoiesis
Skeletal growth
Fertility (male and female) and Embryogenesis
Stages of deficiency
Subclinical

Clinical

reducing stores
lowering serum level

xerophthalmia
- non-blinding

metaplasia

- blinding

Xerophthalmia classification by ocular signs

Night blindness (XN)
Conjunctival xerosis (X1A)
Bitots spot (X1B)
Corneal xerosis (X2)
Corneal ulceration/keratomalacia (X3A)
<1/3 of corneal surface
Corneal ulceration/keratomalacia (X3B)
1/3 of corneal surface
Corneal scar (XS)
Xerophthalmic fundus (XF)
55

Treatment schedule (orally)

Immediately on diagnosis:
<6 months

50,000 IU

6-12 months

100,000 IU

>12 months

200,000 IU

Next day

Same age-specific dose

At least two weeks later

Same age-specific dose

Control of VADD
1.

Supplementation

2.

Fortification

3.

Diet diversification

4.

Infectious disease control

5.

Disaster relief

6.

Plant breeding

Prevention 1: Periodic oral supplementation

Infants <6 months

50,000 IU

Non-breast-fed infants, breast-fed infants

whose mothers have not received supplemental vitamin A
Infants 6-12 months

100,000 IU

Every 4-6 months

Children >12 months

200,000 IU

Every 4-6 months

Mothers

200,000 IU

Within 8 weeks of delivery

Prevention 2: Food fortification Requirements
Scientific rationale

Industrial capacity

Training

Advocacy

Legislative support

Economic viability

Community acceptance

Sustainability
56

 Monitoring

Quality control

Prevention 3: Dietary diversification

Advantages:

Ultimate solution
Community involvement
Generating income

Components:

Provides other nutrients

Production (home, school)

Iron Deficiency
Iron deficiency and iron-deficiency anaemia, as measured by low haemoglobin, are the most
prevalent nutritional deficiencies in the world. Anaemia is the most serious manifestation of iron
deficiency, and it is estimated that for every person with anaemia, there is at least one other
with iron deficiency. Women of reproductive age and small children are at greatest risk, with an
estimated 50% to 60% of pregnant women and 40% of small children suffering from anaemia.
Anaemia during pregnancy is a major health concern because it has been associated with
increased risks of maternal morbidity, maternal mortality, and poor birth outcomes, including
stillbirth, prematurity, low birth weight, and perinatal and neonatal mortality . It is estimated
that favourable pregnancy outcomes are compromised by 30% to 45% when women have
anaemia.
Cut offs for WHO Definition of Anaemia
Age or Sex Group

Haemoglobin below (g/dl) Haematocrit below (%)

Children 6-60 months

11.0

33

Children 5-11 years

11.5

34

Children 12-15 years

12.0

36

Non-pregnant women

12.0

36

Pregnant women

11.0

33

Men

13.0

39

Source: WHO
Iron Deficiency Anaemia
In the human body, when iron intake and absorption no longer meet the need of normal iron
turnover and losses, and iron stores are exhausted then insufficient amounts of iron will be
57

delivered to transferrin, the circulating transport protein for iron. This results in decreased
transferrin saturation (less iron is contained in the iron binding sites), and transferrin receptors
on tissue cell surfaces increase throughout the body.
When the depletion is sufficient to affect haemoglobin synthesis, a state of iron deficiency
anaemia results. The mild, moderate and severe stages of iron deficiency anaemia each
comprise a subset at the low end of the spectrum of iron status.
Anemia: Abnormally low haemoglobin level due to pathological condition(s). Iron deficiency is
one of the most common, but not the only cause of anaemia. Other causes of anaemia include
chronic infections,

particularly

malaria, hereditary haemoglobinopathies

and other

micronutrient deficiencies, particularly folic acid deficiency. It is worth noting that multiple
causes of anaemia can coexist in an individual or in a population and contribute to the severity
of the anaemia.
Iron Deficiency: Functional tissue iron deficiency and the absence of iron stores with or
without anaemia. Iron deficiency is defined by abnormal iron biochemistry with or without the
presence of anaemia. Iron deficiency is usually the result of inadequate bioavailable dietary
iron, increased iron requirement during a period of rapid growth (pregnancy and infancy),
and/or increased blood loss such as gastrointestinal bleeding due to hookworm or urinary blood
loss due to schistosomiasis.
Iron Deficiency Anemia: Iron deficiency when sufficiently severe causes anaemia. Although
some functional consequences may be observed in individuals who have iron deficiency without
anaemia, cognitive impairment, decreased physical capacity, and reduced immunity are
commonly associated with iron deficiency anaemia. In severe iron deficiency anaemia, capacity
to maintain body temperature may also be reduced. Severe anaemia is also life threatening.
Consequences of Iron Deficiency Anaemia
There are consequences of high rates of anaemia to the economic development of an area or
country, just as there are both functional and developmental consequences to an individual and
his or her immediate family.
In pregnant women, anaemia results in retardation of intrauterine growth, low birth weights,
increased perinatal mortality and increased maternal mortality. For all types of persons,
58

morbidity from infectious diseases is increased because anaemia adversely affects the immune
system. Severe anaemia reduces the bodys ability to monitor and regulate body temperature
when exposed to cold. Iron deficiency can impair cognitive performance at all stages of life, and
physical work capacity is significantly reduced. Many studies show a relationship between iron
deficiency and/or iron deficiency anaemia and reduced muscle function, physical activity,
workplace and school productivity, mental acuity and concentration in older children and
adults. Anaemic mothers are less able to care for their children at home.
Infants who become anaemic may suffer permanent impairment of cognitive development.
Anaemia in young children has now been shown to correlate with lower cognitive test scores
with IQ tests showing a loss of 10-15 points. These effects do not improve when the anaemia is
corrected or in later years. Iron deficient children are also more susceptible to poisoning from
heavy metals (including lead).
The overall effect of high levels of anaemia in children and women in a society affect its
potential for technological advancement. They reflect a lack of determination by national
leaders to assure the fulfillment of basic child right to adequate nutrition.
Prevention and Control
Prevention
Prevention of iron deficiency should always be an integral component of measures taken
during nutritional emergencies. It should be based on a combination of dietary approaches,
including food fortification and supplementation .The main preventive measures are outlined
in the following paragraphs.
Dietary improvement
Dietary improvement consists of increasing the amount of bio-available iron in the
diet. This implies the provision of foods that are rich in iron, low in inhibitors of iron
absorption, and high in substances that enhance absorption. Tea and coffee contain
significant quantities of absorption-inhibitors and should therefore be drunk 2 hours
before or after meals rather than with them. Consumption of even small amounts of
meat or other foods of animal origin or of foods rich in vitamin C (e.g. fresh fruits
and vegetables), as well as the regular consumption of foods rich in folid acid

59

(particularly dark green leafy vegetables), will significantly improve the intake and
absorption of iron.
Breast feeding
Every effort should be made to promote the breast-feeding of infants and to encourage its continuation, even for sick children.
Iron fortified food
Although iron-fortified foods are not usually available, iron-fortified breast-milk
substitutes may be available for infants who cannot be breast-fed but should not
be allowed to discourage or prevent mothers from breast-feeding their babies.
Supplementation
In areas where the diet supplies inadequate quantities of iron, and iron-fortified foods are
not available, supplementation becomes necessary, especially for pregnant women and
young children who are the most vulnerable groups. The following recommendations are
based on INACGAVHO/UNICEF guidelines.
Treatment of Anemia
Age group
Children < 2 years
Children 2-12 Years
Adolescent and adults

Daily Dose
Iron
Folic acid
25 mg
100-400 mcg
120 mg
400 mcg
600 mg
400mcg

Duration of Treatment
3 months
3 months
3 months

Pregnant women

Iron during pregnancy and lactation

Iron requirements during pregnancy are well established . Most of the iron required during
pregnancy is used to increase the haemoglobin mass of the mother, which occurs in all healthy
pregnant women who have sufficiently large iron stores or who are adequately supplemented
with iron. The increased haemoglobin mass is directly proportional to the increased need for
oxygen transport during pregnancy and is one of the important physiologic adaptations that
occurs in pregnancy. A major problem for iron balance in pregnancy is that iron requirements
are not equally distributed over its duration. The exponential growth of the foetus implies that
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iron needs are almost negligible in the first trimester and that more than 80 percent relates to
the last trimester. The total daily iron requirements, including the basal iron losses (0.8 mg),
increase during pregnancy from 0.8 mg to about 10 mg during the last 6 weeks of pregnancy.
Iron absorption during pregnancy is determined by the amount of iron in the diet, its bioavailability (meal composition), and the changes in iron absorption that occur during
pregnancy. There are marked changes in the fraction of iron absorbed during pregnancy. In the
first trimester there is a marked, somewhat paradoxical, decrease in the absorption of iron,
which is closely related to the reduction in iron requirements during this period as compared
with the non-pregnant state (see below). In the second trimester iron absorption is increased by
about 50 percent, and in the last trimester it may increase by up to about four times. Even
considering the marked increase in iron absorption, it is impossible for the mother to cover her
iron requirements from diet alone, even if its iron content and bio-availability are very high. It
can be calculated that with diets prevailing in most industrialized countries, there will be a
deficit of about 400-500 mg in the amount of iron absorbed during pregnancy.
Table: Iron requirements during pregnancy
Iron requirements (mg)
IRON REQUIREMENTS DURING PREGNANCY

300

Foetus Placenta

50

Expansion of maternal erythrocyte mass

450

Basal iron losses

240

Total iron requirement

1040

NET IRON BALANCE AFTER DELIVERY

Contraction of maternal erythrocyte mass

+450

Maternal blood loss

-250

Net iron balance

+200

Net iron requirements for pregnancy if sufficient maternal iron

840

stores are present (1040 - 200 = 840)

During the birth process, the average blood loss corresponds to about 250 mg iron. At the same
time, however, the haemoglobin mass of the mother is gradually normalised, which implies that
about 200 mg iron from the expanded haemoglobin mass (150-250 mg) is returned to the
mother. To cover the needs of a woman after pregnancy, a further 300 mg of iron must be
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accumulated in the iron stores in order for the woman to start her next pregnancy with about
500 mg of stored iron.
Iodine deficiency Disorders
Iodine, a nonmetallic trace element, is required by humans for the synthesis of thyroid
hormones. It was one of the first micronutrients to be recognized as vital in nutrition and still it
is considered as one of the most important and essential trace element. Iodine, which is a
Greek word for violet, was first isolated as a violet vapour during the making of gunpowder
at the end of the eighteenth century.
Iodine is a constituent of the thyroid hormones, thyroxine (T4) and triiodothyronine (T3), which
are essential to human functioning because they influence skeletal maturation and the
development of the central nervous system and regulate many other physiological processes 2, 3, 4.
Iodine deficiency in adults and children is usually characterized by low levels of T4 and high
levels of thyroid-stimulating hormone (TSH) .
Iodine deficiency is the most common preventable cause of mental deficits and is a major
public health issue. Iodine deficiency disorders include a wide range of conditions,
including increased pre- and postnatal mortality, goitre, and cretinism. The effects on
development are now thought to include cognitive, sensory, and motor deficits. Iodine
deficiency disorders can also take their toll socio-economically, with lower work output
per capita income and less productive farm animals in iodine deficient areas.
Role of Iodine in the Body
The function of iodine that attracts most attention is its role as parts of thyroid hormones
triiodothyronine (T3) and thyroxine (T4). The thyroid hormones play a major role in regulating
growth and development. They can stimulate the metabolic rate as much as 30%, resulting in
increased rate of oxygen use and increased generation of heat. The activities of thyroid
hormones are critical for the normal development of brain. Anatomical studies have
demonstrated that they increase the proliferation of brain cells and regulate other processes
involved in brain function. The condition of hypothyroidism in which insufficient thyroid
hormones are produced is associated with defective and disorganized development of the brain,
resulting in serious impairment of brain function. Although the role of thyroid hormone in
regulating the rate of general metabolism attracts most attention, an increasing number of other
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roles are becoming apparent. For example, the conversion of carotene to vitamin A, the
synthesis of protein and the absorption of carbohydrate from the intestine. All these proceed less
efficiently when thyroxine levels are below normal.

Daily Requirement of Iodine

Table A: Proposed revision for daily iodine intake recommendations of 1996 by the WHO,
UNICEF and ICCIDD
Population sub-groups
Infants (first 12 months)
Children (1-6 years)
Schoolchildren (7-12 years)
Adults (12+ years)
Pregnant
and
lactating

Total iodine intake g/day

90a
90
120
150
200

Iodine g /kg/day
15.0
6.0
4.0
2.0
3.5

women
a

Revised to 90 g from the earlier recommendation of 50 g.

Dietary Sources of Iodine

The iodine content of food depends on the iodine content of the soil in which it is grown. The
iodine present in the upper crust of earth is leached by glaciation and repeated flooding and is
carried to the sea. Sea water is, therefore, a rich source of iodine.
The seaweed located near coral reefs has an inherent biologic capacity to concentrate iodine
from the sea. The reef fish which thrive on seaweed are rich in iodine. Thus, a population
consuming seaweed and reef fish has a high intake of iodine, as the case in Japan. The amount
of iodine intake by the Japanese is in the range of 2-3 mg/day. In several areas of Asia, Africa,
Latin America, and parts of Europe, iodine intake varies from 20 to 80 mg/day. In the United
States and Canada and some parts of Europe, the intake is around 500 mg/day.

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Clinical Sign Symptoms of Iodine deficiency disorders

Board Spectrum of IDD is given below:
1. Foetus:a. Abortions
b. Still birth
c. Congenital anomalies
d. Increased perinatal mortality
e. Increased infant mortality
2. Neurological cretinism- Mental deficiency.
- Deaf-mutism.
- Spastic diplegia.
- Squint
3. Myoedematous cretinism.
- Dwarfism.
- Mental deficiency.
- Psychomotor defect & Foetal hypothyroidism.
7

Neonatal Changes

a) Neonatal hypothyroidism.
b) Neonatal goiter.
Child & adolescent:a)
b)
c)
d)

Goiter juvenile.
Hypothyroidism.
Impaired mental function.
Retarded physical development.

Changes of Adult
a) Goiter with its complications.
b) Hypothyroidism.
c) Impaired mental function

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Correction of Iodine Deficiency Disorders

The social impact of IDD is great. Prevention will result in improved quality of life, productivity
and educability of children and adults. Now it is clear that iodine deficiency is a major
impediment to human development.
Undisputed evidence shows that iodine deficiency can be successfully and inexpensively
prevented and controlled. The major methods that have been used are20:

Fortification of salt with iodine compounds

Periodic injection of iodized oil

Iodized Salt

The idea of using salt as a vehicle for the addition of iodine to the diet began in Switzerland in
1920s and was soon followed by USA (Michigan) where there was a major problem with
goitre38. Iodization of salt has the long term advantage of high cost effectiveness, assuring
regular salt intakes when salt supplies come from a centralized source 20.The feasibility and
effectiveness of iodination of even crude moist salt was conclusively demonstrated by the
Institute of Nutrition of Central America and Panama (INCAP) in the early 1960s. It can be
highly effective if compliance with the legislation is ensured by careful laboratory monitoring
and enforcement.
The techniques for iodination include dry mixing, drip-feeding, submersion, and spray mixing,
of which the latter is the most widely used. Potassium iodate is the preferred additive,
particularly under conditions of humidity and delay between production and consumption. The
optimum level of fortification is 45-50 ppm at the production level, 20 ppm at the retail shop
level and a minimum of 15 ppm at the consumption level. Packaging in plastic bags decreases
iodine losses. The major cost items of iodination are the chemical, processing, extra packaging
material, amortization, and monitoring. Overall, iodination costs about 2-4 cents (US) per
person per year39.
Important components of the iodination program include assessment of prevailing conditions,
public education, efficient production and marketing, legislation, enforcement, monitoring and
surveillance. Weakness in any of these will comprise the effectiveness of the program.
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Recent Iodization Programmes

The goal of an iodization programme is complete coverage of the iodine deficient population
with iodine supplementation; the problem is similar to that arising with any other preventive
measure although suitable technology is available its successful application is another, and in
general more difficult, matter. The following programmes43 have used different methods or
different combinations of methods to correct iodine deficiency.
Finland
Papua New Guinea
Countries of Central

&

Salt
Oil and salt
South Salt and oil

America
Zaire
Indonesia
China
India

Oil
Salt and oil
Salt and oil
Salt

Universal Salt Iodization

In nearly all countries where iodine deficiency occurs, it is now well recognized that the most
effective way to achieve the virtual elimination of IDD is through universal salt iodization (USI).
USI involves the iodization of all human and livestock salt, including salt used in the food
industry. Adequate iodization of all salt will deliver iodine in the required quantities to the
population on a continuous and self-sustaining basis.

Protein Energy Malnutrition

Protein-energy malnutrition (PEM) is a potentially fatal body-depletion disorder. It is the
leading cause of death in children in developing countries. The World Health Organization
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(WHO) defines malnutrition as "the cellular imbalance between the supply of nutrients and
energy and the body's demand for them to ensure growth, maintenance, and specific functions."
The term protein-energy malnutrition (PEM) applies to a group of related disorders that include
marasmus, kwashiorkor, and intermediate states of marasmus-kwashiorkor. The term marasmus
is derived from the Greek word marasmus, which means withering or wasting. Marasmus
involves inadequate intake of protein and calories and is characterized by emaciation. The term
kwashiorkor is taken from the Ga language of Ghana and means "the sickness of the weaning."
Williams first used the term in 1933, and it refers to an inadequate protein intake with
reasonable caloric (energy) intake. Edema is characteristic of kwashiorkor but is absent in
marasmus.
PEM is also referred to as protein-calorie malnutrition. It develops in children and adults whose
consumption of protein and energy (measured by calories) is insufficient to satisfy the body's
nutritional needs. While pure protein deficiency can occur when a person's diet provides enough
energy but lacks the protein minimum, in most cases the deficiency will be dual. PEM may also
occur in persons who are unable to absorb vital nutrients or convert them to energy essential for
healthy tissue formation and organ function.
Although PEM is not prevalent among the general population of the United States, it is often
seen in elderly people who live in nursing homes and in children whose parents are poor. PEM
occurs in one of every two surgical patients and in 48% of all other hospital patients.
Types of PEM
Primary PEM results from a diet that lacks sufficient sources of protein and/or energy.
Kwashiorkor
Kwashiorkor is one of the serious forms of PEM. It is seen most frequently in children one to
three years of age, but it may occur at any age. It is found in children who have a diet that is
usually insufficient in energy and protein and often in other nutrients. Often the food provided to
the child is mainly carbohydrate; it may be very bulky, and it may not be provided very
frequently.
Clinical signs of kwashiorkor

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Kwashiorkor is relatively easy to diagnose based on the childs history, the symptoms reported
and the clinical signs observed (Figure 6). Laboratory tests are not essential but do throw more
light on each case. All cases of kwashiorkor have oedema to some degree, poor growth, wasting
of muscles and fatty infiltration of the liver. Other signs include mental changes, abnormal hair,
a typical dermatosis, anaemia, diarrhoea and often evidence of other micronutrient deficiencies.
Oedema
The accumulation of fluid in the tissues causes swelling; in kwashiorkor this condition is always
present to some degree. It usually starts with a slight swelling medical attendant presses with a
finger or thumb above the ankle. If oedema is present the pit formed takes a few seconds to
return to the level of the surrounding skin.of the feet and often spreads up the legs. Later, the
hands and face may also swell. To diagnose the presence of oedema the
Poor growth
Growth failure always occurs. If the childs precise age is known, the child will be found to be
shorter than normal and, except in cases of gross oedema, lighter in weight than normal
(usually 60 to 80 percent of standard or below 2 SD). These signs may be obscured by oedema
or ignorance of the childs age.
Wasting
Wasting of muscles is also typical but may not be evident because of oedema. The childs arms
and legs are thin because of muscle wasting.
Fatty infiltration of the liver
This condition is always found in post-mortem examination of kwashiorkor cases. It may cause
palpable enlargement of the liver (hepatomegaly).
Mental changes
Mental changes are common but not invariably noticed. The child is usually apathetic about his
or her surroundings and irritable when moved or disturbed. The child prefers to remain in one
position and is nearly always miserable and unsmiling. Appetite is nearly always poor.

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FIGURE-1: Characteristics of kwashiorkor

Hair changes
The hair of a normal Asian, African or Latin American child is usually dark black and coarse in
texture and has a healthy sheen that reflects light. In kwashiorkor, the hair becomes silkier and
thinner. African hair loses its tight curl. At the same time it lacks lustre, is dull and lifeless and
may change in colour to brown or reddish brown. Sometimes small tufts can be easily and
almost painlessly plucked out. On examination under a microscope, plucked hair exhibits root
changes and a narrower diameter than normal hair. The tensile strength of the hair is also
reduced. In Latin America bands of discoloured hair are reported as a sign of kwashiorkor.
These reddish-brown stripes have been termed the flag sign or signa bandera.
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Skin changes
Dermatosis develops in some but not all cases of kwashiorkor. It tends to occur first in areas of
friction or of pressure such as the groin, behind the knees and at the elbow. Darkly pigmented
patches appear, which may peel off or desquamate. The similarity of these patches to old sunbaked, blistered paint has given rise to the term flaky-paint dermatosis. Underneath the
flaking skin are atrophic depigmented areas which may resemble a healing burn.
Anaemia
Most cases have some degree of anaemia because of lack of the protein required to synthesize
blood cells. Anaemia may be complicated by iron deficiency, malaria, hookworm, etc.
Diarrhoea
Stools are frequently loose and contain undigested particles of food. ometimes they have an
offensive smell or are watery or tinged with blood.
Moonface
The cheeks may appear to be swollen with either fatty tissue or fluid, giving the characteristic
appearance known as moonface.
Signs of other deficiencies
In kwashiorkor some subcutaneous fat is usually palpable, and the amount gives an indication
of the degree of energy deficiency. Mouth and lip changes characteristic of vitamin B deficiency
are common. Xerosis or xerophthalmia resulting from vitamin A deficiency may be seen.
Deficiencies of zinc and other micronutrients may occur.
Severe hookworm anaemia
Oedema may result from this cause alone. In young children kwashiorkor is often also present.
In pure hookworm anaemia there are no skin changes other than pallor. In all cases the stools
should be examined.

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Pellagra: Pellagra is rare in young children. The skin lesions are sometimes similar to those of
kwashiorkor, but in pellagra they tend to be on areas exposed to sunlight(not the groin, for
example). There may frequently be diarrhoea and weight loss, but no oedema or hair changes.
Nutritional Marasmus
In most countries marasmus, the other severe form of PEM, is now much more prevalent than
kwashiorkor. In marasmus the main deficiency is one of food in general, and therefore also of
energy. It may occur at any age, most commonly up to about three and a half years, but in
contrast to kwashiorkor it is more common during the first year of life. Nutritional marasmus is
in fact a form of starvation, and the possible underlying causes are numerous. For whatever
reason, the child does not get adequate supplies of breastmilk or of any alternative food.
Perhaps the most important precipitating causes of marasmus are infectious and parasitic
diseases of childhood. These include measles, whooping cough, diarrhoea, malaria and other
parasitic diseases. Chronic infections such as tuberculosis may also lead to marasmus. Other
common causes of marasmus are premature birth, mental deficiency and digestive upsets such
as malabsorption or vomiting. A very common cause is early cessation of breastfeeding.
Clinical features of nutritional marasmus
The important features of kwashiorkor and nutritional marasmus are compared in Table 21. The
following are the main signs of marasmus.
Poor growth
In all cases the child fails to grow properly. If the age is known, the weight will be found to be
extremely low by normal standards (below 60 percent or -3 SD of the standard). In severe cases
the loss of flesh is obvious: the ribs are prominent; the belly, in contrast to the rest of the body,
may be protuberant; the face has a characteristic simian (monkey-like) appearance; and the
limbs are very emaciated. The child appears to be skin and bones. An advanced case of the
disease is unmistakable, and once seen is never forgotten.
Wasting

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The muscles are always extremely wasted. There is little if any subcutaneous fat left. The skin
hangs in wrinkles, especially around the buttocks and thighs. When the skin is taken between
forefinger and thumb, the usual layer of adipose tissue is found to be absent.
Alertness
Children with marasmus are quite often not disinterested like those with kwashiorkor. Instead
the deep sunken eyes have a rather wide-awake appearance. Similarly, the child may be less
miserable and less irritable.
Appetite
The child often has a good appetite. In fact, like any starving being, the child may be ravenous.
Children with marasmus often violently suck their hands or clothing or anything else available.
Sometimes they make sucking noises.
Anorexia: Some children are anorexic.
Diarrhoea
Stools may be loose, but this is not a constant feature of the disease. Diarrhoea of an infective
nature, as mentioned above, may commonly have been a precipitating factor.
Anaemia: Anaemia is usually present.
Skin sores: There may be pressure sores, but these are usually over bony prominences, not in
areas of friction. In contrast to kwashiorkor, there is no oedema and no flaky-paint dermatosis
in marasmus.
Hair changes: Changes similar to those in kwashiorkor can occur. There is more frequently a
change of texture than of colour.
Dehydration:

Although not a feature of the disease itself, dehydration is a frequent

accompaniment of the disease; it results from severe diarrhoea (and sometimes vomiting).

Marasmic kwashiorkor
72

Children with features of both nutritional marasmus and kwashiorkor are diagnosed as having
marasmic kwashiorkor. In the Wellcome classification (see above) this diagnosis is given for a
child with severe malnutrition who is found to have both oedema and a weight for age below 60
percent of that expected for his or her age. Children with marasmic kwashiorkor have all the
features of nutritional marasmus including severe wasting, lack of subcutaneous fat and poor
growth, and in addition to oedema, which is always present, they may also have any of the
features of kwashiorkor described above. There may be skin changes including flaky-paint
dermatosis, hair changes, mental changes and hepatomegaly. Many of these children have
diarrhoea.

73