VARIOUS NUTRITIONAL PROBLEMS

Nutrition may be defined as a science of food and its relationsi! to ealt" It is

concerned !rimarily #it te !art !layed by nutrients in body $ro#t%
de&elo!ment and maintenance"

Te #ord nutrient or 'food factor( is used for s!ecific dietary constituents
suc as !roteins% &itamins and minerals" )ietetics is te !ractical
a!!lication of te !rinci!les of nutrition* it includes te !lannin$ of meals
for te #ell and te sic+" ,ood nutrition means -maintainin$ a nutrition
status tat enables us to $ro# #ell and en.oy $ood ealt/"
Nutrition !lays an im!ortant role in te !romotion and maintenance of ealt and
in te !re&ention of ealt and in te !re&ention of uman disease" Malnutrition
and undernutrition are te $reatest international ealt !roblems of te !resent
day" A sound +no#led$e of nutrition is terefore essential for a nurse"
In te $lobal cam!ai$n of ealt for all% !romotion of !ro!er nutrition is one of te
ei$t elements of !rimary ealt care" ,reater em!asis is no# !laced on
inte$ratin$ nutrition into !rimary ealt care systems #ene&er $oals to !romote
ealt and nutritional status of families and communities"
FOOD RELATION OF NUTRITION TO HEALTH
,ood relation of nutrition is a basic com!onent of ealt" Te relation of nutrition
to ealt may be seen from te follo#in$ &ie# !oints"
,ood nutrition is essential for te attainment of normal $ro#t and
de&elo!ment not only for !ysical $ro#t and de&elo!ment% but also for te
intellectual de&elo!ment"
Malnutrition is directly res!onsible for certain s!ecific nutritional deficiency
disease"
Te commonly re!orted ones in India are*
0" +#asior+or
1" marasmus"
2" blindness due to &itamin a deficiency
3" anemia
4" beri5beri
6" $oiter%etc
$ood nutrition terefore is essential for te !re&ention of s!ecific nutritional
deficiency diseases and !romotion to ealt"
To $i&e resistance a$ainst infection"
Malnutrition !redis!oses to infection li+e tuberculosis" Infection in turn may
a$$ra&ate malnutrition by effectin$ te food inta+e% absor!tion and
metabolism"
To reduce morbidity and mortality"
Indirect effects of mal malnutrition are7
0" 8i$ $eneral deat rate"
1" 8i$ infant mortality rate"
2" 8i$ sic+ness rate or morbidity rate"
3" Lo#er e9!ectation of life"
4" O&ernutrition #ic is anoter form of malnutrition" it is res!onsible
for7
Obesity"
)iabetes"
8y!ertension"
:ardio&ascular diseases"
Renal diseases"
)isorder of te li&er and $allbladder"
Nutrition deficiency disorders
Deficiency diseases are diseases in umans tat are directly or indirectly
caused by a lac+ of essential nutrients in te diet" )eficiency diseases are
commonly associated #it cronic malnutrition" Additionally% conditions suc as
obesity from o&ereatin$ can also cause% or contribute to% serious ealt
!roblems" E9cessi&e inta+e of some nutrients can cause acute !oisonin$"
Malnutrition
Tese results from te deficiency in te diet of ener$y% !rotein% &itamin% fibers or
all some of tem" Occasionally tese arise e&en tou$ te foods are not
deficient in nutrients" Tey are ten +no#n as -secondary malnutrition/" ;ollo#in$
are some of te causes of secondary malnutrition75
<a= Malabsor!tion from alcoolism% celiac diseases etc"
<b= Increased demand of foods as in !rotracted fe&ers"
<c= Increased e9cretion !roduced by diarreas and ancyclostomias"
<d= Inade>uate utili?ation of food on accounts of diabetes"
Following are the conseuences of !alnutrition"#
<a= Malnutrition !re&ents te affected cild from attainin$ full
$enetic !otential"
<b= It reduces bodily resistance to infection and !rolon$s reco&ery
follo#in$ illness"
<c= It im!airs mental ca!acity% co$niti&e ability and motor s+ills
<d= It reduces !ysical ca!acity and alertness
THE $RO%LEM OF MALNUTRITION
Mal nutrition as been defined as -a !atolo$ical state resultin$ from a relati&e or
absolute deficiency or e9cess of one or more essential nutrients/" It com!rises
four forms75
Undernutrition%
O&ernutrition%
Imbalance and
S!ecific deficiency"
UNDERNUTRITION7 tis is te condition #ic results #en insufficient food is
eaten o&er an e9tended !eriod of time" In e9treme cases% it is called star&ation"
Undernutrition is a form of malnutrition" Undernutrition can result from inade>uate
in$estion of nutrients% malabsor!tion% im!aired metabolism% loss of nutrients due
to diarrea% or increased nutritional re>uirements <as occurs in cancer or
infection=" Undernutrition !ro$resses in sta$es* eac sta$e usually ta+es
considerable time to de&elo!" ;irst% nutrient le&els in blood and tissues can$e%
follo#ed by intracellular can$es in biocemical functions and structure"
Ultimately% sym!toms and si$ns a!!ear"
Ris& Factors
Undernutrition is associated #it many disorders and circumstances% includin$
!o&erty and social de!ri&ation" Ris+ is also $reater at certain times <ie% durin$
infancy% early cildood% adolescence% !re$nancy% breastfeedin$% and old a$e="
Problems $enerated due to undernutrition are75
:arnitine )eficiency
"Essential ;atty Acid )eficiency
Protien ener$y malnutrition <PEM=
$ROTIEN ENER'( MALNUTRITION )$EM*"#
$EM is a $rou! of !atolo$ical conditions of &aryin$ de$ree of se&erity
arisin$ from a lac+% in &aryin$ !ro!ortions% of !roteins and calories" Tey are
!reci!itated by attac+s of infections"
Tey manifest as $ro#t failure% lo# body #ei$t and nutritional
y!o!rotinemia" It accounts for 4@ of deats in !rescool cildren" About 0A@ of
cases are se&ere enou$ to need os!itali?ation" About 04@ of !ediatric beds% at
any one time% are occu!ied by cases of $EM+
,LA--IFI,ATION
Under nutrition in $eneral is classified as follo#s75
'RADE .75BA5BC@ of reference #ei$t for a$e <RDA=% #ic is te 4A
t
centile
<median= #ei$t of 8ar&ard standards"
'RADE /75 6A56C@ of RDA"
'RADE 075 Less tan 6A@ of RDA"
An additional $rade 4
t
is reco$ni?ed by te Indian academy of !ediatrics
and is defined as less tan 4A@ RDA"
TREATMENT"##
)e!ends on te se&erity of PEM755
).*"# For !ild to !oderator cases1 the 2arents are ad3ised to do
as follows"#
,i&e te cild more of foods bein$ already $i&en"
Increase te number of meals includin$ snac+s of 4 or 6"
Include ,LVs in te diet"
Enric te meals #it te addition of a little oil% an e$$ or e9tra mil+"
)/*"#Nutrition reha4ilitation75
Moderate cases of PEM and tose se&ere cases tat
do not re>uire os!itali?ation are treated at a -nutrition reabilitation centre/" Tis
is a sim!le% ut li+e structure #it a &e$etable and fruit $arden around it" In tis
centre cildren are treated for PEM and teir moters educated in te ri$t
metods of cildcare% feedin$% $ardenin$ and nutrition"
Te !ediatrician% a nurse% a !armacist% a ealt instructor% #ard boys%
el!ers and $ardeners staff te nutrition reabilitation centre" Te moter stays
eiter full time in te centre% or only durin$ te day% returnin$ ome for te li$t"
Te moters are $i&en education and so#n demonstration of te correct
coo+in$ metods #it te el! of te locally a&ailable foods" Te &essels% te
fuel% te sto&e% etc% in tese demonstration bear te local caracter of te &illa$e
#ere te centre is set u!" Te moters are encoura$ed to discuss te learnt
sub.ects amon$st temsel&es" Tey !artici!ate in loo+in$ after +itcen $arden
attaced to te Ecentre" Te moters ta+e !art in te treatment of te cild and
note te im!ro&e tat e or se s!eedily ma+es"
<2= Se&ere cases of PEM are admitted to a !ediatric os!ital or #ard" Te
!rinci!les of teir mana$ement are $i&en belo#7
<a= Pro&ision of 1AA +calF+$ of ener$y and 3 $F+$ of !rotein $radually in
te case of marasmus and a$$ressi&ely in tat of +#asior+or"
<b= Treatment of accom!anyin$ nutritional deficiencies"
<c= Treatment of underlyin$ or accom!anyin$ infections% if any"
<d= Early detections of com!lications li+e deydration% y!otermia%
y!o$lycemia% etc"% by +ee!in$ a continuity &i$il and teir !rom!t treatment
sould tey de&elo!"
<e= Nutrition education of te !arents"
$RE5ENTION OF $EM
).* Educate about ome made i$ !rotein mi9ture" Moters are educated to
!re!are te follo#in$ i$5 !rotein mi9 at ome and use it in cild feedin$75 Ra$i
14A,
Deat or rice 14A,
,reen ,ram 14A,
,roundnuts 0AA,
Til <sesame= 4A,
Su$arFGa$$ery 2AA,
All te items e9ce!t su$ar or .a$$ery are se!arately fried" Ten tey are
mi9ed to$eter% su$ar or .a$$ery added% and #ole $round" Te resultin$ !o#der
is stored in a tin #it a ti$t lid" Si9ty , is mi9ed #it a little #ater to form
!orrid$e and fed to te cild t#o times a day" Alternati&ely te !o#der is mi9ed
#it a little $ee and made into ladoos" T#o of tem are $i&en to te cild e&ery
day"
)/* Education about breast feedin$" Moters are educated to start breast H
feedin$ te baby #itin I our of its birt and continue for t#o years" ;or te first
four monts tey are told not to $i&e anytin$ to te baby oter tan moter(s
mil+" All os!itals and maternity omes are ad&ised to !romote e9clusi&e breast5
feedin$ as abo&e"
)0* Early detection of PEM" Tis is !ossible trou$ $ro#t monitorin$" If PEM is
detected it is at once suitably treated"
)6* Nutrition su!!lementation #it te el! of mil+ !o#der% mid day etc"% is
carried out for te benefit of te &ulnerable $rou!s suc as te !re$nant and
lactatin$ #omen% !rescool etc"
)7* Te follo#in$ measures are underta+en to increase food !roduction%
im!ro&e food distribution and lo#er te food !rice7
Land reforms"
Im!ro&ed food tecnolo$y"
)istribution of certified im!ro&ed seeds to farmers"
)ri! irri$ation"
Subsidy for fertili?ers"
Subsidi?ed foods trou$ !ublic distribution system"
Post5 ar&est $odo#n <stora$e= facilities"
:reation of a buffer stoc+ of foods"
)8* All !ossible measures for te stabili?ation of te !o!ulation"
)9* Po&erty alle&iation measures" Tese are te follo#in$ 7 trainin$ of
yout in tecnical s+ills% easy loan facilities for settin$ u! business &entures*
community centers for andicraft* food for #or+* and #a$es for #or+"
):* :ontrol of endemic diseases trou$ immuni?ations% ORS tera!y%
!eriodic de#ormin$% cotrima9a?ole for ARIs% !rotected #ater su!!ly% sanitary
dis!osal of e9creta etc"
/" O3ernutrition" Tis is te !atolo$ical state resultin$ from te consum!tion
of e9cessi&e >uantity of food o&er an e9tended !eriod of time" Te i$ incidence
of obesity% ateroma and diabetes in #estern societies is attributed to
o&ernutrition"
O%E-IT(
Obesity is e9cess body fat* conse>uences de!end not only on te absolute
amount but also on te distribution of te fat" :om!lications include
cardio&ascular disorders% diabetes mellitus% many cancers% colelitiasis% fatty
li&er and cirrosis% osteoartritis% re!roducti&e disorders in men and #omen%
!sycolo$ic disorders% and !remature deat" )ia$nosis is based on body mass
inde9 <BMIJcalculated from ei$t and #ei$t= and #aist circumference" BP%
fastin$ !lasma $lucose% and li!id le&els sould be measured" Treatment includes
!ysical acti&ity% dietary and bea&ioral modification% and sometimes dru$s or
sur$ery"
Etiology
Almost all cases of obesity result from a combination of $enetic !redis!osition
and a cronic imbalance bet#een ener$y inta+e% ener$y utili?ation for basic
metabolic !rocesses% and ener$y e9!enditure from !ysical acti&ity"
'enetic factors" 8eritability of BMI is about 66@" ,enetic factors may affect te
many si$nalin$ molecules and rece!tors used by !arts of te y!otalamus and
,I tract to re$ulate food inta+e" Rarely% obesity results from abnormal le&els of
!e!tides tat re$ulate food inta+e <e$% le!tin= or abnormalities in teir rece!tors
<e$% melanocortin53 rece!tor="
,enetic factors also re$ulate ener$y e9!enditure% includin$ BMR% diet5induced
termo$enesis% and non&oluntary acti&ityHassociated termo$enesis" ,enetic
factors may a&e a $reater effect on te distribution of body fat% !articularly
abdominal fat <see Obesity and te Metabolic Syndrome7 Metabolic Syndrome=%
tan on te amount of body fat"
En3iron!ental factors" Dei$t is $ained #en caloric inta+e e9ceeds ener$y
needs" Im!ortant determinants of ener$y inta+e include !ortion si?es and te
ener$y density of te food" 8i$5fat foods% !rocessed foods% and diets i$ in
refined carboydrates% soft drin+s% fruit .uices% and alcool !romote #ei$t $ain"
)iets i$ in fres fruit and &e$etables% fiber% and com!le9 carboydrates% #it
#ater as te main fluid consumed% minimi?e #ei$t $ain" A sedentary lifestyle
!romotes #ei$t $ain"
Regulatory factors" Prenatal maternal obesity% !renatal maternal smo+in$%
intrauterine $ro#t restriction% and insufficient slee! can disturb #ei$t
re$ulation" About 04@ of #omen !ermanently $ain K 1A lb #it eac !re$nancy"
Obesity tat !ersists beyond early cildood ma+es #ei$t loss in later life more
difficult"
)ru$s% includin$ corticosteroids% litium% traditional antide!ressants <tricyclics%
tetracyclics% and monoamine o9idase inibitors LMAOIsM=% ben?odia?e!ines% and
anti!sycotic dru$s% often cause #ei$t $ain"
Uncommonly% #ei$t $ain is caused by one of te follo#in$ disorders7
Brain dama$e caused by a tumor <es!ecially a cranio!aryn$ioma= or an
infection <!articularly tose affectin$ te y!otalamus=% #ic can stimulate
consum!tion of e9cess calories
8y!erinsulinism due to !ancreatic tumors
8y!ercortisolism due to :usin$Ns syndrome% #ic !roduces
!redominantly abdominal obesity
8y!otyroidism <rarely a cause of substantial #ei$t $ain=
Eating disorders" At least 1 !atolo$ic eatin$ !atterns may be associated #it
obesity7
%inge eating disorder is consum!tion of lar$e amounts of food >uic+ly
#it a sub.ecti&e sense of loss of control durin$ te bin$e and distress after it"
Tis disorder does not include com!ensatory bea&iors% suc as &omitin$"
Pre&alence is 0 to 2@ amon$ bot se9es and 0A to 1A@ amon$ !eo!le
enterin$ #ei$t reduction !ro$rams" Obesity is usually se&ere% lar$e amounts
of #ei$t are fre>uently $ained or lost% and !ronounced !sycolo$ic
disturbances are !resent"
Night#eating syndro!e consists of mornin$ anore9ia% e&enin$ y!er!a$ia% and
insomnia" At least 14 to 4A@ of daily inta+e occurs after te e&enin$ meal" About
0A@ of !eo!le see+in$ treatment for se&ere obesity may a&e tis disorder"
Rarely% a similar disorder is induced by use of a y!notic suc as ?ol!idem
,o!2lications
:om!lications of obesity include te follo#in$7
Metabolic syndrome
)iabetes mellitus
:ardio&ascular disease
Nonalcoolic steatoe!atitis <fatty li&er=
,allbladder disease
,astroeso!a$eal reflu9
Obstructi&e slee! a!nea
Re!roducti&e system disorders
Many cancers
Osteoartritis
Social and !sycolo$ic !roblems
Diagnosis
BMI
Daist circumference
Sometimes body com!osition analysis
Treat!ent
Nutrition mana$ement
Pysical acti&ity
Bea&ioral tera!y
)ru$s <e$% sibutramine% orlistat=
Nutrition" A normal eatin$ !attern is im!ortant" Peo!le #o miss brea+fast tend
to !assi&ely consume too many calories later in te day" Patients sould eat
small meals and a&oid or carefully coose snac+s" Lo#5fat <!articularly &ery lo#
saturated fat=% i$5fiber diets #it modest calorie restriction <by 6AA +calFday=
and substitution of some !rotein for carboydrate a!!ear to a&e te best lon$5
term outcome" ;res fruits and &e$etables and salads sould be substituted for
refined carboydrates and !rocessed food% and #ater for soft drin+s or .uices"
Alcool consum!tion sould be limited to moderate le&els"
$hysical acti3ity" E9ercise increases ener$y e9!enditure% BMR% and diet5
induced termo$enesis" E9ercise also seems to re$ulate a!!etite to more closely
matc caloric needs" Oter benefits include
Increased insulin sensiti&ity
Im!ro&ed !lasma li!id !rofile
Lo#er BP
Better aerobic fitness
Im!ro&ed !sycolo$ic #ell5bein$
Stren$tenin$ <resistance= e9ercises increase muscle mass" Because muscle
tissue burns more calories at rest tan does fat tissue% increasin$ muscle mass
!roduces lastin$ increases in BMR" E9ercise tat is interestin$ and en.oyable is
more li+ely to be sustained" A combination of aerobic and resistance e9ercise is
better tan eiter alone"
%eha3ioral thera2y" Bea&ioral tera!y aims to im!ro&e eatin$ abits and
!ysical acti&ity le&el" Ri$id dietin$ is discoura$ed in fa&or of ealty eatin$"
:ommon5sense measures include te follo#in$7
A&oidin$ i$5calorie snac+s
:oosin$ ealtful foods #en dinin$ out
Eatin$ slo#ly
Substitutin$ a !ysically acti&e obby for a !assi&e one
Social su!!ort% co$niti&e tera!y% and stress mana$ement may el!% !articularly
durin$ te la!ses usually e9!erienced durin$ any lon$5term #ei$t loss !ro$ram"
Self5monitorin$ is useful% and maintenance of a diet diary is !articularly effecti&e"
Drugs" )ru$s may be used if BMI is O 2A or if BMI is O 1B and !atients a&e
com!lications <e$% y!ertension% insulin resistance=" Most #ei$t loss due to dru$
treatment is modest <4 to 0A@= at best and occurs durin$ te first 6 mo* not all
!atients benefit" )ru$s are more useful for maintainin$ #ei$t loss but must be
continued indefinitely for #ei$t loss to be maintained" Premeno!ausal #omen
ta+in$ systemically actin$ dru$s for #ei$t control sould use contrace!tion"
Metabolic syndrome <syndrome P% insulin resistance syndrome= is caracteri?ed
by a clusterin$ of ris+ factors for cardio&ascular disease and ty!e 1 diabetes
-urgery" Sur$ery is te most effecti&e treatment for e9tremely obese !atients
Metabolic Syndrome
mellitus" Tey commonly include e9cess intra5abdominal fat% insulin resistance%
and K 0 of te follo#in$7 ele&ated !lasma tri$lyceride le&els% decreased i$
density li!o!rotein <8)L= colesterol le&el% and y!ertension" :auses%
com!lications% dia$nosis% and treatment are similar to tose of obesity"
2+ I!4alance7 it is te !atolo$ical state resultin$ from a dis!ro!ortion amon$
essential nutrients #it or #itout te absolute deficiency of any nutrient"
Some of te common !roblems #ic lead to nutritional imbalance are discuss
belo# #it teir solutions"
Decreased a22etite
Heart4urn
Nausea
Diarrhoea
,onsti2ation
6+ -2ecific Deficiency
Menral deficiency and to;icity
Si9 macrominerals are re>uired by !eo!le in $ram amounts" ;our <Na% Q% :a%
and M$= are cations* t#o <:l and P= are accom!anyin$ anions" )aily
re>uirements ran$e from A"2 to 1"A $" Bone% muscle% eart% and brain function
de!end on tese minerals"
Nine trace minerals <microminerals= are re>uired by !eo!le in minute amounts7
cromium% co!!er% iodine% iron% fluorine% man$anese% molybdenum% selenium%
and ?inc"
TRACE ELEMENTS
IRON
The iron is of great importance in human nutrition. The adult human body contains
between 4 to 5 mg of iron, of which about 60-70 percent is present in blood as circulating
iron, and the rest as storage iron. Each gram haemoglobin contains about .4 mg of iron.
EFFECTS OF IRON-DEFICIENCY
The end result of iron-deficiency is nutritional anaemia which is not a disease entity. !t is
rather a syndrome caused by malnutrition. besides anaemia there may be other functional
disturbance to infection, increased mobidity and mortality and diminished wor"
performance.
$re3ention of Iron Deficiency
It can el! to understand o# to !re&ent iron deficiency if you understand o#
te body stores iron" Babies% unless tey are born !remature% are born #it all of
te iron tey need for te first 456 monts of life" After tat% unless tey are $i&en
an iron su!!lement% tey can de&elo! iron deficiency% #ic means tat tey
donNt a&e enou$ iron in teir body" If it continues% it #ill ten lead to iron
deficiency anemia"
So to !re&ent iron deficiency% you sould breastfeed or $i&e your infant an iron
fortified infant formula <a&oidin$ lo# iron formula= until tey are at least 01
monts of a$e% and be$in an iron su!!lement by about 6 monts of a$e"
Startin$ an iron su!!lement doesnNt necessarily mean startin$ tem on a &itamin
#it iron tou$" Te usual su!!lement is sim!ly an iron fortified infant cereal
$i&en once or t#ice a day" Remember tat !reemies or lo# birt #ei$t infants
do usually also need a &itamin #it iron"
After you a&e introduced an iron fortified infant cereal% start one feedin$ a day of
foods ric in &itamin : <e"$"% fruits% &e$etables% or .uice= to im!ro&e iron
absor!tion% !referably #it meals"
$re3ention of Iron Deficiency in Teens
To !re&ent iron deficiency in teens% tey sould be encoura$ed to eat iron5ric
foods and foods tat enance iron absor!tion" Tose #o are at ris+ of becomin$
iron deficient sould be tested and $i&en an iron su!!lement if tey do a&e iron
deficiency
,hro!iu!75Only 0 to 2@ of biolo$ically acti&e tri&alent cromium <:r= is
absorbed" Normal !lasma le&els are A"A4 to A"4A R$FL <0"A to C"6 nmolFL="
:romium !otentiates insulin acti&ity and increases te $ro#t rate in
malnourised cildren" Su!!lements do not enance muscle si?e or stren$t in
men"
Deficiency" ;our !atients recei&in$ lon$5term TPN de&elo!ed !ossible
cromium deficiency% #it $lucose intolerance% #ei$t loss% ata9ia% and !eri!eral
neuro!aty" Sym!toms resol&ed in 2 #o #ere $i&en tri&alent cromium 04A to
14A m$"
To;icity" 8i$ doses of tri&alent cromium $i&en !arenterally cause s+in
irritation% but lo#er doses $i&en orally are not to9ic" E9!osure to e9a&alent
cromium <:rO
2
= in te #or+!lace may irritate te s+in% lun$s% and ,I tract and
may cause !erforation of te nasal se!tum and lun$ carcinoma"
Fluorine
Most of te bodyNs fluorine <;= is contained in bones and teet" ;luoride <te ionic
form of fluorine= is #idely distributed in nature" Te main source of fluoride is
fluoridated drin+in$ #ater"
Deficiency" ;luorine deficiency can lead to dental caries and !ossibly
osteo!orosis" ;luoridation of #ater tat contains S 0 !!m <te ideal= reduces te
incidence of dental caries" If a cildNs drin+in$ #ater is not fluoridated% oral
fluoride su!!lements can be !rescribed"
To;icity" E9cess fluorine can accumulate in teet and bones% causin$ fluorosis"
)rin+in$ #ater containin$ O 0A !!m is a common cause" Permanent teet tat
de&elo! durin$ i$ fluoride inta+e are most li+ely to be affected" E9!osure must
be muc $reater to affect deciduous teet"
Treatment in&ol&es reducin$ fluoride inta+e* e$% in areas #it i$ fluoride #ater
le&els% !atients sould not drin+ fluoridated #ater or ta+e fluoride su!!lements"
:ildren sould al#ays be told not to s#allo# fluoridated toot!astes
IODINE
In te body% iodine <I= is in&ol&ed !rimarily in te syntesis of 1 tyroid ormones%
tyro9ine <T
3
= and triiodotyronine <T
2
=" Iodine occurs in te en&ironment and in
te diet !rimarily as iodide" In adults% about TA@ of te iodide absorbed is
tra!!ed by te tyroid $land" Most en&ironmental iodine occurs in sea#ater as
iodide* a small amount enters te atmos!ere and% trou$ rain% enters $round
#ater and soil near te sea" Tus% !eo!le li&in$ far from te sea and at i$er
altitudes are at !articular ris+ of deficiency" ;ortifyin$ table salt #it iodide
<ty!ically BA R$F$= el!s ensure ade>uate inta+e <04A R$Fday=" Re>uirements are
i$er for !re$nant <11A R$Fday= and lactatin$ <1CA R$Fday= #omen"
IODINE DEFI,IEN,(
)eficiency is rare in areas #ere iodi?ed salt is used but common #orld#ide"
Iodine deficiency de&elo!s #en iodide inta+e is S 1A R$Fday" In mild or moderate
deficiency% te tyroid $land% influenced by tyroid5stimulatin$ ormone <TS8=%
y!ertro!ies to concentrate iodide in itself% resultin$ in colloid $oiter" Usually%
!atients remain eutyroid* o#e&er% se&ere iodine deficiency in adults may cause
y!otyroidism <endemic my9edema=" It can decrease fertility and increase ris+
of stillbirt% s!ontaneous abortion% and !renatal and infant mortality" Se&ere
maternal iodine deficiency retards fetal $ro#t and brain de&elo!ment%
sometimes resultin$ in birt defects% and% in infants% causes cretinism% #ic may
include mental retardation% deaf mutism% difficulty #al+in$% sort stature% and
sometimes y!otyroidism"
Treat!ent
UIodide #it or #itout le&otyro9ine
Infants #it iodine deficiency are $i&en L5tyro9ine 2 R$F+$ !o onceFday for a
#ee+ !lus iodide 4A to CA R$ !o onceFday for se&eral #ee+s to >uic+ly restore a
eutyroid state" :ildren are treated #it iodide CA to 01A R$ onceFday" Adults
are $i&en iodide 04A R$ onceFday" Iodine deficiency can also be treated by $i&in$
le&otyro9ine
IODINE TO<I,IT(
:ronic to9icity may de&elo! #en inta+e is O 0"0 m$Fday" Most !eo!le #o
in$est e9cess amounts of iodine remain eutyroid" Some !eo!le #o in$est
e9cess amounts of iodine% !articularly tose #o #ere !re&iously deficient%
de&elo! y!ertyroidism <God5Basedo# !enomenon=" Parado9ically% e9cess
u!ta+e of iodine by te tyroid may inibit tyroid ormone syntesis <called
Dolff5:ai+off effect=" Tus% iodine to9icity can e&entually cause iodide $oiter%
y!otyroidism% or my9edema" Very lar$e amounts of iodide may cause a brassy
taste in te mout% increased sali&ation% ,I irritation% and acneiform s+in lesions"
Patients e9!osed to fre>uent lar$e amounts of radio$ra!ic contrast dyes or te
dru$ amiodarone
Manganese
Man$anese <Mn=% necessary for ealty bone structure% is a com!onent of
se&eral en?yme systems% includin$ man$anese5s!ecific $lycosyltransferases and
!os!oenol!yru&ate carbo9y+inase" Median inta+e is bet#een 0"6 and 1"2
m$Fday* absor!tion is 4 to 0A@"
Deficiency as not been conclusi&ely documented% altou$ one e9!erimental
case in a &olunteer resulted in transient dermatitis% y!ocolesterolemia% and
increased al+aline !os!atase le&els"
To;icity is usually limited to !eo!le #o mine and refine ore* !rolon$ed
e9!osure causes neurolo$ic sym!toms resemblin$ tose of !ar+insonism or
DilsonNs disease"
FI%RE DEFI,IEN,( DI-ORDER-"## ;oods tat are deficient in fiber
<residue or rou$a$e= !redis!ose to consti!ation% iatus ernia% emorroids%
dee! &ein trombosis% &aricose &ein% inflammation of te a!!endi9 and cancer
of colon"
5ita!ins deficiency disorders"#
5ITAMIN A DEFI,IEN,(
Te si$ns of &itamin A deficiency are !redominantly ocular" Tey includes ni$t
blindness% con.uncti&al 9erosis% bitot(s s!ots% corneal 9erosis and +eratomalacia"
Te term -9ero!talmia/ <dry eye= com!rises all te te ocular manifestation of
&itamin A deficiency from ni$t blindness to +eratomalacia"
,i&en belo# is a sort descri!tion of te ocular manifestations"
NI'HT %LINDNE--
Lac+ of &itamin A first causes ni$t blindness or inability to see in dim li$t" Te
moter erself can detect tis condition #en er cild cannot see in late
e&enin$s or find er in dar+ened room" Ni$t blindness is due to im!airment in
dar+ ada!tation" Unless &itamin A inta+e is increased% te condition may $et
#ourse% es!ecially #en cildren also suffer from diarrea and oter infections"
,ON=UN,TI5AL <ERO-I- Tis is te first clinical si$n of &itamin A deficiency"
Te con.uncti&a become dry and non5#ettable" Instead of loo+in$ smoot and
siny% it a!!ears muddy and #rin+les"
%ITOT- -$OT
Bitot s!ots are trian$ular%0 to 1 cm diameter si?e% !early5#ite or yello#is%
foamy s!ots on te sclera or #ite !art of te eye ball on eiter side of cornea"
Tey are fre>uently bilateral" Bitot(s s!ots in youn$ cildren usually indicate
se&ere% &itamin A deficiciency" In older indi&iduals% tese s!ots are often inacti&e
se>uelae of earlier disease"
>ERATOMALA,IA
Qeratomalacia or li>ue facition of cornea is $ra&e medical emer$ency" Te
cornea became soft and may burst o!en"
RI,>ET-
INTRODU,TION"# Ric+ets is a disease of cildren caused by te
deficiency of &itamin ) and calcium% and caracteri?ed by te non H
ardenin$ of te $ro#in$ end of bones" Te deficiency arises in te follo#in$
#ays75
)iet is deficient in &itamin ) and calcium
Te !ytic acid in te diet combines #it te calcium and !re&ents
its absor!tion
E9!osure to solar li$t is scanty eiter because of cloudy #eater
or of !ollution
RE,O'NITION"# Te racitic cild com!lains of s+eletal !ains% #ea+ness%
loss of muscle tone% irritability% res!iratory difficulties% s#eatin$ of scal! and
foreead and con&ulsions
,INI,AL FEATURE-"#
Didenin$ of te s+ull sutures% due to softenin$ of s+ull
Bossin$ of te foreead
Irre$ular and ill5 formed teet
Side to side com!ression of te cest !roducin$ !i$eon cest
Protuberance of abdomen !roducin$ !ot li+e .elly
8uncin$ of te &ertebral column
;lattenin$ of te feet
$RE5ENTION"##Pro!yla9is is acie&ed #it 4 m$ of &itamin )
administered to !rescool cildren at inter&als of 6 monts" If it is !ossible
ten increase &itamin ) consum!tion
%ERI%ERI"#
INTRO)U:TION755 BERIBERI of &itamin B0 deficiency arises from
consumin$ i$ly !olised rice or o&er refined #eat flour" Alcoolism
!redis!oses to it" Beriberi is no# rarely encountered"
RE,O'NITION"#A,UTE OR INFANTILE %ERI%ERI"# Tis occurs
in infants #ose moters are sufferin$ from sub clinical tiamine deficiency"
Te infant is !ale and a!atetic" Infant cannot old is ead erect" Vomitin$%
oarseness and ble!aro!tosis are !resent" Edema and eart failure occur" If
treatment is delayed te infant dies from con&ulsions and coma"
,HRONI, %ERI%ERI"# Tiamine deficiency ta+es one of te follo#in$
tree forms75
<a= Te !atient% usually a male adult en$a$ed in ea&y manual #or+%
com!lains of a!aty% anore9ia% #ea+ness% ata9ia% calf tenderness%
tin$lin$% numbness% and decreased attention s!an" On e9amination%
y!orefle9ia and foot or #rist dro! are found" 8e is sufferin$ from dry
beriberi"
<b= Te !atient com!lains of !al!itations% sortness of breat% and
cest !ain" On e9amination% edema% increased systolic !ressure and
!ulmonary con$estion are found" Tis is a case of #et beriberi"
<c= Te !atient com!lains of double &ision% difficulty in readin$%
insomnia% loss of memory% ata9ia and deterioration in i$er mental
functions" 8e is a case of Dernic+e(s ence!alo!aty"
$RE5ENTION"# Peo!le are educated to consume !arboiled or ome H
!ounded rice" Tey are moti&ated not to #as rice re!eatedly% not to coo+ in
e9cess #ater% and not to discard $ruel"
Te !ossible a!!roaces to !re&ention are te
fortification of rice #it tiamine% su!!ly of tiamine tablets to !re$nant
#omen and culti&ation of ybrid rice containin$ a i$ !ercenta$e of tiamine"
RI%OFLA5IN DEFI,IEN,("# Te indi&idual sufferin$ from ribofla&in
deficiency com!lains of #ea+ness% sore troat% burnin$ and itcin$ in te eye%
on e9amination% ceilosis% $lossitis% an$ular stomatitis% nasolabial seborroeic
dermatitis and corneal &asculari?ation are found" Educatin$ te !eo!le to
consume !lenty of colored &e$etables and fruits is effecti&e in !re&entin$ tis
disease"
$ELLA'RA"#
INTRODU,TION"# Pella$ra < )ry s+in = is a cronic disease of s+in%
intestinal canal and te ner&ous system caused by te deficiency of niacin or
its !recursor try!ti!an" It is !reci!itated by an imbalance bet#een leucine
and isoleucine" Unli+e most oter nutritional deficiency states tat are
common amon$ youn$ cildren% !ella$ra affects !redominantly adults a$ed
1A53C years" Te !atients are $enerally farmers and !easants #o #or+ for
ours in te ot sun and #ose sta!le diet is eiter .o#ar or mai?e" Pella$ra
is a disease of !o&erty < .o#ar and mai?e are cea! cereals =% lo# standard of
li&in$ and !oor en&ironmental sanitation"
Te !ella$ra !atients com!lains of diarrea% letar$y% #ea+ness in lo#er
limbs% confusion% &erti$o and occasionally loss of memory and decrease in
i$er mental functions"
Pella$ra dermatitis is se&ere in #inter tan in summer" It is seen on !arts
of s+in e9!osed in sun" dermatitis on foreead% nose% and cee+s form a
butterfly on a face" )ermatitis on nec+ and u!!er !art of te cest $i&es rise
to :asal(s nec+lace" )ermatitis of dorsum of ands and forearms u! to te rim
of slee&es !roduces !ella$ra $lo&es" And dermatitis of feet and le$s u! to te
ed$e of trousers !roduces !ella$ra soes" Tere is a clear demarcation
bet#een te effected and ealty s+in"
$RE5ENTION"# Peo!le are educated to !roduce and consume a &ariety of
cro!s instead of mai?e or .o#ar alone" A !ossible metod of !re&ention is te
fortification of mai?e or .o#ar #it niacin
-,UR5("#
INTRODU,TION"# Scur&y% &itamin : deficiency% !re&iously used to occur
amon$ sailors and te inmates of .ails% Military barrac+s and or!ana$es" It is
no# seen in !ersons #ose diet lac+s fres fruits and &e$etables and rarely
in infants and !e!tic ulcers !atients #o are subsistin$ on mil+ not
su!!lemented #it ascorbic acid"
RE,O'NITION"# -,UR5( IN ADULT-"# Deariness% letar$y% acin$
in limbs% de!ression% loss of moti&ation are te cief sym!toms of scur&y in
adults"
Te si$ns are bleedin$ from $ums and delayed #ound ealin$
-,UR5( IN INFANT-"## Te moter of an infant older tan 6 monts
see+s ad&ice for its irritability% e9cessi&e cryin$% anore9ia and inability to mo&e
its le$s"
$RE5ENTION"# Peo!le are educated to $ro# and consume fruits" Tey are
ad&ised to conser&e &itamin : by obser&in$ te follo#in$ rules"
Eatin$ te fruits and &e$etables as soon after $aterin$ tem as
!ossible
:uttin$ tem only #it a sar! +nife
A&oidin$ e9!osure of te cut fruits and &e$etables #it te air and
li$t
:oo+in$ &e$etables #it teir s+in on
;irst boilin$ #ater and ten addin$ te &e$etables into it rater tan
addin$ &e$etables to cold #ater and ten boilin$ it
A&oidin$ te use of soda for coo+in$
FLUORO-I-"#
;luorosis results from% drin+in$ #ater containin$ more
tan 0"4 m$Fl of fluorides" It is common in tose #ose sta!le diet is sor$um"
It is a !ublic ealt !roblem in Andra Prades% Qarnata+a% and Tamil nadu%
Pun.ab% 8aryana% Ra.astan and Uttar Prades" E9cessi&e fluoride in$estion
$i&es rise to de!osition of calcium in bones% tendons and .oints" S!inal cord
and ner&e roots are affected secondarily on account of te in&ol&ement of te
&ertebral column"
RE:O,NITION75 Te !atients com!lains of tin$lin$ and numbness in te
limbs% abnormal breatin$ and inability to #al+ and loo+ side#ays" On
e9amination te bac+ is cur&ed% te .oints of te lo#er e9tremities are often
fi9ed and !ainful" On ins!ection of te oral ca&ity% te !ermanent teet are
seen to be cal+y #ite and riddled #it bro#n mottlin$
$RE5ENTION"## ;luorosis is !re&ented by te defluoridation of community
#ater su!!ly"
NUTRITIONAL DEFI,IEN,( ANAEMIA"#
;or Indians anemia is a condition in #ic emo$lobin is less tan
0A$F0AAml <D8O cutoff !oint is 02$Fdl" Anemia is te commonest N)) in
India"
;ollo#in$ are te im!ortant e!idemiolo$ical factors contributin$ to te
de&elo!ment of anemia
<a= :onsum!tion of a !redominantly cereal based diet% tou$ te iron
content of te diet is ade>uate% yet only 4@ of it is actually absorbed"
<b= :onsum!tion of diet lo# in calcium% co!!er and &itamin :% all of
#ic are necessary for te formation of emo$lobin"
<c= Ancylostomias and% to a lesser e9tent% tricuriasis" Te elmintes
res!onsible drin+ blood of te ost and cause loss of iron tat could be
as i$ as 1m$Fday"
RE,O'NITION "
Te anemic !atient com!lains of lac+ of concentration% ready fati$ability%
insomnia% !al!itation% eadace% tinnitus% consti!ation% e9ercise intolerance%
difficulty in s#allo#in$ solid foods% burnin$ sensation in ton$ue% bone !ains% loss
of libido and menstrual irre$ularity
On e9amination is s+in% ton$ue% oral mucosa and con.uncti&a are !ale"
In se&ere cases te !almer creases too !ale" Nails are !ale% brittle and so#
s!oon sa!ed conca&ity" ,lossitis is !resent" Tere is restin$ tacycardia"
TREATMENT"
Anemia is treated #it ferrous sulfate% 1AAm$ of elemental iron% !er day"
It is continued till te emo$lobin reaces normal &alue of 0A$F0AAml" in !re$nant
#omen 2 tablets of folifer% eac #it elemental iron of 6Am$ and folate
4AAumFday are $i&en for 0AA days
Te !atient is treated for oo+#orm infestation #it mebenda?ole
0AAm$Fday for 2 days
IN5E-TI'ATION
Any cause for blood loss is in&esti$ated% for e9am!le stool for occult
blood
$RE5ENTATION"#durin$ !re$nancy 1 tablets of folic acid daily are $i&en for
0AA days" Prescool cildren are $i&en folic acid !ediatrics tablets #it 1Am$
elemental iron and 0AAu$ folate% one tablet a day for 0AA days" Peo!le are
educated and moti&ated to consume ra$i% .a$$ery% and $roundnuts and to a&oid
tea and antacids" Tey are ad&ised to use iron coo+#are" To a&oid oo+#orm
diseases tey are e9orted to use sanitary latrines and #ear foot #ares" A
!ossible metod of !re&ention is te fortification of salt% #eat flour or su$ar #it
iron and &itamin :"
,(ANO,O%ALAMIN DEFI,IEN,( ANEAMIA
Tis is not a !ublic ealt !roblem" It occurs in
infants #ose nursin$ moters are recei&in$ !oor su!!ly of cyanocobalamin in
teir diet" It is also seen in !ersons sufferin$ from )i!yllobotrium latum
infestation" Tis #orm absorbs all te &itamin B01 !resent in te diet" Lastly it is
seen in te $astrectomised !atient" In tem% te cause is te absence of te
'intrinsic factor( tat normally occur in te stomac" Tis factor is necessary for
te absor!tion of cynocobalamin" <Te anemia tat occurs from te con$enital
absence of intrinsic factor is called !ernicious anemia"="
RE,O'NITION"#
Te clinical !icture is similar to tat of folate deficiency anemia"
Additionally neurolo$ical sym!toms li+e sensory disturbance% motor #ea+ness%
!eri!eral neuro!aties and sub acute combined de$eneration of te s!inal cord
may be !resent"
TREATEMENT"#
Vitamin B01"
$RE5ENTION"#
Tem!orary cyanocobalamin su!!lementation is recommended
for te &e$etarian moters #o are nursin$ teir baby and !ermanent
re!lacement tera!y for !ersons #o a&e under$one $astrectomy"
OTHER NUTRITIONAL $RO%LEM-
;ood aller$y
Eatin$ disorders
Anore;ia ner3osa
;ailure to tri&e
Nutritional 2ro4le!s of children"#
Obesity%
)iabetes%
8eart )isease%
Eatin$ )isorders%
Malnutrition%
deficiency disorders etc"
Nutritional problems of adolesents#-
$besity,%iabetes, &eart %isease.Eating %isorders.
High#Ris& 'rou2s
:ertain $rou!s of adolescents may be at ris+ for nutritional inade>uacies"
$regnant Teens+
Den a teena$er becomes !re$nant% se needs enou$ nutrients to su!!ort
bot er baby and er o#n continued $ro#t and !ysical de&elo!ment" If er
nutritional needs are not met% er baby may be born #it lo# birt #ei$t or oter
ealt !roblems" ;or te best outcome% !re$nant teens need to see+ !renatal
care and nutrition ad&ice early in teir !re$nancy"
Athletes+
Adolescents in&ol&ed in atletics may feel !ressure to be at a !articular #ei$t or
to !erform at a certain le&el" Some youn$ atletes may be tem!ted to ado!t
unealtful bea&iors suc as cras dietin$% ta+in$ su!!lements to im!ro&e
!erformance% or eatin$ unealtful foods to fulfill teir earty a!!etites" A
balanced nutritional outloo+ is im!ortant for $ood ealt and atletic
!erformance"
5egetarians+
A &e$etarian diet can be a &ery ealty o!tion" 8o#e&er% adolescents #o follo#
a &e$etarian diet% #eter for reli$ious or !ersonal reasons% need to carefully
!lan teir inta+e to $et te !rotein and !inerals tey need" Strict &e$etarians
<tose #o do not eat e$$s or dairy !roducts=% also +no#n as 3egans % may need
nutritional su!!lements to meet teir needs for calcium% &itamin B
01
% and iron"
Nutritional 2ro4le!s of elderly
Malnutrition is common in elderly !ersons li&in$ in institutions and in te
community" In many cases% te !roblem arises from a i$ly indi&idual
constellation of interactin$ !ysiolo$ic% economic% and !sycosocial causes tat
a&e te common effect of reducin$ nutrient inta+e" Protein5calorie and
micronutrient undernutrition added to te normal effects of a$in$ can undermine
functional inde!endence and diminis te >uality of life of te elderly" Te
s!ectrum of te elderly is e9tremely broad% and% conse>uently% nutritional
assessment and su!!ort must be i$ly indi&iduali?ed to be effecti&e" A
multidisci!linary a!!roac focusin$ on !rom!t identification and treatment of
correctable causes of undernutrition is most effecti&e" Tere is a #ide ran$e of
su!!ort modalities% from sim!le su!!lemental foods to total !arenteral nutrition%
any of #ic may be used successfully in an elderly !atient% !ro&ided tat te
necessary care is ta+en to define te $oals of tera!y and to !ro&ide !atient
assessment and monitorin$"
%I%LIO'RA$H(
indrani TQ" Nursin$ manual of nutrition and tera!eutic diet" 0
st
Ed" 'ew
%elhi# (aypee publishers# )p*++-,04.
.)ar" ". )re-enti-e and social health medicine. Ed ,7
th
. 'ew %elhi. (aypee
publishers# )p*+4-4+
.%r./ 0 1. principles of community health nursing. Ed
rd
. 2!T/1 publishers.
new %elhi# pp-,5-,34
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CLASS
PRESENTATION
SUBJECT- ADVANCED NURSING PRACTICE
TOPIC- !ARIO"S N"TRITIONAL #RO$LEMS
SUBMITTED TO- Ms.JISA GEORGE.
(LECTURER)
S.G.R.D.C.O.N,
HOSHIARPUR.
SUBMITTED BY- RAMANDEEP KAUR
ROLL NO- 10
M.Sc.(N) 1
s
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