Nutrition 151121063433 Lva1 App6892

GOLLIS UNIVERSITY
DEPARTMENT OF PUBLIC HEALTH
Course: Nutrition
Lecturer: Sa’ad Ahmed Abdiwali

Dean of Public Health, Nutrition and Laboratory
BSc, MPH
1
Course content
1. Introduction
– Human nutrition
– Public health nutrition
– Nutrition and development
– Causes of malnutrition
– Malnutrition and infection
2. Nutritional requirements
– Energy
– Proteins
– Fat
– Carbohydrates
– Vitamins 2
– Minerals
Course content…
3. Nutritional assessment
– Methods of nutritional assessment
– The present nutrition situation
– Nutritional surveillance
4. Nutrition through the lifecycle

– Maternal nutrition through the lifecycle
– Low birth weight
3
Course content…
5. Nutritional problems of public health importance

– Protein-energy malnutrition
– Vitamin A deficiency
– Iron deficiency anemia
– Iodine deficiency disorders
– Zinc deficiency
6. Nutrition interventions
– Essential nutrition actions
– Emergency Nutrition Interventions
– Somaliland National Nutrition strategy
7. Nutrition and Development
8. Nutrition in emergencies
9. Food security
10. Infant and young child feeding in emergencies 4
situation
Course Objective
Enable the student acquire theoretical

knowledge (principles) and analytical skills
(methods) in Human Nutrition
5
Course Organization
• Course delivery modalities;

– Lectures
– Group Assignments
• Literature Review and Presentations
– Reading Assignments
6
Examples of topics for Literature
Review and Presentation
• Breast feeding and cognitive development
• Breast feeding and Social
development/family attachment
• Developmental origins of diseases
• HIV/AIDS and infant feeding
• Biofuels and Nutrition security
• Climate change and food security
• Etc.
7
Unit one: Introduction -
Outline:
– Definitions
– Forms of Malnutrition
– Causes/Etiology of Malnutrition
8
Nutrition
The science of Nutrition:
• Nutrition studies the interaction between the

individual and the environment mediated by food
• Study of food in relation to man, and study of

man in relation to food
• Science of food as it relates to optimal health

and performance
9
Nutrition…
• Human Nutrition is a scientific discipline,

concerned with the access and utilization
of foods and nutrients for life, health,
growth, development, and well- being
10
The science of Nutrition:
• Areas of Study
– Food production
– Diet composition (including non-nutritive
substances)
– Food intake, appetite, food preferences
– Digestion and absorption of nutrients
– Intermediary metabolism, nutritional
biochemistry
11
The Science of Nutrition:
 Areas of Study
– Biological actions of essential nutrients

– Nutrient requirements in individuals and
populations
– Heath effects of nutrient deficiencies and
excesses
– Long-term effects of diet constituents
– Therapeutic and preventive effects of foods
12
Nutrition…
• Dietetics
– Science/ art of applying the principles of
nutrition in feeding
– Older subject, practiced by Hippocrates 460-
360 BC.
13
Public Health Nutrition
• Public Health Nutrition focuses on issues

that affect the whole population rather
than the specific dietary needs of
individuals
• The emphasis is on promoting health and

disease prevention
14
Malnutrition
• A pathological state resulting from a

relative or absolute deficiency or excess
of one or more essential nutrients, this
state being clinically manifested or
detected only by biochemical,
anthropometric or physiological tests
15
Forms of Malnutrition
• Under nutrition
– Pathological state resulting from the consumption of
an inadequate quality/ quantity over an extended
period of time
• Over-nutrition
– Pathological state resulting from the consumption of
an excess quantity of food, and hence an energy
excess, over an extended period of time
16
The Scale of the Problem
– Protein−energy malnutrition (PEM),

– vitamin A deficiency,
– iodine deficiency disorders (IDD) and
– nutritional anaemias − mainly resulting from
iron deficiency or iron losses −
• are the most common serious nutritional problems

in almost all countries of Asia, Africa, Latin
America and the Near East.
17
Global Distribution of Malnutrition
18
Prevalence of chronic undernutrition in
developing regions (1969-1992)
19
Estimated prevalence and number of underweight
children 0−5 years old 1990−2005
20
Trends of malnutrition in Sub-Saharan
Africa (1983-2001)
21
Population at risk of and affected by micronutrient
malnutrition (millions) - 1992
22
23
24
What Is a Healthy Diet?
– Fulfills energy needs (macronutrients)
– Provides sufficient amounts of essential

nutrients (micronutrients)
– Reduces risk of disease
– Is safe to consume (low contaminants or

potentially harmful added substances)
25
26
Causes of Malnutrition
• Malnutrition, is not a simple problem with a

single, simple solution
• Multiple and interrelated determinants are

involved in why malnutrition develops, and
a similarly intricate series of approaches,
multifaceted and multisectoral, are needed
to deal with it
27
Causes of Malnutrition…
• Causes could be categorized as:

– Immediate causes
– Underlying causes, and
– Basic causes
28
29
Malnutrition - Immediate causes
Immediate causes
• The interplay between the two most significant

immediate causes of malnutrition - inadequate
dietary intake and illness - tends to create a
vicious circle:
• A malnourished child, whose resistance to

illness is compromised, falls ill, and
malnourishment worsens
30
Malnutrition - Immediate causes…
• Children who enter the malnutrition-infection

cycle can quickly fall into a potentially fatal spiral
as one condition feeds off the other
• Malnutrition lowers the body’s immune-response

mechanisms.
– This leads to longer, more severe and more frequent
episodes of illness
31
Inadequate dietary intake/disease cycle
Weight loss Disease:

Growth faltering - incidence
Immunity lowered - severity
Mucosal damage - duration
Appetite loss
Nutrient loss
Inadequate dietary intake
Malabsorption
Altered metabolism
32
Malnutrition - Immediate causes…
• Infections cause loss of appetite,

malabsorption and metabolic and
behavioral changes.
• These, in turn, increase the body’s

requirements for nutrients, which further
affects young children’s eating patterns
and how they are cared for
33
Malnutrition - Underlying causes
• Three clusters of underlying causes lead

to inadequate dietary intake and infectious
disease:
– inadequate access to food in a household;
– insufficient health services and an
unhealthful environment; and
– inadequate care for children and women
34
(HHFS)…
Household food security (HHFS)
– is defined as sustainable access to safe

food of sufficient quality and quantity -
including energy, protein and micronutrients -
to ensure adequate intake and a healthy life
for all members of the family
35
(HHFS)…
• In rural areas, HHFS may depend on access to land

and other agricultural resources to guarantee
sufficient domestic production
• In urban areas, where food is largely bought on the

market, foods must be available at accessible prices
• Other potential sources of food are by exchange, gifts

from friends or family and in extreme circumstances food
aid provided by humanitarian agencies
36
(HHFS)…
• HHFS depends on access to food -

financial, physical and social - as
distinct from its availability
37
(Services and sanitation)…
• Health services, safe water and
sanitation
– access to curative and preventive health
services that are affordable and of good
quality
– Families should have a health centre within a

reasonable distance, and the centre’s staff
should be qualified and equipped to give the
advice and care needed
38
(caring)…
• Caring practices
– even when there is adequate food in the house and a
family lives in a safe and healthful environment and
has access to health services, children can still
become malnourished
– Inadequate care for children and women, the third

element of malnutrition’s underlying causes, has only
recently been recognized and understood in all its
harmful ramifications
39
(caring)…
• Care is manifested in the ways a child is

fed, nurtured, taught and guided
• Nutritionally, care encompasses all

measures and behaviors that translate
available food and health resources into
good child growth and development
40
(caring)…
• In communities where mothers are

supported and cared for, they are, in turn,
better able to care for young children
• Among the range of caring behaviors that

affects child nutrition and health, the
following are most critical:
41
(caring)…
• Feeding:
– The introduction of complementary foods is a critical
stage. A child will be put at increased risk of
malnutrition and illness if these foods are introduced
much before the age of six months, or if the
preparation and storage of food in the home is not
hygienic
– Good caring practices need to be grounded in good

information & knowledge and free of cultural biases
and misperceptions
42
(caring)…
– Other behaviors that affect nutrition include
whether children are fed first or last among
family members, and whether boys are fed
preferentially over girls
• Protecting children’s health:

– Ensure that children receive essential health
care at the right time (e.g. immunizations, and
early treatment)
43
(caring)…
• Support and cognitive stimulation for
children:
– For optimal development, children require
emotional support and cognitive stimulation,
and parents and other caregivers have a
crucial role in recognizing and responding to
the actions and needs of infants
– Breastfeeding affords the best early occasion

to provide support and stimulation
44
(caring)…
– Verbal stimulation by caregivers is particularly

important for a child’s linguistic development
– Ill or malnourished children who are in pain

and have lost their appetite need special
attention to encourage them to feed and take
a renewed interest in their surroundings
during recovery
45
(caring)…
• Care and support for mothers:
– As long as the unequal division of labour and
resources in families and communities continues to
favour men, and as long as girls and women face
discrimination in education and employment, the
caring practices vital to the nutritional well-being of
children will suffer
– Adolescent pregnancy is a major risk factor for both

mother and infant, as the girl may not have finished
growing before her first pregnancy, making childbirth
dangerous
46
Malnutrition - Basic causes
– It is often said that poverty at the family level

is the principal cause of child malnutrition
– Political, legal and cultural factors at the

national and regional levels may defeat the
best efforts of households to attain good
nutrition for all members
47
Malnutrition - Basic causes…
– These include:
• the degree to which the rights of women and girls
are protected by law and custom;
• the political and economic system that determines
how income and assets are distributed; and
• the ideologies and policies that govern the social
sectors
48
Nutrition Intervention
• A wide variety of policies and programs can

improve nutrition
• Could be seen as short or long-term

interventions
• Several short route interventions can improve

child nutrition fast - in 2 to 5 years, within the
time frame in which politicians need to see
results
49
Nutrition Interventions – short routes
• Community-based nutrition and health services

(community growth promotion programs, community
Integrated Management of Childhood Illnesses [C-IMCI])
• Facility-based nutrition and health services (health and

nutrition services, and antenatal care)
• Micronutrient supplements, Micronutrient fortification
• Targeted food aid
50
Nutrition Interventions – short routes…
• Conditional cash transfers
• Food supplementation
• Food stamps
51
Nutrition Interventions – short routes…
Behavior change
• Maternal nutrition, knowledge, and care-seeking during

pregnancy and lactation
• Infant and young child feeding
• Hygiene education
• Promoting healthy life styles (increase physical activity;

consume more fruits and vegetables and less salt,
sugar, and fat, and so on)
52
Nutrition Interventions – Long routes
• Primary health services (such as family planning) and infectious

disease control
• Safe water and sanitation
• Policies on marketing breast milk substitutes
• Food and agricultural policies to increase supply of safe and healthy

food, or of healthier foods
• Food industry development and market incentives (disincentives) for

developing healthy (unhealthy) food
53
Nutrition Interventions – Long routes…
• Economic development (incomes of the poor)
• Employment creation
• Food price policies to increase poor peoples’

purchasing power for the right kind of foods
• Marketing regulation of unhealthy food
54
Nutrition Interventions – Long routes…
Behavior change
• Improving women’s status
• Reducing women’s workload, especially in

pregnancy
• Increasing women’s education

55
The energy requirements of
individuals depend on
• ♦ Physical activities ♦ Body size and
composition ♦ Age may affect
requirements in two main ways
• – During childhood, the infant needs more
energy because it is growing
• – During old age, the energy need is less
because aged people are engaged with
activities that requires less energy.
• ♦ Climate: Both very cold and very hot
climate restrict outdoor activities. 57
• In general feeding is dependent on the
controlling centres, appetite and satiety in
the brain. There are a variety of stimuli,
nervous, chemical and thermal, which may
affect the centres and so alter feeding
behaviour.
58
Daily calorie requirements of
individuals
• Infants 1 - 3 years need 1,000 cal/day

• Children 5 years need 1,500 cal/day
• Children 5 – 8 years need 1,800 cal/day
• Children 10 – 12 years need 2,000 cal/day

• For adolescents and adults calorie
requirements depend on the degree of
physical activities 59
From 13 – 20 years of age
Office worker Heavy work

2, 800 cal/day 3,500 cal/day
Adults
2,300-cal/day 2,700 cal/day
60
• Very heavy work up to 4,000 cal/day
• For pregnant woman, the daily figure must
be increased by 150 calories for the first
trimester and 350 for the second and third
trimester. For the nursing mother the daily
figure must be increased by 800 calorie.
61
Staple foods
• Staple foods are foods, which form the

largest part of a nation’s diet.
They are of plant origin and are classified
into three main groups:
• The grain and cereals
• The roots and tubers
• The starchy fruits
62
Good nutrition enhances your quality of life and
helps you prevent disease. It provides you with the
calories and nutrients your body needs for maximum
energy and wellness.
NUTRITION: THE PROCESS BY WHICH THE BODY TAKES IN
AND USES FOOD.
NUTRIENTS: SUBSTANCES IN FOODS THAT YOUR BODY
NEEDS TO GROW, TO REPAIR, AND TO PROVIDE ENERGY.
CALORIES: UNITS OF HEAT THAT MEASURE THE ENERGY
USED BY THE BODY AND ENERGY SUPPLIED TO THE BODY
BY FOODS.
1. Hunger and Appetite:
Hunger: Natural need to eat and not starve.
Appetite: A desire to eat.
2. Emotions:
•Stress, Anger, Happy, Sad, Boredom, etc,
3. Environment:
•Family and Friends
4. Cultural and Ethnic Background:
•Race, Religion, Heritage
5. Convenience and Cost:
•Where you live, On the go lifestyle, Family income
6. Advertising:
•Health messages, Influence your looks
6 GROUPS OF NUTRIENTS:
•Carbohydrates
•Proteins
•Fats
•Vitamins
•Minerals
•Water
Carbohydrates: are the starches Simple carbohydrates: are
and sugars present in food. sugars. Examples include:
They are classified as either simple •glucose
or complex. •fructose
Complex carbohydrates are •lactose.
starches. Examples include:
•whole grains
•Body’s preferred source of
•seeds energy.
•legumes • Body converts all carbohydrates
to glucose, a simple sugar.
- Fiber is an indigestible complex
carbohydrate that helps move waste • Glucose is not used right away
through the digestive system. and it is stored as glycogen.
• Too many carbohydrates will
cause the body to store the excess
as fat.
carbohydrate
• Carbohydrates • On the other hand, in the

provide a great part of diet of the rich people in
many countries the
the energy in all
proportion may be as low
human diets. as 40%.
• In the diet of poor • However, the cheapest
people, especially in and easily digestible fuel
the tropics up to 85% of humans is
of the energy may carbohydrate.
come from this source
67
carbohydrate
• Carbohydrates are • Nervous tissue,

components of body connective tissue,
substances needed various hormones,
for the regulation of and enzymes also
body processes. contain carbohydrate.
Heparin, which
prevents blood from
clotting, contains
carbohydrate
68
carbohydrate
• Ribose, another • Carbohydrate is also

carbohydrates are a component of a
part of compound in the liver
Deoxyribonucleic acid that destroys toxic
(DNA) and ribonucleic substances.
acid RNA), the
substance that carry
the hereditary
factorsin the cell.
69
carbohydrate
• Carbohydrates are • The body is unable to

necessary for the handle the excessive
breakdown of fat. As a
proper use of fats.
result, the fat does not
• If carbohydrate burn completely, and
intake is low, larger abnormal amounts of
than normal amounts certain breakdown
of fats are called on to products accumulate in
the blood, causing a
supply energy. condition known as
ketosis
70
CLASSIFICATION OF CARBOHYDRATES
Free Oligo- Polysaccharides (Complex

Sugars saccharid Carbohydrates)
es
1. Monosacch 1.Starch Polysaccharides.
arides (One These are  Amylose(straight chain
CHO carbohydrate starch)
molecule) s that  Amylopectin (branched
e.g. contain from chain starch)
 Glucose 3-10 2. Non starch polysaccharides
 Fructose Monosaccha  Cellulose
 Galactos rides units in  Pectin
e their  Hemicellulose
 manose, molecules.  Gums
 Ribose The  Mucilage
 Deoxirib following are 3. Glycogen
ose some
2. examples
Disaccharides  Raffinos
(Two CHO e
molecule) e.g..  Stachyo
 Maltose se
 Sucrose  Verbasc
 Lactose
 Trehalo
ose
 Fructans
Glycaemic index
s  Galactan
3.Sugar s
alcoholes e.g.
 Sorbitol
 manitol 71
 Inisitol
 Dulcitol
Classification of carbohydrates
Types of carbohydrates
• Monosaccharides:
• Glucose
• Fructose
• Mannose
• Galactose
72
• Disaccharides:
Sucrose (a disaccharide present taste
sugar)
Lactose (a disaccharide present in milk)
Maltose (a disaccharide present in starch)
73
cont,,,,
• Sugar alcohol: is found in nature and
also prepared commercially.
• Mannitol and dulcitol are alcohol derived
from mannose and galactose. Both have a
variety of uses in medicine and food
manufacture.
74
cont,,,,
• Honey: is a mixture of glucose and fructose.
It is a balanced diet as it contains all the
nutrients in sufficient amount and proper ratio.
Honey has also medicinal effect. The bees first
cover the beehive with antibiotics to prevent the
growth and multiplications of microorganisms.
• If you keep honey for a long time, it will not be
spoiled because of antibiotics.
75
cont,,,,
Glycogen:
is the animal equivalent of starch
present in the liver and muscle. In most
foods of animal origin it is a negligible
source of dietary carbohydrate.
• The glycogen in the liver is a reserve fuel
and it serves between meals and over
night. The breakdown of glycogen in the
liver is facilitated by the hormone
glucagons. 76
cont,,,,
• Starch: is one form of carbohydrate
that is stored in granules in the roots
and seeds of plants.
77
How does fiber prevent different health
problems?
Cancer (Colonic, breast..)

• Prevents secondary bile acid circulation
• Decrease intestinal transit time
• Decrease contact of carcinogens with
intestinal cells
• Fermentation product butyrate has apoptotic
effect
• Decreases absorption fats and sugars 78
WHY DO WE NEED CARBOHYDRATES TO
SURVIVE?
We need this amount of carbohydrate because:

– 45% - 65% of calories should come from carbohydrate
– Carbohydrates are the body’s main source of fuel.
– All of the tissues and cells in our body can use glucose for
energy.
– Carbohydrates are needed for the central nervous system, the
kidneys, the brain, the muscles (including the heart) to function
properly.
– Carbohydrates can be stored in the muscles and liver and later
used for energy(glycogen).
– Carbohydrates are important in intestinal health and waste
elimination (e.g.. Dietary fiber).
79
Digestion and absorption of
carbohydrates
• The digestion of carbohydrates begins in the mouth
by Ptyalin(amylase) produced by the salivary
glands.
• No carbohydrate digestion takes place in the
stomach. Digestion occurs mainly in the small
intestine through the action of pancreatic and
intestinal juices:
• Amylase
• Lactase
• Sucrase
• Maltase 80
• Dextrin is degradation products of
starch in which the glucose chains
have been broken down to smaller
units by partial hydrolysis.
• Dextran is a carbohydrate polymer
obtained from bacterial cell wall. This
has no part in dietetics but is used in
medicine as plasma expander.
81
Carbohydrate digestion
a. Digestion of starch and disaccharides
-Chemical Starch, Lactose
salivary Amylase Dextrin, Lactase Sucrose
Mouth and
(Ptyalin) &
small
Pancreatic
intestine Sucrase
amylase Glucose
 -Mechanical;- + Glucose
biting action of +
Galactose
the teeth Fructose
From the small
Maltoseintestine
Maltase
Glucose + Glucose
Absorbed by simple
diffusion
Absorbed by active transport

mechanism coupled with sodium
82
b. Digestion of oligosaccharides, resistant starch
and non-starch polysaccharides
Oligosaccharides (eg. Raffinose, Stachyose)
and non-starch polysaccharides resistant
starch
Escape digestion in the

upper gut (small intestine
They get fermented in the

colon by anaerobic bacteria
Production of
gases likes co2, Production of
methane and short chain fatty Increased faecal Biomass
hydrogen acids (SCFA) resulting in increased
sulphide  Acetate peristalsis
 Propionate
Abdiwahab H 83
 Butyrate
Metabolism of Carbohydrates
Glucose –6-Phosphate
Glycolysis Fructose-6-phosphate
Fructose1, 6-diphosphate
3-Dihydroxy Acetone phosphate

Glyceraldehyde-3 phosphate
bGlyceraldehyde 3-phosphatephosphate
Acetyl CoA
Crebs Cycle
CO2+ Energy+H2O
84
• In Health and with normal diet, the available
carbohydrate is digested and absorbed completely
in the small intestine.
• If an excess of unabsorbed carbohydrate arise due
to a disorder of the absorption mechanisms or
occasionally to excessive intake, the osmotic
pressure (effects) leads to retention of fluids in the
lumen and as the result there will be watery
diarrhoea. This diarrhoea is known as osmotic
diarrhoea.
85
• The tissues use as fuel a mixture
of glucose and fatty acids. But the
brain normally uses only glucose
and requires around 80g daily.
86
• In starvation glucose may be provided by
gluconeogenesis from the amino acids in
tissues proteins, mainly from muscle
proteins, but fats cannot be converted into
glucose. With prolonged starvation the
brain adapts and can then utilize fatty
acids and ketone.
87
• The two hormones, which control the
metabolisms of carbohydrates,are insulin
and glucagons
Insulin is secreted by the beta cells of the
islets of Langerhans and the secretion is
stimulated by:
– Hyperglycemias
– Parasympathetic nervous activity
88
Function of insulin
• To facilitate glucose transport to the

liver and muscle cells
• To facilitate formation of glycogen in the
liver and muscle cells
• To incorporate formation of protein from
the amino acids.
89
• Glucagons is secreted by the alpha cells
of the islet of Langerhans and the
secretion is stimulated by
Hypoglycaemia
Sympathetic nervous activity
90
Function of glucagons
• To facilitate the breakdown of glycogen in

the liver and muscle cells into glucose
91
Proteins are nutrients that help build and maintain body cells and tissues.
Proteins are classified into two • Proteins have many

groups: complete and
incomplete. functions:
• Complete proteins contain - Help make new cells.
amounts of all nine essential -Help make and repair
amino acids.
tissues.
SOURCES INCLUDE:
*Fish, meat, poultry, eggs, - Help make enzymes,
milk, cheese, yogurt, and hormones, and antibodies.
many soybean products. - Provide energy.
• Incomplete proteins lack one
or more essential amino acids.
SOURCES INCLUDE:
*Beans, peas, nuts, and
whole grains.
Proteins
• The basis of protein structure is the amino acid, of which 20 have
been recognized as constituents of most proteins
• All Amino acids have amino group(NH2) and Carboxylic
Group(COO2)
• But, they are differentiated by the remainder of the molecule (R)
as shown in the figure. H
R C COOH
NH2
Those amino acids that cannot be synthesized in the body and need
to be taken from food are essential (indispensable) amino
acids. 93
Cont..
• Absence Essential a.a.from the diet leads to poor growth
performance by a growing animal. Essential amino acids are
labelled by (**) sign in the following table .
94
WHY DO WE NEED PROTEIN TO SURVIVE ?
We need protein for:

 Growth (especially important for children, teens, and pregnant women)
 10% - 35% of calories should come from protein.
 Tissue repair
 Immune function
 Making essential hormones and enzymes
 Energy when carbohydrate is not available
 Preserving lean muscle mass
 Synthesis of enzymes, hormones all antibodies
 Control Fluid movement in the body
 Buffer(PH control): Due to the carboxyl or acid group (-COO) and amino
or basic group (- NH2 )
95
Classification of proteins
I. Based on chemical composition.
a)Simple protein - yield amino-acids upon
complete hydrolysis
E.g.: - albumin - in eggs, zein of corn
b.Compound/conjugated proteins
Protein + Non protein
E.g.: - Hgb (Protein + hem) - Blood
96
Cont..
II. Based on Nutritional Value:- This classification
depends on the essential amino acids content of the
protein.
a. Complete proteins: Contain all the essential amino
acids in the proportion that is required to support growth
and maintain tissues. E.g. Almost all animal proteins
except gelatine (lack two essential A.As.). They are
denoted as complete because they resemble body
protein (Egg & Milk).
b. Incomplete Proteins: This refers to proteins that do
not contain all essential amino acids in the proportion
that is required to maintain growth and tissue repair.
97
III. Based on Conformation of the Protein: This refers
to the three dimensional shape of the protein in its natural state.
Based on this proteins are classified as:
a.Globular proteins
-Tightly folded poly peptide chain - spherical or globular shape
-Mostly soluble in water
E.g.: - Enzymes, antibodies, and many hormones, Hgb
b. Fibrous proteins
-Polypeptide chains arranged in parallel manner along an axis
-Tough & in soluble in water
E.g.: - Collagen of tendons & bone matrix
- Keratin of hair, skin, nails and
- Elastin of blood vessels
98
IV. Based on their Chemical Structure
a. Primary structure : refers to the sequence of amino acids in
the polypeptide chain of proteins held by peptide bond.
Eg. Ala---gyc---Phenala---histd---tyr---trp
b. secondary Structure: This refers to the folding of the polypeptide

chain upon itself resulting in alpha helix (right twisted or left twisted)
and or B-pleated sheet. This structure is held strong by intra
molecular hydrogen bonding.
1. Alpha helices OR
2. B-Pleated Sheath
99
c. Tertiary Structure: - This refers to the three dimensional arrangement of the protein
structure (whether it is folded upon itself giving rise to globular proteins or whether its
straight chain of poly peptides resulting in fibrous protein). This structure is maintained by the
sulfide bond.
Globular protein Fibrous protein
d. Quaternary Structure:- This refers to the aggregation of individual poly peptide chains by
electrostatic bonding. Hemoglobin is a typical example of the quaternary structure of protein.
Hemoglobin A1 A2
B1 B2
100
Proteins
• Proteins have long been recognized as

fundamental structural elements of
every cell of the body. Specific proteins
and protein derivatives have been
recognized as functional elements in
certain specialized cells glandular
secretion, enzymes and hormones.
101
Proteins
• A good quality or a • In general all proteins

complete protein is from animal source,
the one that supplies such as meat, poultry,
all the essential fish, eggs, milk and
amino acids in milk products provide
sufficient quantities good quality proteins.
and in proper ratio for
normal growth and
maintenance
102
Source of proteins
• Milk and milk

products such as • Eggs are in a class
cheese, ice cream all by themselves a
derive their protein protein food of high
from milk. nutritive value.
• Meat, poultry, and
fish are all forms of
animal tissues
103
Source of proteins
Vegetables are poor source of protein.

Legumes provide more than 4 or 6 percent. They
are listed as meat alternates in the four-food
group chart because they provide one of the
better quality plant proteins.
Bread and cereals make an important contribution
to the protein of the diet, the protein of uncooked
grain ranges 7 to 14 percent.
104
Digestion and absorption of protein
• The digestion of protein in the alimentary tract is

accomplished by the action of several proteolytic
enzymes in the gastric, pancreatic and intestinal
juices.
• Any of these enzymes that have the power to
attack native proteins must be secreted in an
inactive form to prevent damage to the tissues
where they are formed.
105
Types of enzymes
• ƒ Pepsinogen is secreted by the gastric juice

and activated by the Hydrochloric acid
• ƒ Trypsinogen is secreted by pancreatic juice
and activated by entropeptidase
• ƒ Chemotrypsinogen is secreted by pancreatic
juice and activated by the active tripsin
• Peptidase intestinal juice
106
Summary of protein digestion
• See in your book/////
107
The Amino Acid Pool
• The amino acids from the food or from the body

tissues enter a common pool, which is drawn upon
for the synthesis of proteins, hormones, enzymes,
blood protein and nucleic acids,
• or some of the amino acids are degraded for
energy needs.
• Proteins are absorbed as amino acids. Ideally,
they are used to build or maintain body proteins. If
carbohydrates and fats are not meeting the energy
needs of the body, amino acids can be used to
provide energy. 108
Danger of the weaning period
• The weaning period is fraught with dangers for a large
proportion of the world’s children and nutritional disorders
are common at this time of life. In the West a general
awareness of the nutritional needs of the weaning, together
with the ability of the average family to provide the
necessary foods, have helped to remove most of the
dangers of the weaning period.
• In the peasant society of developing countries, however,
parents are generally are unaware of the dietary needs of
children, and several customs associated with weaning are
likely to give rise to nutritional deficiencies.
109
Danger of the Weaning period cont;;;;;
• In the traditional society, weaning is commonly

abrupt and unplanned. Often it is brought by the
occurrence of another pregnancy. There are
superstitions and beliefs concerning the effects of
another pregnancy on the quality of the breast
milk. It is believed that the heat from the womb
“poisons” the milk in the breast.
110
Danger of the Weaning period
cont;;;;;
• They also think that the baby in the womb is
jealous of the older sibling on the breast. It is
therefore considered urgent that the child should
be taken off the breast immediately
111
cont;;;;;
• The mother may • The child has very
apply potions (bitter close relationship with
material) to the the mother, the
nipples so that when mother takes him/her
the child takes the back wherever and
breast the sharp bitter whenever she goes to
taste makes him/her fetch water or to bring
give up suckling.. firewood, the child
has also access to
breast milk on
demand.
112
cont;;;;;
• The child sleeps on • This is a psychological
her back, but this blow for the child and
intimacy will be causes poor appetite
interrupted when the and as the result the
mother knows that child can develop
she is pregnant for protein energy
the subsequent child. malnutrition.
113
Protein energy malnutrition (PEM)
• PEM is today the most serious nutritional problem

in Africa and other developing countries. Its two
clinical forms are Kwashiorkor and Marasmus.
• The diseases occur mostly in children between
one and three years of age, after they have been
taken of the breast.
114
PEM:
• Although there is no final clarity about the etiology

of kwashiorkor in biomedical terms, it is
nevertheless, clear that it is related to nutritional
deficiencies
117
PEM:
• Therefore, all factors that could possibly contribute to the

child malnutrition in general should be avoided.
These include: Š
 Seasonal food shortage Š
 Unfavorable family condition, Š
 Inadequate water supply and sanitary facilities,
 Š Certain traditional attitudes during pregnancy, prenatal
period, breast-feeding and weaning periods, and
 All infectious diseases, which generally reduce immunity.
118
PEM:
Other diseases may sometime play an important role
in precipitating the onset of kwashiorkor in already
malnourished child.
E.g. ƒ Gastrointestinal tract infection
ƒDiarrhea
Intestinal worms share the diet and cause other ill-
health and
poor appetite ƒ
Constipation ƒ
Childhood diseases such as measles, whooping
cough, etc, 119
Signs and symptoms of kwashiorkor
• ƒ Growth failure occurs always ƒ

• Wasting of muscle is also typical but may not be
evident because of edema
• ƒ There may be mental change ƒ
• Hair and skin color change ƒ
• Diarrhea and vomiting ƒ
• Sign of other micronutrient deficiencies
120
Skin changes
• Mild: localized hyper pigmentation and skin

cracks
• Moderate: skin peals off, desquamation.
• Severe: superficial ulceration, bleeding
121
Hair changes
• Hair changes are classified into three categories:

Mild: beginning of visible color and structural
changes
• Moderate: color and structural changes, loss of
hair
• Severe: loss of hair together with ulceration of
head
122
Physiological functions of the various
systems are markedly disturbed with:
• ƒ Diarrhea ƒ
• Electrolyte disturbance ƒ
• Circulatory insufficiency ƒ
• Metabolic imbalance ƒ
• Poor renal functions
• Hence the child with kwashiorkor should be
thought of as an emergency in need of referral to
the nearest health facility.
123
Nutritional Marasmus
• ƒThere is a failure to thrive ƒ

• Irritability, restlessness and diarrhea are frequent.
ƒ
• Many infants are hungry, but some anorexic. ƒ
• There are little or no subcutaneous fats. ƒ
• The weight is much below the standard for age. ƒ
Temperature may be subnormal. ƒ
• The abdomen may be shrunken or distended with
gas. ƒ
124
Nutritional Marasmus
• Because of the thinness of the abdominal wall,

peristalsis may be easily visible. ƒ
• The muscles are weak and atrophic and this
makes the limbs appear as skin and bone ƒ
• Evidence of vitamin deficiencies may or may not
be found.
125
Criteria for referral to the nearest health
facility
• Substantial weight def.<60%WAF or <70%
HFA
• Severe generalized edema and any of the
following:
– Anorexia
– Diarrhea and vomiting
– Dehydration
– Loss of consciousness and convulsion
126
Criteria for referral ……….
• ƒSevere anemia <15%of Hematocrit ƒ

• Respiratory distress ƒ
• Hypothermia <35.50c ƒ
• Jaundice
127
After discharge management of PEM:
• ƒTo prevent relapse and future deterioration,

through nutrition education and demonstration of
the parents.
• ƒTo achieve long term follow up
128
Child status after discharge from
hospital
• ƒ Mental state has improved as shown by
smiling, response to stimuli, awareness, and
interest in the surroundings ƒ
• Appetite has returned and he/she is eating well ƒ
• Shows physical activity ƒ
• Temperature is normal ƒ
• No vomiting or diarrhea
• ƒ No edema ƒ
• Starting to gain weight.
129
Protein energy malnutrition
Severe acute malnutrition

Outline for nutritional requirement
 Feeding during the 1st 6 month of life –

BF
 Feeding during the second 6 month of
life
 Feeding problems during the 1 st year of
life
 Feeding during second year of life
 Feeding during later childhood
Objective
 Atthe end of this lecture the students

should be able to
 Describe the nutritional requirement of
infants and children
 Identify common problems encountered
during feeding of infants
Breast feeding
 Feeding should be initiated as soon after birth
as possible unless contraindicated.
 maintains normal metabolism during transition
 Promotes maternal infant bonding
 Thetime required for an infant stomach to
empty may vary from 1-4 hrs
 6 – 9 feedings in 24 hrs
 Most infants take 80-90ml per feed
 Satisfactory feeding
 No more wt loss at the end of 1st week
 Started to gain wt at the end of 2 nd week
Advantage of BF
 Always available at a proper temperature and
requires no preparation time
 Fewer feeding difficulties, low incidence to
allergy
 Contains bacterial and viral antibodies
 High conc. Of secretary IgA
 Substances that inhibit growth of many common
viruses
 Macrophages synthesize complement, lysozyme
and lactoferrin
 Lower incidence of diarrhea as well as otitis media,
pneumonia, bacteremia, and meningitis
Continued…
 Contains bile salt-stimulated lipase, which kills giardia lamblia
and enteameba histolytica
 Supply all necessary nutrients except flouride and
after several months vit. D
 The psychological advantage of BF to the mother and
the infant – well known
 Establishing and maintaining the milk supply
 Empting of the breast – most important stimulus
Suckling – afferent to hypothalamus –pituitary – prolactin and
oxytocin
 Tender or sore nipples- nursing more frequently, manually
expressing milk, nursing in diffirent conditions, and keeping
the breast dry
 Less relaxed anxious mother – express milk feeding
Maternal diet
 Should contain enough calories and other nutrients
 To compensate those secreted in the milk and those required
to produce it
 Role – to maintain wt and generous in fluid, minerals and
vitamin
 Milk is an important component of the diet
 No food need to be withheld from the mother
 Should not take drugs
 Antithyroid medications, lithium, anticancer agent, INH,
chloramphenicol, metronidazole
 Smoking cigarettes and drinking alcohol- discouraged
Feeding during the second 6 month
of life
 By 6 month of age infants capacity to
 Digest and absorb a variety of dietary components
 Metabolize, utilize and excrete the absorbed products of
digestion is near adult capacity
 Teeth are beginning to erupt
 Begin to explore his surrounding
 Addition of other foods is recommended ( weaning)
 Complementary foods – additional foods including
formulas, given to breast fed infants
 Replacement foods – foods other than formula given
to formula fed infants
 Weaningshould be stepwise to both breast fed
and formula fed infants
 Cereals, a good source of iron, usually should be
the first food
 Vegetable and fruits are introduced next
 Meats follows shortly and finally eggs
 One new food should be introduced at a time
 Additional new foods should be spaced by 3-4 days

 Adverse reactions (families with food or other allergies)
 Either home prepared or manufactured
complementary foods can be used
 The latter are more convenient and likely to
contain less salt – have supplemental nutrients
( eg Iron)
 Egg containing products should be delayed
 Food should be served 3 -5 time per day
including night
 With this most infants receive adequate
nutrients
Feeding problems during the 1st
year of life
 Underfeeding
 Suggested by restlessness and crying
 Failure to gain wt
 Possible causes
 Check frequency of feeding, mechanics of feeding
 Abnormal mother infant bonding
 Possible systemic disease
 Rx – instructing mother about the art of BF and

psychological support
_ specific management of systemic illnesses
 Overfeeding
 Regurgitation and vomiting
 Reg. –return of small amount of swallowed food
 Vomiting – more complete emptying of stamach
 Too high in fat – delay in gastric emptying, cause

distention and abd. Discomfort,
 Too high in CHT- distention and flatulance
 Loose stools
 Milk stool – loose, greenish yellow containing
mucus with freq. of 6-8 times/24hrs
 All diarrhea - infectious
 Constipation
 Consistency rather than freq. is the basis for
diagnosis
 Perform PR exam
 Aganglionic megacolon, tight or spastic anal
sphincter
 May be caused by an insufficient amount of food or
fluid
 From diets that are too high in fat or protein or
deficient in bulk
 Functional constipation – the most common
 Enemas and suppositories – temporary use
 Colic – infantile colic
 Common in infants younger than 3 month
 The attack usually begins suddenly with a
loud continuous cry
 Etiology is not usually apparent
 Holding the infant upside helps and burping
 Occasionally sedation for prolonged attack

Feeding during the 2nd year of life
 By the end of 1st year- 3 meals a day plus 1-2 snacks

 Changes in eating behavior
 Reduced food intake –rate of growth declines
 Lack of interest in food – temporary
 Never force feed
 Self selection of diets – should be respected
 Self feeding by infant
 Basic daily diets
 Grains, fruits, vegetables, meats and dairy products-balanced
diet with
 Snacks between meals- orange or other fruit juice with biscuit
 Vegetarian diet – vitamin B12 and trace mineral deficiency
Feeding during later childhood
 After the age of 2 years

 Thechild's diet – the same as family diet
 Emphasis on grains, fruits, and vegetables
 Restrictionof dietary fat to 30% of total energy
 Saturated fatty acid -< than 10%
 Cholesterol – not more than 100mg/1000kcal
 Poly unsaturated fatty acid -7-8% of energy
 Unsaturated fatty acid – 12-13% of energy
 Such diet support normal growth of children

Bread, cereals,rice and pasta group
6-11 servings
Milkand milk product

Meat, poultry, fish
2-3 servings
Vegetable and fruit groups

2-4 servings
 These servings usually meat the daily
requirement of 1600kcal(less active
child) and 2800kcal ( more active child)
Severe malnutrition
 Objective
 Atthe end of this lecture the students
should be able to describe the def.,
pathogenesis, clinical feature and
management of severe acute malnutrition
Outline
 Introduction
 Epidemiology
 Cause
 Classification
 Pathogenesis
 Clinicalfeature
 Diagnosis
 Complications
 Principles of management
 Prognosis and mortality
HUMAN NUTRITION
 Nutrients are substances that are crucial
for human life, growth & well-being.
 Macronutrients (carbohydrates, lipids,
proteins & water) are needed for
 energy and
 cell multiplication & repair.
 Micronutrients are trace elements &

vitamins,
 which are essential for metabolic processes.
HUMAN NUTRITION/2
 Obesity & under-nutrition are the 2 ends of
the spectrum of malnutrition.
 A healthy diet provides a balanced
nutrients that satisfy the metabolic needs
of the body without excess or shortage.
 Dietary requirements of children vary
according to
 age,
 sex &
 development.
Assessment of Nutritional status
Clinical
Anthropometric
Dietary
Laboratory
Clinical Assessment
 Useful in severe forms of PEM

 Based on thorough physical
examination for features of PEM &
vitamin deficiencies.
 Focuses on skin, eye, hair, mouth &
bones.
Clinical Assessment/2
ADVANTAGES
Fast & Easy to perform
Inexpensive
Non-invasive
LIMITATIONS
Did not detect early cases
Trained staff needed
ANTHROPOMETRY
 Objective with high specificity &

sensitivity
 Measuring Ht, Wt, MUAC, HC, skin fold
thickness, waist & hip ratio & BMI
 Reading are numerical & gradable on
standard growth charts
 Non-expensive & need minimal training
ANTHROPOMETRY/2
LIMITATIONS
Inter-observers’ errors in
measurement
Limited nutritional diagnosis
Problems with reference standards

Classification
 Wellcome classification
 based on the presence or absence of edema
and a deficit on body weight
 some children with features of kwashiorkor with
wt above 80% are classified
Weight(% of Edema present Edema absent
standard)
60 - 80 kwashiorkor underweight
< 60 Marasmic marasmus

kwashiorkor
Continued..
 Advantage  Disadvantage
-simplicity  If the age of the

patient is not
known-difficult to
use
 It doesn’t take into
consideration the
chronicity of the
disease process
continued
 Gomez classification
 Grade I – 90 -75 percent –mild malnutrition(1st )
 Grade II – 75-60 % -moderate malnutrition (2 nd )
 Grade III -< 60 % -severe malnutrition (3 rd )
 Drawbacks –
 combines in one number two different kinds of
deficit: in wt for ht and in ht for age
 90% is too high as well nourished children are
labeled malnourished
 A child can have wasting but not stunting
 A child can have also wasting and stunting
 Doesn’t consider the presence of edema
Waterlow classification: takes Wt & Ht.
Wt/Ht (%)= Wt of subj/ Wt of Nl child of the same Ht Χ
100
HFA= Ht of subj/ Ht of child of same age x 100.
W F H
>90% ≤90%
H >95% normal wasted

F
A ≤95% stunted Stunted
&wasted
Waterlow classification
% of reference standard
normal mild moderate
severe
Ht for age 95 90-95 85-90 85
(stunting)
Wt for age 90 80-90 70-80 70
(wasting)
Continued…
Indicators Age group Moderate Severe

malnutritio malnutritio
n n
Bilateral Children No Yes
edema Adolescent Bilateral
Adults edema
W/H % Children>6 70 To 79% <70 %
months Moderate Severe
Adolescent wasting wasting
MUAC 11 to 12cm <11cm
LAB ASSESSMENT
Biochemical
Serum proteins,
creatinine/hydroxyproline
Hematological
CBC, iron, vitamin levels
Microbiology
Parasites/infection
4. Biochemical Examination
Marsmus Kwash
 Serum protein (alb)- Nl/mod ↓  ↓
 Hgb/hct- ↓  ↓↓
 Non ess to ess AA ratio- Nl  ↑
 Serum FFA- Nl  ↑
 Blood glu- Nl/low  Nl/low
 Total body protein- ↓  ↓↓
 Transaminases- Nl/high  High
DIETARY ASSESSMENT
 Breast & complementary feeding

details
 24 hr dietary recall
 Home visits
 Calculation of protein & Calorie
content of children foods.
 Feeding technique & food habits
OVERVIEW OF PEM
 The majority of world’s children live
in developing countries
 Lack of food & clean water, poor
sanitation, infection & social unrest
lead to LBW & PEM
 Malnutrition is implicated in >50% of
deaths of <5 children (5 million/yr)
CHILD MORTALITY
 The major contributing factors are:

 Diarrhea 20%
 ARI 20%
 Perinatal causes 18%
 Measles 07%
 Malaria 05%
55% of the total have malnutrition
EPIDEMIOLOGY
 The term protein energy malnutrition

has been adopted by WHO in 1976.
 Highly prevalent in developing
countries among <5 children;
 severe forms 1-10% &
 underweight 20-40%.
 All
children with PEM have
micronutrient deficiency.
PEM
 In2000 WHO estimated that 32% of <5
children in developing countries are
underweight (182 million).
 78% of these children live in South-
east Asia &
 15% in Sub-Saharan Africa.
 The reciprocal interaction between
PEM & infection is the major cause of
death & morbidity in young children.
Cycle
malnutrition infection
Worsening of malnutrition
PEM in Sub-Saharan Africa
 PEM in Africa is related to:

 The high birth rate
 Subsistence farming
 Overused soil, draught & desertification
 Pets & diseases destroy crops
 Poverty
 Low protein diet
 Political instability (war & displacement)

PRECIPITATING FACTORS
• LACK OF FOOD (famine, poverty)

• INADEQUATE BREAST FEEDING
• WRONG CONCEPTS ABOUT NUTRITION
• DIARRHOEA & MALABSORPTION
• INFECTIONS (worms, measles, T.B)
Introduction
Malnutrition is defined as chronic
inadequacy in food instances
combined with high levels of illness
Is a long term year round
phenomena
Chronic problem found in majority of
households
More than half of the deaths in
children have stunting and wasting
as the underling cause
 Occurs more frequently when
infections impose additional
demands, induce greater loss of
nutrients
 Most deaths in children have some form
of malnutrition as the background
 Stunting is due to chronic malnutrition
 Wasting and edema are due to acute
malnutrition
 Is both medical and social disorder so
management includes both medical and
social problems identified and managed—
this prevents relapse of the problem
Epidemiology
 Most malnourished persons live in
developing countries,
 One of every three children under the
age of 5 years in the developing country
 177million children –are or had been
malnourished
 Inindustrialized countries, malnutrition is

seen mainly among
 young children of low socioeconomic groups,
 the elderly who live alone,
 adults addicted to alcohol and drugs
According to unicef the extent of
malnutrition in Ethiopia is
Stunting ( 24 -59 months) – 43%
Underweight ( 0 -4 yrs) – 38
Wasting (12 -23 months) – 19%
Cause
 There are two types
 Primary – nutritional insufficiency
Inadequate protein, calorie and nutrient
intake
 Secondary – malnutrition following
infections, injury, chronic disease, excessive
nutrient loss as occurs in chronic diarrhea,
HIV, malabsorption syndrome etc…
 Social,
economic, biologic, and
environmental factors underlying
severe malnutrition
 Social
and economic –
 Poverty that results in
 low food availability,
 overcrowding and
 unsanitary living condition
 ignorance by itself or associated with
poverty leads to poor infant and child
rearing practices
 misconception about the use of certain
foods
 inadequate feeding conduct during illness
 inadequate BF and weaning practices
-Social problems like child abuse,

Continued…
 Biologic factors
 Maternal malnutrition prior or during
pregnancy
 Infectious diseases like diarrheal disease,
measles, respiratory and other infections
 Diets with low concentration of proteins and
energy like over diluted milk formulas or
bulky vegetable foods that have low nutrient
densities
 Infection
 Anorexic
 Malabsorption
 Intestinal damage
 Increased metabolic rate
 Redistribution of nutrients
 Activation of inflammatory responses
 End result –
 reduced nutrient intake,
 reduced nutrient absorption,
 nutrient loss,
 increased nutrient requirement
Environmental factors
Overcowded or unsanitary living
conditions
Agricultural patterns, drought, floods,
wars and forced migration lead to
 cyclic, sudden or prolonged food
scarcities
Pathogenesis
1) Dietary theory –believed in 1960’s
 Kwashiorkor-is primary protein malnutrition
accompanied by a relatively excess of
energy
 Marasmus is under nutrition with lack of
predominantly energy
 Marasmic kwashiorkor is a combination of
chronic energy deficiency and chronic or
acute protein deficit.
 Early weaning and prolonged BF without
weaning
2) Maladaptation theory –
• kwashiorkor is essentially failure of
adaptation where the body utilized
proteins and conserve S/C fat
• marasmus is due to the elevated plasma
glucocorticoid concentration which are
associated with an increased rate of muscle
protein catabolism which provided
• energy for the body’s needs and
• released amino acids for the hepatic synthesis
of protein.
Continued…
Aflatoxin theory –
 kwashiorkor results from aflatoxin
poisoning but
 there is no difference in the
amount of aflatoxin in both
marasmus and kwashiorkor
 Free radicals theory – Michael Golden
 Imbalance between the
production of toxic free radicals
(superoxide,peroxidase) and their
safe disposal
The factors that increase free
radicals are
infections,
 toxins,
 sunlight,
 trauma, and catalysts such as iron
Formation of free radicals is
decreased by the antioxidant function
of vitamin A, C, and E, by ceruplasmin
and transfferin
The toxic effect of free radicals would
be responsible for cell damage leading
to alteration seen in kwashiorkor, such
as edema, fatty liver, skin changes.
more comprehensive and include all
other theories
Summary
Low nutrient intake
 Dysadapted  Reductive
adaptation
marasmus
 Small bowel
bacterial overgrowth  Vitamin A, C, E
 Infection  Mn, Zn, Se
 Aflatoxin  Essential fatty acids
 Fe  Sulfur containing
amino acids
kwashiorkor
Birth / breast feeding
 Early abrupt weaning  Late gradual

 Dirty diluted formula weaning
 Repeated infections  Starchy family diet
e.g GE  Acute infections e.g

 Negative energy measles
balance  Negative nitrogen
 Marasmus balance
 Marasmic  Kwashiorkor
kwashiorkor  Marasmic
kwashiorkor
Pathophysiology
Develops gradually allowing the body
to adapt for the low food intake,
 enabling survival in a compensated manner.
The adaptive mechanisms:
1. functional limitation & ↓ interaction
with the physical & social environment.
↓Energy expenditure- Body fat mobilizn
↓ energy intake ↓ activity = wt loss
↑ muscle pro
↓ dietary amino acids ↓Protein synt in viscera
Catabolism=↑
& muscles
AA for visceral
Synt of alb, LP
2. hormonal changes in metabolism of
proteins, CHO, &fats.
- Marked recycling of aminoacids (AA),
- ↓ urea synth & excretion,
- t ½ of serum proteins ↑,
- rate of albumin synth ↓ ,  shift of
extracellular alb to intravascular space
(failure of this ↓ serum alb ↓ oncotic
pressure  edema).
Cont…
 Hormonal changes
Low plasma ↓insulin & somatomedin
Glu & AA ↑ epinephrine & GH
def food intake

stress ↑ Glucocorticoids
Infection, DHN
Reverse T3 ? ↓ T3 & T4
Cont…
 Adaptive endocrine changes result in:

- ↑ glycolysis & lipolysis,
- ↑ AA mobilization,
- ↓ storage of glycogen, fats, & proteins,
- ↓ energy expenditure.
Cont…
 3. hematological & Oxygen transport:

Low protein intake
↓ physical act ↓ lean body mass Low availability

Of AA for protein
synth
Lower tissue oxy

demand Reduced Hgb & RBC
synth
Lower Hgb levels as body adapts to Lower needs

for oxy transport (no tissue hypoxia b/c of ↓ demand)
Rx with dietary protein & energy leads to ↑
tissue synth & lean body mass, and ↑
physical activity  greater tissue oxy
demand
 greater needs for hematopoietic
factors.
This leads to:
 ↑ Hgb & RBC synth (when available),
 anemia & tissue hypoxia (if not
available).
► iron should only be given during the
recovery phase.
4. CV & Renal functions
 CV reflexes will be depressed, central circulation

takes precedence over the peripheral
 peripheral circulatory failure which sometimes
mimics hypovolemic shock.
 GFR & renal plasma flow will reduce
5. immune system:
- marked depletion of lymphocytes from the
thymus (atrophy of the gland),
- ↓ complement number & function (↓ opsonin
activity),
Cont…
- phagocytosis, chemotaxis, & IC killing are all

impaired,
- the circulating levels of B-cells & Ig remain
normal, except for IgA- slightly depressed.
6. electrolytes:
- total body K+ ↓(↓ muscle protein & loss of IC
K+,
- IC Na+ ↑ (low insulin action impt for
mobilization of Na+-K+ into & out of the cell
and ↓ in ATP & phosphocreatinine).
7. GI function:
a. atrophy/edema of intestinal epithelium,
b. ↓ brush border enzymes (e.g. disaccharidase)
 mal absorption,
c. gastric, pancreatic, & billiary secretions will all
be depleted,
d. GI mobility ↓  paralytic ileus,
e. def of enzymes, overgrowth of bacteria 
diarrhea,
f. fat accumulation in the liver from def of
lipoprotein.
Cont…
8. CNS & peripheral NS: a long term

complication and includes:
- decreased growth of the brain,
- decreased myelination,
- decreased neurotransmitters,
 decreased velocity of nerve conduction.
Pathophysiologic changes
 Kidney –
 reduced GFR and renal blood flow
 decreased capacity to concentrate or dilute urine or to excrete
an acid urine
 Heart – fragmentation of myofibril and atrophy,
 small flabby heart. Decreased rate and stroke volume.
 Low voltage EKG
 Intestine – thin atrophic wall with a reduction in villous
height.
 marked reduction in the functional capacity of the digestive,
bile salt and transport system for nutrient absorption.
 Liver –
 fatty liver is probably due to reduced release of fats from the
liver to plasma in lipoproteins
Continued…
 Endocrine –
 GH increased with decreased insulin
 cortisol increased,
 T3 and T4 decreased
 Hair – there is atrophy of hair roots of the
scalp.
 Fluid and electrolytes –
an increased of total body Na
 with a loss of total body K . This loss of K is due to
loss of K rich tissues
 Immune response:
Disruption of skin integrity and mucus membrane
 Impaired bactericidal action of phagocyte
 Impaired cell mediated immunity
 Low serum transferrin
 low complement level
 low activity of IL-1(poor febrile response),
cachectin, TNF
 Lower mucosal secretory IgA antibody titer
 Nervoussystem – decreased brain growth,
neurotransmitter prod’n
Clinical features
• PEM can affect all ages but
common among infants and young
children
• Marasmus – before 1 year of age
• Kwashiorkor – after 18 months of
age
• Diagnosis is principally based on
• dietary history and
• clinical features
MARASMUS
 The term marasmus is derived from
the Greek marasmos, which means
wasting.
 Marasmus involves inadequate intake
of protein and calories and is
characterized by emaciation.
 Marasmus represents the end result
of starvation where both proteins and
calories are deficient.
MARASMUS/2
 Marasmus represents an adaptive

response to starvation, whereas
kwashiorkor represents a maladaptive
response to starvation
 In
Marasmus the body utilizes all fat
stores before using muscles.
EPIDEMIOLOGY &
ETIOLOGY
 Seen most commonly in the first year

of life due to lack of
 breast feeding and
 the use of dilute animal milk.
 Poverty or famine and diarrhoea are

the usual precipitating factors
 Ignorance & poor maternal nutrition
are also contributory
Clinical Features of Marasmus
 Severe wasting of muscle & s/c

fats(60% or less of wt for age)
 Severe growth retardation(stunted)
 Child looks older than his age
 Alert but miserable
 Hungry
 Diarrhoea & Dehydration
 No edema
• The hair sparce, thin, dry, and easily
pluckable
• The skin is dry, thin, and wrinkles –
‘baggy pant ‘
 Irritable, ravenously hungry but vomit
easily
 Loss of bichat fat pad, last fat tissue to
disappear (monkey’s or little old man’s
face)
 Marked weakness
 Abdominal distention(due to distended
bowel)
KWASHIORKOR
 Cecilly Williams, a British nurse, had

introduced the word Kwashiorkor to
the medical literature in 1933.
 The word is taken from the Ga
language in Ghana & used to describe
the sickness of weaning.
ETIOLOGY
 Kwashiorkor can occur in infancy but

its maximal incidence is in the 2nd yr
of life following abrupt weaning.
 Kwashiorkor is not only dietary in
origin.
 Infective, psycho-socical, and cultural
factors are also operative.
ETIOLOGY (2)
 Kwashiorkor is an example of lack of

physiological adaptation to unbalanced
deficiency where the body utilized
proteins and conserve S/C fat.
 One theory says Kwash is a result of
liver insult with hypoproteinemia and
oedema.
 Food toxins like aflatoxins have been
suggested as precipitating factors.
CLINICAL
PRESENTATION
 Kwash is characterized by certain
constant features in addition to a variable
spectrum of symptoms and signs.
 Clinical presentation is affected by:
• The degree of deficiency
• The duration of deficiency
• The speed of onset
• The age at onset
• Presence of conditioning factors
• Genetic factors
CONSTANT FEATURES OF KWASH
OEDEMA(doesn’t involve serous
membrane)
PSYCHOMOTOR CHANGES(Apathetic
and irritable, cry easily, and have an
expression of misery and sadnes
GROWTH RETARDATION
USUALLY PRESENT
SIGNS
MOON FACE
HAIR CHANGES
SKIN DEPIGMENTATION
ANAEMIA
OCCASIONALLY PRESENT
SIGNS
HEPATOMEGALY
FLAKY PAINT DERMATITIS

CARDIOMYOPATHY & FAILURE
DEHYDRATION (Diarrh. & Vomiting)
SIGNS OF VITAMIN DEFICIENCIES
 SIGNS OF INFECTIONS
Continued…
Kwashiorkor –
 soft, pitting, painless edema, usually in
the feet and leg
 Subcutaneous fat is preserved
 Weight deficit is not as severe as
marasmus
 Height may be normal or retarded
Continued…
The hair is dry, brittle, easily
pulled out without pain, pigment
changed to brown, red, or
even yellow white
‘Flag sign’ – due to alternating
period of poor and good protein
intake
 Anorexic and diarrhea is common
 Hepatomegaly
 Protuberant abdomen and peristalsis is
slow
 Muscle tone and strength is reduced
Marasmic kwashiorkor
 Combines clinical feature of both

kwashiorkor and marasmus
 Edema
 Musclewasting and decreased

subcutaneous fat
 When edema subsides, the patient
appearance resembles that of
marasmus
 Wt less that 60%and edema
Diagnosis
 History – nutritional history
 Physical findings
 Anthropometric measurements
-most children have similar growth potential
regardless of ethinicity
-need for international reference standard
-WHO recommends NCHS as a reference
-wt for ht –index of current nutritional
status
-ht for age –index of past nutritional history
-Harvard status – for under 5th
Assessment of Nutritional Status
1. Nutritional Hx & Dietary measurement:
- hx of breast feeding (frequency, day & night ?),
- total duration of breast feeding,
- any additional food (when was it started? If cow’s milk is
used, is it diluted/not?),
- amount, frequency, & type of additional food. Nutritional
hx should continue until present age.
 Dietary measurement
- measuring the diet/replica of the diet the child is getting,
- referring to the reference diet .
2. Anthropometric Measurement
Wt, ht/length, MUAC, HC, & skin fold thickness
(SFT).
Interpretation:
1. NCHS (National Curve for Health Statistics): widely
employed, extends from 5th to 95th centile.
Children below the 5th centile are considered abnormal. In
areas where PEM is prevalent a 3rd centile is used as a
cut off point.
2. Harvard/Wellcome curve:
- impt for under five children,
- takes the wt & age,
- uses standard wt (expected wt for age, 80%) &
presence/absence of edema. The standard is equivalent
to the 50th centile of the NCHS curve.
Gomez classification:
WFA(% of ref)= Wt of subj/ Wt of Nl child of the same
age
WFA (% of ref) Interpretation

90-100 normal
75-89 Grade I/ mild

malnutrition
60-74 G II/ moderate
malnutrition
<60 G III/ severe
malnutrition
Cont…
Wellcome’s Classification:
Wt for Age edema no edema
(WFA)
60-80% Kwashiorkor Underweight
<60% Marasmic Marasmus

kwash
Waterlow classification: takes Wt & Ht.
Wt/Ht (%)= Wt of subj/ Wt of Nl child of the same Ht Χ
100
HFA= Ht of subj/ Ht of child of same age x 100.
W F H
>90% ≤90%
H >95% normal wasted

F
A ≤95% stunted Stunted
&wasted
Investigation
 Hct and Hgb
 WBC count and differential
 RBS
 Urinalysis and urine culture
 Chest X-ray
 Blood culture
 Total serum protein
 Ratio of non essential to essential a.a-
 Reduced urinary creatinine clearance
Poor prognostic signs
 Age less than 6 months
 Deficit in Wt for Ht > 30%
 Stupor, coma, or other alteration in mental status
 Infections, particularly pneumonia or measles
 Petechiae or hemorrhagic tendencies
 Dehydration and electrolyte disturbances, particularly
hypokalemia, and severe acidosis
 Heart failure, hypothermia, hypoglycemia
 Total serum protein below 3 gm/dl
 Severe anemia with clinical signs of hypoxia
 Clinical jaundice or elevated serum bilirubin
 Extensive exudative or exfoliative cutanous lesions
Complications
 Hypoglycemia
 Hypothermia
 Dehydration
 Infectionespecially pneumonia, sepsis,
UTI, gastroenteritis
 Fluid and electrolyte imbalance
 Anemia
 Developmental delay
Hypoglycemia
 Life threatening comp’n

 At risk because of alteration in glucose
metabolism
 Signs –low body temperature, lethargy,
eye lid retraction, twitching or convulsion
 RBS <54 mg/dl
 Immediately give glucose containing
solution po or iv
 Hypoglycemia: a common cause of
death in the 1st 2 days.
 Can be due to a systemic infec or not
being fed for 4-6 hr.
- often have hypothermia, limpness,
drowsiness, lethargy.
- rx should be immediate (before lab
confirmation): 5ml/kg of 10% glucose,
this can also be given orally.
- also consider broad spectrum
antibiotics.
Dehydration
Useful signs –
thirst,
dry tongue and mouth,
 low urinary output,
weak and rapid pulse,
 low blood pressure,
 cool and moist extremities, and
declining state of consciousness.
Unreliablesigns – sunken eyeball,
decreased skin turgor, irritability and
apathy
 Rehydration should be preferably orally
or through NG tube
 Solution should contain less Na and
more K – ORS ( not ideal) Resomal
(best)
 Indication for iv fluid – shock and coma
Types of ORS
Solution Glu Na K Cl
g/dl mEq/L meq/L meq/L
WHO 2.0 90 20 80
Rehydralyt 2.5 75 20 65
e
Pedialyte 2.5 45 20 35
Infalyte 2.0 50 20 40
257
particular renal problem that makes the
children sensitive to sodium overload.
 Dehydration:
- ‘narrow therapeutic window”

inappropriate rehydration can lead to
fluid overload & cardiac failure
- rx when possible should be orally, even
for severe DHN, unless there is shock,
loss of consciousness, or confirmed
severe DHN.
- fluids: half strength Darrow’s solution,
RL with 5% dextr, half strength saline
with 5% dextrose,
- oral rehydration: 5ml/kg of ReSoMal q 30min
for the 1st 2 hr, orally/ NG tube, then adjust
according to wt,
i.e. if continued wt loss, ↑ the rate by
10ml/kg/hr;
if no wt gain, ↑ rate by 5ml/kg/hr;
if wt gained but still signs of DHN, continue
same rx;
wt gained & no signs of DHN, stop rehydration.
NB: continuous reassessment vital!!
- in kwash, increased total body water &
Na+,
- frequently hypovolemic due to dilatation
of the blood vessels with a low cardiac
output,
-
definite watery diarrhea, clinical
deterioration DHN.
- a fast weak pulse, cold peripheries,
disturbed consciousness, absence of
signs of heart failure shock
(hypovolemic/ septic).
- mx uses the same fluids as in marasmus,
amount 10ml/kg/hr for 2 hr.
- watch for signs of over-hydration: ↑ RR,
grunting, ↑ liver size, vein engorgement,
- as soon as the patient improves, stop
all IV intake.
- also treat hypoglycemia, hypothermia,
infection.
If pts is in shock
give 15ml/kg over the 1st hr & reassess,
dose can be repeated if wt loss/ wt is
stable.
- as soon as consciousness improves/
PR drops, stop the drip &
Give NG tube with 10ml/kg/hr
ReSoMal.
SIGN OF OVERHYDRATION
 .Engorged neck vein

 RR increment by more than 10
 PR increment by 15
 RUQ tenderness
 Liver size increased by 1cm
 Peripheral edema
 Any sign of respiratory distress like
grunting and cyanosis
Hypothermia
 Body temperature <35.5 degree

 Due to impaired thermoregulatory
mechanism, reduced fuel substrate or
severe infection
 Use kangaroo technique, put a hat
and the room should be kept warm
(b/n 28 -32 degree)
 The should always sleep with the mother
Anemia
 Usually due to Fe and/or folic acid

deficiency
 Clinically pale , low HGB/ HCT
 Fe treatment in phase II
 Indication for transfusion –HGB
<4gm/dl , HCT <12% or heart failure
10ml/kg of packed RBC/ whole blood
slowly over 3hr.
Infection
Clinical manifestations may be

mild
Classical signs ( fever,
tachycardia and leukocytosis)
may be absent
Assume that children with
severe malnutrition have a
bacterial infection
 Gram positive and gram negative
 Safer to treat all with broad spectrum
antibiotics
 Po route is preferred unless the patient
is in septic shock (a fast and weak pulse,
cold extremities, low BP and disturbed
consciousness)
Management
 Ten essential steps in the routine care of severely
malnourished children
 Treat / prevent hypoglycemia
 Treat / prevent hypothermia
 Treat / prevent dehydration
 Correct electrolyte imbalance
 Treat infection
 Correct micronutrient deficiencies
 Initiate feeding
 Replete wasted tissue (catch-up growth)
 Provide sensory stimulation and emotional support
 Prepare for follow up after recovery
Admission criteria
Age 6mo to 18 yrs - W/H or W/L <70% or

- MUAC <11cm with L
>65cm or
- Bilateral pitting edema
Adults -MUAC <170mm or

- BMI <16 or
-Presence of bilateral
pitting edema (exclude
other causes)
Nutritional therapy
Routine medicines
• Vitamin A – one capsule on the day of
admission and discharge
• Folic acid – a single dose of 5mg folic
acid
• Other nutrients – no need b/c F75 and
F100
• Antibiotics – should be given to all
• 1st line treatment – oral amoxacillin
(ampicillin)
• 2nd line teatment – Add chloramphenicol or
gentamycin
Routine medicines
1. Vitamin A
Continued…
 Duration of antibiotic –
 every day during phase I and 4 more days –in
patient
 7 days total in out patient care
 Malaria
 Measlesvaccine on the 4th week of treatment
 Deworming – at the start of phase II
 worm medicine is only given children who can walk
 Albendazole 400mg PO STAT
 mebendazole 100mg TWICE DAILY FOR 3 DAYS
Cont…
2. Folic acid: on the day of admission, one dose of folic

acid (5mg) to children with anemia.
3. Antibiotics: should be given to every severely
malnourished patient, even if no clinical signs of
systemic infection (nearly all are infected).
- small bowel bacterial overgrowth occurs in all these
children: systemic infection, malabsorption, & chronic d.
- in children with kwash, bacteria that are normally not
invasive, such as S. epidermidis can cause systemic
infection/ septicemia.
- recommended also in those who go to phase II directly.
Antibiotic regimen:
 Oral amoxicillin (oral ampicillin, if unavailable): 1st line,
 2nd line rx: add chloroamphenicol, or
- add gentamicin, or
- change to amoxicillin/clavulinic acid.
4. Iron: given in phase II.
 Phase I:
- pts with inadequate appetite and/or a
major medical cxn,
- formula used in this phase is F-75,
- promotes recovery of normal metabolic
fn & nutrition-ele balance,
- rapid wt gain is dangerous (F-75
ensures that).
Phase I
 Diet– F75 (one sachet mixed
with 2 liters of water)
 provides 75 kcal per 100 ml
 8 feeds per day –larger volume
feeding can result in osmotic
diarrhea
 Naso-gastric feeding is used if
 the child takes less than 75% of the prescribed
diet
 pneumonia with fast breathing
 painful lesions of the mouth
 cleft palate or other physical deformity
 disturbance of consciousness
 Surveillance using multichart

Transition phase
 Criteria to progress from phase I
 Return of appetite
 Beginning of loss of edema and
 No iv line, no NG tube
 Diet – F100 (100kcal in 100ml)
 The no. of feeds, their timing, and volume is the
same as phase I this leads to a 30% increase in
energy intake & thus the wt gain should be
~6g/kg/day,
 Transition phase should last 1-5 days
- criteria to move back to phase I include:
1. Increasing edema, new onset edema,
2. Rapid increase in liver size,
3. Significant refeeding diarrhea (& wt
loss),
4. Medical cxn, if NG tube needed,
5. Intake <75% of feeds in transition
phase,
6. Wt gain >10g/kg/d (excess fluid
retention).
Phase II
 Criteria to progress
 Good appetite (taking >90% of F-100)
 Loss of edema entirely
 designed for rapid wt gain (>8g/kg/day).
 Diet – F100
 Have unlimited intake
 5 feeds of F100 are given
 One porridge may be given
 Always offer plenty of clean water while eating
 Children must never be forced fed
 Provide additional quantity of diet after feeding
 Phase II: amount increased to ~180-
225ml/kg/day of F-100,
 iron is added here
 .
- criteria to move back to phase I:
Development of edema,
refeeding diarrhea with wt loss,
Wt loss of >5% of body wt at any visit
Wt loss for 2 consecutive weighing,
Static wt for 3 consecutive weighing.
Criteria for failure to respond
 Primary failure to respond (phase I)
 Failure to regain appetite (Day 4)
 Failure to start to loss edema (Day 4)
 Edema still present (Day 10)
 Failure to enter phase II and gain 5g/kg/d (Day 10)
 Secondary failure to respond
 Failure to gain more than 5g/kg/d for three
consecutive days (during phase II)
 Measure to take
 Extensive history and examination or lab. Test
 Look for hidden infection
Cont…
Discharge criteria:
Age • W/L (W/H) ≥85% on
6mo-18 more than one occasion,&
yr No edema for 10 days.
• target wt gain reached &
no edema for 10 days.
Prognosis
 Upon treatment the acute signs of the disease
are corrected
 Catch-up growth in height may take long or
might never be achieved
 Mortality rate can be as high as 40%
 Immediate cause of death are comp’n
particularly infections, hypoglycemia, and
dehydration
 Mortality rates can be reduced to < 10% by
prevention and treatment of comp’n
• Fats are a type of lipid, a fatty
substance that do not dissolve in water.
• The building blocks of fats are called
fatty acids
• Fatty Acids are classified as two types
• Saturated:
– Animal fats and tropical oils
– High intake is associated with an
increased risk of heart disease
• Fatty acids that the body needs, but is
• Unsaturated:
unable to make are called essential fatty
– Vegetable fats acids
– Associated with a reduced risk of • Transport vitamins A, D, E, and K
heart disease
• Sources of linoleic acid- essential fatty acid
that is needed for growth and healthy skin
• High intake of saturated fats is linked to
increased cholesterol production
• Excess cholesterol can lead to an increased
risk of heart disease
Lipids
• are a group of organic compounds that are

insoluble in water but soluble in organic solvents.
• Lipids are fats and oils.
295
Lipids:
• ƒ Are the form of stored energy in animals
• Have high energy value 9 kcal/gm of fat ƒ
• Act as carriers for fat soluble vitamins ƒ
• Are palatable giving good taste and satiety ƒ
• Serve as insulator preventing heat loss from the
body ƒ
• Lubricate the gastrointestinal tract ƒ
• Protect the delicate organs such as Kidney,
Eyes, heart and the like.
296
Classification of lipids
Lipids are classified into 3 on the basis of their

chemical structure. ƒ
•Simple lipids = Fats and oils ƒ
•Compound lipid = Phospho-lipids and lipoproteins
ƒ
•Derived lipids= fatty acids and sterols
297
• ƒHuman beings cannot synthesize the Poly
Unsaturated Fatty Acids (PUFA), hence they are
termed as essential FA. ƒ
• Saturated fatty acids tend to raise blood
cholesterol level. ƒ
• Polyunsaturated Fatty Acids lowers blood
cholesterol and large amounts of unsaturated
Fatty Acids are of vegetable origin and have
lower melting point.
298
Phospholipids, sterols and lipoproteins
• Phospholipids are structural compounds found in

cell membranes.
• They are essential components of enzyme
systems and are involved in the transport of
lipids in plasma.
299
Sterols
• These are precursors of vitamin D, which are
found both in plants and animals. Cholesterol in
animal’s tissues, egg yolk butter. Ergosterol in
plants
• Lipids are transported in the blood in the form of
lipoprotein (soluble fat protein complexes).
• They are 25-30% proteins and the remaining as
lipids
300
Lipoprotein
• These are compound lipids that contain both

protein and various types and amounts of lipids.
• They are made mostly in the liver and are used to
transport water-soluble lipids throughout the body
and the types of lipoproteins are VLDL, LDL, HDL,
and Chylomicrons.
301
• Low-density lipoprotein (LDL) This is composed
mainly of cholesterol.
• LDL. Transports cholesterol from the liver to the
tissues. High serum level of LDL greatly increases
the risk of atherosclerosis ” is a disease in which
fatty deposits collect along the inside walls of
large or medium - sized arteries. These deposits
clog or narrow the passageway. If blood clots
become lodged in the narrowed vessels, the
blood flow to the heart or brain many be partially
or completely blocked, resulting in a heart attach
or stroke”. Diets that are high in saturated fatty
acids are associated with elevation in LDL
302
cholesterol.
Cholesterol
• Cholesterol is found • It is a major part of
only in animal brain and nerve
products. Plant foods, tissues. Cholesterol is
regardless of their fat necessary for normal
content, do not body functioning as
contain cholesterol. structural material in
Cholesterol is a fatlike the body cells, and in
lipid that normally the production of bile,
occurs in the blood vitamin D and a
and all cell number of hormones
membranes. including cortisone
and sex hormone. 303
• Hereditary, diet, exercise, and other conditions
affect blood cholesterol levels. Persons with high
blood cholesterol levels appear to be more likely
than those with normal levels to develop
atherosclerosis.
• No recommended dietary allowance has been
established for total fat or essential fatty acids;
however, the reduction in total fat is
recommended.
304
The essential fatty acids are: Š
• Linoleic acid Š
• Linolnic acid Š
•Arachidonic acid
305
The essential fatty acids are:
• Essential Fatty Acids are needed for the normal
functioning of all tissues
• Essential Fatty Acids form a part of the structure
of each cell membrane.
• Essential Fatty Acids help transport nutrients
and metabolites across the cell membrane
• Essential Fatty Acids are also involved in brain
development
• Essential Fatty Acids are needed for the
synthesis of prostaglandin
306
Linoleic acid:
Linoleic acid: occurs abundantly in vegetable oils

such as: ƒ
•Corn oils ƒ
•Cottonseed oils ƒ
•Soybeans oils ƒ
•Sesame oils ƒ
•Sunflower oils
307
Digestion of fats:
• In the mouth • In the stomach

• Enzyme – lingual • Enzyme – Gastric
lipase lipase
• End products – • End products – Fatty
diglycerides acids, glycerol,
diglycerides and
monglycerides
308
Digestion of fats:
• In small intestine Food source of fats

Triglycerides, •Animal – Fish, butter,
diglycerides beef, pork, and lamb
• Enzyme – Pancreatic • Plant - vegetable,
lipase fruit avocado, nuts,
• End products – margarine, cooking oils
monglycerides, fatty
acids, glycerol
309
Vitamins are compounds that help regulate many vital body
processes that include:
1. Digestion 2. Absorption 3. Metabolism 4. Circulation
Vitamins are classified into two groups:

– Water-soluble vitamins – Fat-soluble vitamins are
dissolve in water and pass absorbed, stored, and
easily into the blood during transported in fat. Your body
digestion. The body does not stores these vitamins in your
store these so they need to be fatty tissue, liver, and kidneys.
replenished regularly. Excess buildup can be
Includes vitamins C, B1 ,B2, toxic.These include vitamins
Niacin, B6, Folic acid, and B12. A, D, E, and K.
Minerals are substances that the body cannot

manufacture but are needed for forming healthy bones
and teeth and regulating many vital body processes.
Important minerals include:
-Calcium -Phosphorus –Magnesium -Iron
Vitamins;
• Vitamins: are defined • All animals need
as organic vitamins, but not every
compounds, other than vitamin that has been
any of the amino acids, discovered is needed in
fatty acids and the diet of each animal
carbohydrates that are species. E.g. humans
necessary in small and guinea pigs need
amounts in the diet of Vitamin C, but dogs,
higher animals for rats, do not need
growth, maintenances vitamin C in their diet
of health and because they can
reproduction. synthesis this vitamin311in
their bodies.
Classification of vitamins:
• Š Vitamin A (Retinol)
• Š Vitamin B1 (Thiamine)
• Š Vitamin B2 (Riboflavin)
• Š Vitamin B6 (pyridoxine) Š
• Vitamin B12 (Cyanocobalamine) Š
• Niacin Š
• Panthotonic Acid Š
• Folacin Š
• Biotin Š
• Vitamin C (Ascorbic acid)
312
Classification of vitamins:
• Š Vitamin D (Cholecalciferol)
• Š Vitamin E (Tocopherol) Š
• Vitamin K (Antihemorrhagic vitamin)
• These vitamins are found in wholesome foods,

milk, vegetables, fruits, eggs, meat, beans,
wholegrain cereals etc
313
Function of vitamins:
• ƒTo promote Growth ƒ

• To promote Reproduction ƒ
• To promote Health & vigor ƒ
• To promote Nervous activity ƒ
• To promote Normal appetite ƒ
• To promote Digestion
• ƒTo promote Utilization ƒ
• To promote Resistances to infection.
314
Groups of vitamins:
 Š Water soluble Vitamins are:

(C and B group) Š
 Fat-soluble Vitamins are
(A, D, E, and K)
315
Characteristics of water soluble
vitamins
• ƒ They are widely distributed in natural foods ƒ
• B 12 is found only in animal products ƒ
• Soluble in water and absorbed in the intestine ƒ
• Excess will be excreted, thus not toxic. ƒ
• Most functions of these vitamins are as co-
enzymes ƒ
• They are important for energy production ƒ
• They are heat labile
316
Characteristics of fat - soluble
vitamins
• ƒ Metabolize along with fats ƒ
• Resistance to heat ƒ
• Stored in the liver and adipose tissue ƒ
• Slow to develop deficiency syndrome ƒ
• Present only in certain foods, mostly in animal
products, oily foods, yellow and green vegetable
ƒ
• Excess can be toxic to the body.
317
Function of vitamin A
 It controls the general state of the epithelial cells
and reduces the risk of infection. ƒ
 It is required for the regeneration of two pigments,
visual purple in the rods of retina and visual violet
in the cones of the retina.
 These two pigments are responsible for vision in
dim and bright light ƒ
 It aids growth and development during childhood
ƒ
 It helps to keep the cornea of the eye in healthy
condition.
318
Function of vitamin A
 Š Dietary Vitamin A is required for the growth and

survival of all animals and it is present in most
biological tissues. ƒ
 In the visual system the retina is dependent on
Vitamin A and its metabolites. ƒ
 In the auditory system vitamin A plays a role in
the maintenance of the middle and inner ear and
it also helps the olfactory system, ƒ
 It is required for reproduction, embryonic
development and bone formation. 319
Who is affected by Vitamin A
deficiency?
• Vitamin A deficiency is a major health problem in
many developing countries. Many children do not
survive.
• Recent research findings suggest that improving
vitamin A status amongst deficient populations
can significantly reduce young child mortality.
• The population groups at highest risk of the
deficiency are infants and young children under
five years.
320
Vitamin A deficiency
• Vitamin A deficiency occurs when vitamin A

intakes (or liver stores) fail to meet daily metabolic
requirements. The most common cause is
inadequate consumption of vitamin A – rich foods.
Deficiency also occurs when there is problem of
absorption, conversion or utilization of vitamin A
or when there are repeated infections of diseases
such as measles or diarrhea. In the absence of
foods containing oils or fats in the diet, vitamin A
is not well absorbed and metabolized.
321
Animal source of vitamin A
• The best sources of • Animal sources contain
vitamin A is animal preformed active
products such as retinol, which can be
organ meat like liver, used effectively by the
whole milk and milk body. The best source
products, eggs, of vitamin A for infants
butter, cheese, and is breast milk
fish liver oils. • The mother’s secretion
of vitamin A into breast
milk, however, is
related to her own
vitamin A status. 322
Plant source of vitamin A
• Plants contain beta- • Dark green

carotene that can be vegetables.
converted into vitamin
A by the body.
• The best plant sources of
vitamin A are orange,
yellow colour fruits and
vegetables (papaya,
mango, pumpkin,
tomatoes, carrots, yellow
sweets potatoes)
323
What are the consequences of vitamin
A deficiency?
• Vitamin A deficiency has long been associated
with blindness. But more importantly, vitamin A
deficiency is associated with increased morbidity
and mortality among young children.
• Improvement of vitamin A levels among deprived
populations has been associated with reduction in
young child mortality.
324
The common symptoms of vitamin A
deficiency
• Š Night blindness: • Š Conjuctival xerosis:
The child cannot see The conjuctival
in the dark. He/she covering the white
has to go in to the surface of the
house early in the eyeballs become dry
evening. and rough instead of
being moist, smooth
and shining. The child
cannot open and
close his/her eyes
because it is painful.
325
The common symptoms of vitamin
A deficiency
• Bitot’s spots: A foamy or cheesy accumulation,
which forms in the inner quadrant of the cornea in
the eyes.
• The cornea the central transparent part of the eye
becomes cloudy.
• It reflects more advanced vitamin A deficiency,
but tends to be reversible with treatment.
326
The common symptoms of vitamin
A deficiency
• ŠCorneal ulceration: an ulcer on the cornea may
leave scar, which can affect vision. Š
• Keratomalacia: The eyeballs become opaque and
soft, jelly like substance; hereafter there will be a
rapid destruction of the eyeball and no hope of
recovery after the condition reached the stage of
keratomalacia.
327
• Diagnostic criteria for vitamin A deficiency at the
community level, WHO identifies a vitamin A
deficiency as a major public health problem if
prevalence of any one of the following in children
below six years of age exceeds the prescribed
levels.
328
Identifications of vitamin A deficiency at
the community level
Who cut - off level for identifying a
Vitamin A deficiency sign/symptoms public health problem
Night blindness >1%
Bitot’s Spot(s) >0.5%
Conjuctival >0.01%
Xerosis/ulceration/keratomalacia
Corneal scar >0.05%
329
Prevention of vitamin A deficiency
• A diet containing plenty of vitamin A is the best.

• Breast-feed infants for at least one year.
• Do not discard the 1st breast milk soon after
delivery.
• At 6 months start to feed infants with dark green
vegetables, yellow and orange fruits and if
possible, some finely chopped and well cooked
liver.
• Include some fats in the child’s diet
330
Prevention of vitamin A deficiency
• Children with diarrhea, measles, respiratory and

other serious infections need extra vitamin A. ƒ
•Pregnant and lactating mothers should eat foods
rich in vitamin A every day. ƒ
•Tell families that night blindness is an early warning
sign of xerophthalmia (Vitamin A deficiency). ƒ
•Teach school children to look for night blindness in
young children. ƒ
•Learn which vitamin A rich food is available in the
locality 331
Strategies to control and eliminate
vitamin A deficiency ƒ
• Universal supplementation of vitamin A ƒ
• Food fortification ƒ
• Food diversification
332
Universal supplementation of vitamin a
capsules (short term strategy)
• ƒ Children 6-59 months of age ƒ

• Lactating mothers ƒ
• Pregnant women ƒ
• Targeted diseases i.e. Measles, diarrhea, acute
respiratory infection, xerophthalmia and PEM.
333
Fortification of foods
• Fortification of a widely consumed centrally

processed staple food with a nutrient is one way
of controlling deficiencies of certain nutrients such
as iron, vitamin B1 and vitamin A in many
countries.
334
Fortification of foods
• Fortification of a nutrient is the addition of the

deficient nutrient supplements in processed
dietary components in factories.
• In industrialized countries the most commonly
fortified food products are:
Wheat flour
ƒBread ƒ
Milk products ƒ
Infant formulas ƒ
Weaning foods. 335
Food diversification
• Food diversification is an important strategy, which

is considered as a long term and sustainable
strategy for the prevention of vitamin A deficiency.
• In this regard, people should be encouraged to
grow and consume vitamin A rich foods at a vast
scale in all regions
336
Vitamin B1 (Thiamine)
• The vitamin B1 (thiamine) plays an important part

in the utilization of carbohydrates, cereals, roots
and tubers are especially rich in carbohydrates
and if these foods are to be properly utilized, it is
essential that the daily food intake should supply
sufficient vitamin B1.
• It occurs particularly in cereals but it is localized
on the outer surface of the grain close to the
sheath.
337
Vitamin B1 deficiency
1. Acute Beriberi (Dry Beriberi)

Symptoms: Š
 Epigastric pain Š
 Nausea & Vomiting Š
 Urgent Cardiac sign of cardiac failure & death
338
Vitamin B1 (Thiamine) deficiency
2. Wet Beriberi
Symptoms: ƒ
•Gradual onset ƒ
•Loss of power of limbs ƒ
•Gradually develops edema and ascitis
339
Vitamin B1 (Thiamine) deficiency
3. Chronic Beriberi
•Symptoms: ƒ
•Paralysis of the lower extremities ƒ
•Cramping of the calf muscle ƒ
•Coldness of the feet ƒ
•Stabbing pain on walking ƒ
•Absence of knee and ankle jerks
340
Vitamin B2 (Riboflavin)
• Vitamin B2 is found in many foods, especially in

milk, certain vegetables and meat.
• It plays a very important role in assisting the
various chemical activities, which are essential to
life such as cellular oxidation, co-enzymes, and
function of the nervous system
341
Deficiency of vitamin B2 is characterized by:
• ƒ Angular Stomatits with fissuring at the angle of

the mouth ƒ
• Cheilosis (Red shiny lips) ƒ
• Glossitis (inflammation of the tongue) ƒ
• Scrotal dermatitis ƒ
• Lacrimation ƒ
• Corneal vascularization
342
Vitamin B6 (Pyridoxine)
• It is one of the vitamins about which little is known.

It is found in both animal and plant foods. The
animal foods include chicken, fish, kidney, liver,
pork, eggs, and plant foods include wheat germ
oils, soybeans, brawn rice, peanuts and walnuts.
Dairy products and vegetables are poor sources.
Yeast is an important source of B6.
343
Deficiency of Vitamin B6
• ŠOccurs in combination with deficiencies of other

B-complex vitamins. Š
• Nervous disturbance such as irritability and
insomnia is observed.
• ŠMuscular weakness, fatigue and convulsion
have been recorded in infants.
344
Vitamin B12 (Cobalamin)
• According to the present evidence this vitamin is

found only in animal products.
• Source of vitamin B12:

The content of liver and kidney is high, the content
of fish, milk and meat is medium, and however,
the source of B12 has not been widely
investigated.
345
Deficiency of vitamin B12:
• ƒThe red blood cells are abnormally large and are

reduced in number ƒ
• Stomatits ƒ
• Lack of appetite ƒ
• Poor coordination in walking & mental disturbance
346
Note:
• The body effectively regulates the vitamin from

bile and other secretions.
• This accounts for its long biologic effectiveness.
• Vegetarians who eat no animal products develop
a vitamin B12 deficiency only after 20 to 30 years
347
Source of Niacin
• ƒ Meat, liver, fish, poultry ƒ Peanut, peas, beans,

and whole grains ƒ Milk, eggs, and cheese are
poor source, however, they are good source of
Tryptophan (one of the essential amino acids ),
which is converted to Niacin.
348
Functions of Niacin
• It affects a number of important metabolic

activities needed for the maintenance of healthy
skin and the proper functioning of the nervous
and digestive system.
• Niacin is a coenzyme in energy metabolism along
with other B-complex vitamins
349
Deficiency of Niacin
• Niacin deficiency is common in areas where the

staple food is Maize because Maize is low in
Niacin and Tryptophan one of the essential amino
acids which is a precursor of Niacin.
350
Early signs and symptoms of Niacin
deficiency
• ƒFatigue,
• poor appetite, ƒ
• Weakness,
• mild digestive disturbance, ƒ
• Anxiety, irritability, ƒ
• Pellagra (a prolonged niacin deficiency), which is
characterized by the 4Ds which are:
 Diarrhea
 Dermatitis
 Dementia
 Death if the disorder is untreated. The skin is dry, scaly,
and cracked and the condition is aggravated by exposure 351
to heat or light.
Vitamin C (Ascorbic Acid)
• ƒ Found in fresh vegetables and citrus fruits ƒ

Vegetables and fruits should not be left soaked in
water for a long time since it is soluble in water ƒ
• Cooking itself destroys about half of the vitamin C
present in the food ƒ
• The best way to make sure of a regular intake of
vitamin C is to eat raw fruits or salad every day
352
Functions of vitamin C
• Helps the formation of

various body tissues, •Stimulates the
particularly production of red blood
connective tissues, cells,
bones, cartilage and •Helps resistance to
teeth. infection and neutralizes
poisons.
353
Vitamin C
• Vitamin C is unstable and easily destroyed. Foods

lose almost half of their vitamin C content when
they are cooked and when the foods are kept hot
after they have been cooked.
• Drying, storage, bruising, cutting, and chopping of
fruits and vegetables lead to the loss of vitamin C.
• Potatoes boiled in their skin retain most of their
Vitamin C.
• Therefore, to ensure a regular intake of vitamin C
is to take fruits and vegetable every day.
354
Deficiency of Vitamin C
• Weakness of the wall of the capillaries,

• Gum bleeding,
• Loosening of the teeth,
• Browsing of the skin and petechia
• The bones become painful, swollen and brittle
• General weakness and anemia may result if the
disorder is not treated.
• Skin abnormalities such as adult acne may be the
earliest sign of scurvy
355
Deficiency of Vitamin C
• Hardening and scaling of the skin surrounding the
hair follicles and hemorrhages surrounding the
hair follicles also point to scurvy
• The skin of the forearm, legs and thighs is most
affected
• Scurvy: symptoms include weakness, fatigue,
restlessness, and neurotic behavior, aching
bones, joints, and muscles.
356
Vitamin D (cholecalciferol)
• Vitamin D is known as the antirachtic vitamin and

chemically as calciferol.
• The two most important vitamin D compounds are
ergocalciferol (vitamin D2) and cholecalciferol (vitamin
D3).
 These substances are formed from precursors in
plants, animal and in the skin and are converted to
vitamin D. by the ultraviolet rays of the sun.
357
• Vitamin D is stored in the liver mainly; some is
stored in the brain, bones and skin as well.
• It undergoes changes in the liver, and in the
kidneys that convert it to active, hormone like
form.
358
Functions of vitamin D
• Absorption of calcium and phosphorous

• The presence of vitamin D is essential to the
activity of the parathyroid hormone in removing
calcium and Phosphorous from the bone in order
to maintain normal serum levels of calcium.
• Stimulates the reabsorption of Calcium by the
kidney when serum calcium level is low.
• Bone formation
359
Source of vitamin D
• Fish liver oil is a rich source of vitamin D.

• A nonfood source is the sunlight for the action of
sunlight on the skin changes the cholesterol to
vitamin D.
360
Deficiency of vitamin D
• It leads to rickets, which is characterized by
weakness and deformity of bones.
• Rickets generally occurs between the six months
to the second year of life, during the weaning
period.
361
On examination the skull bone of rachitic child, we will
find the following characteristics:
• Depression will be seen along the suture

• The forehead is prominent
• The anterior fontanel remains wide open
• The abnormalities give the head the general
appearance of a box
• If you press the skull bone with your thumb of a
rachitic child, it will remain depressed and this
known as craniotabus.
362
On examination the skull bone of rachitic child,
we will find the following characteristics:
• The chest is narrow and deformed
• The long limbs curve and may take the shape of a
bow and the sufferers are referred as bowlegs or it
may take the opposite shape i.e. the knees may
knock together and the sufferers may be described
as knock-knees.
• The vertebral column may curve, causing Kyphosis.
• Rickets in adults is known as osteomalacia, the
bones become soft and very painful.
• In women it causes difficult labor, as the pelvis
becomes contracted, thus narrowing the birth canal.
363
Vitamin k (Antihemorrhagic vitamin)
• This vitamin can be synthesized by the action of

bacteria in the intestinal tract of a healthy person.
• It is also found in liver, fish, and green vegetables.
• Daily requirement is not known. Cooking does not
destroy it. The liver requires vitamin K for the
formation of prothrombin a substance needed for
clotting mechanism of blood.
364
Deficiency of vitamin K
• A person deficient in Vitamin K shows a tendency

to bleed profusely whenever blood vessels are
injured.
• The treatment and prevention is to provide with
high content of vitamin K foods and give vitamin K
injection to stop active bleeding.
365
Minerals
• Minerals: are inorganic elements occurring in
nature. They are inorganic because they do not
originate in animal or plant life but rather from the
earth’s crust.
• Although minerals make up only a small portion of
body tissues, they are essential for growth and
normal functioning of the body.
• The body can make most of the things it needs
from energy foods and the amino acids in proteins
but it cannot make vitamins and minerals.
366
Benefits of minerals
• Minerals are essentials both as structural
components and in many vital processes,
• Some form hard tissues such as bones and teeth
• Some are in fluids and soft tissues.
• For normal muscular activity the ratio between
potassium and calcium in the extra cellular fluid is
important.
• Electrolytes, sodium and potassium are the most
important factors in the osmotic control of water
metabolism.
367
• Some minerals may act as catalysts in the enzyme
system, or as integral parts of organic compounds
in the body such as:
�Iron in hemoglobin
�Iodine in thyroxin
�Cobalt in vitamin B12.
�Zinc in insulin and
�Sulfur in thiamine.
 Plants, animals, bacteria, and other one celled
organisms all require proper concentration of
certain minerals to make life possible. 368
• The principal minerals, which the body requires.
Calcium Chlorine Iron
Phosphorus Sodium Iodine
Magnesium Potassium Sulfur
369
Minerals cont,,,,
• Animals, in trace quantities, use minerals and these
are: Copper, Manganese, Cobalt, Zinc, and Fluorine.
• Other trace elements are present in animal tissues,
but their functions are uncertain and these are
Aluminum, Arsenic, Boron, Cadmium, and Silicon.
370
Minerals
• In natural foods, minerals present in various

forms mixed or combined with:
• � Protein
• � Fats and
• � Carbohydrate
371
Minerals
• Iron • Daily requirements for

Sources of Iron men and women are 8
�Beef, liver, egg yolk to 10mg and 10 to 18
mg respectively.
�Wheat and Teff
• For pregnant and
� Dark green lactating mother the
vegetables, onions & requirement increases
fresh fruits. to 20mg. Absorption of
iron is enhanced in the
presence of
• vitamin C. 372
Functions of Iron
• It is an essential component of hemoglobin,

responsible for the red coloring of blood and for
the transportation of oxygen to the tissues.
373
Causes of Iron Deficiency
• � Insufficient iron in diet

• � Blood loss during menstruation
• � Hook worm infestation
374
Causes of anemia
• Causes of anemia are multiple and the main

causes are nutritional deficiencies, which
represent more than half of all cases, blood loss
through hemorrhage, destruction of red blood
cells by infections such as malaria and parasitic
infections, genetic defects of red blood cells and
infections by most of febrile diseases and chronic
diseases like tuberculoses.
375
Consequences of anemia
• Delayed psychomotor
development and • In adults, anemia with
cognitive performance in hemoglobin concentration
children and reduces work
adolescence.
• capacity, mental
• Neurological performance and
manifestation in children tolerance to infections.
and adolescents.
376
Consequences of anemia
• When the level of • Maternal anemia can

hemoglobin cause prenatal infant
concentration falls loss, low birth weight
below 4g/ld it may and prematurity,
cause death from • Prenatal deaths
anemic heart failure. • Reduces work
• can also cause capacity in adults and
increased maternal learning ability in
mortality due to children.
adverse immune
reaction, 377
Strategies for prevention and treatment
of iron deficiency
• Supplementation of • Fortification of foods
iron tablets (with with iron
folates) preferably with • Control of malaria
vitamin B12 and infection
vitamin C • Control of febrile and
• Dietary improvement of chronic diseases,
iron rich foods • Promotion of hygiene
• Changing of dietary and sanitation,
habits and food
preparation practices
through nutrition 378
Strategies for prevention and treatment of
iron deficiency
• Education, information and communication on

iron supplementation,
• Networking and collaborating with relevant
sectors on issue,
379
Who needs more iron?
• Pregnant women require much higher amount of

iron than is met by most diets.
• Many infants beyond 6 months of age need more
iron than is available in breast milk and common
weaning foods.
• Infants with low birth weight have less iron stores,
and are thus at a higher risk for deficiency after
two months of age.
380
• Therefore, it is important that pregnant women
routinely receive iron supplements. In places
where anemia prevalence is high,
supplementation should continue into the
postpartum period, to enable them acquire
adequate stores of iron.
381
Iodine
• Iodine is one of the micronutrients, which is highly

essential for regulation of physical growth and
neural developments.
• Iodine is an essential component of the thyroid
hormones, thyroxin.
• Failure to have adequate level of iodine in the
blood leads to insufficient production of these
hormones, which affect many different parts of the
body, particularly muscle, liver, kidney, and the
developing brain.
382
Sources of Iodine
• Milk and sea food

• Drinking water
• Plant source depends on whether or not iodine
present in the soil
• Iodized salt
383
Functions of Iodine
• It is required for normal physical and mental

growth.
• It is required by the thyroid gland for the
production of thyroxin, which regulates the
metabolic rate.
384
Iodine
• soil erosion and • People of all ages

flooding, thus the crop and sexes are
we grow for food do vulnerable but
not have iodine in become acute in
them and as a result fetus, children,
leads to iodine pregnant women and
deficiency. lactating mothers.
385
Iodine
• Livestock suffer from iodine deficiency in the

same way that humans do.
• They eat the same iodine deficient food and drink
the same iodine deficient water.
• The introduction of iodized salt in their diet will
improve their health and productivity; livestock
fed iodized salt will produce iodine rich milk and
meat. An iodine deficient diet will lead to
increased stillbirth and miscarriages and a
reduced yield of milk, eggs, meat and wool.
386
How do we prevent Iodine
Deficiency Disorder?
• Iodine Deficiency Disorder can be eliminated by
the daily consumption of iodized salt.
• That is why Universal Salt Iodization is a crucial.
387
Why salt is iodized?
• Salt has been chosen as vehicle for the supply of

iodine because it is used universally by all ages,
sexes, socio-economic, cultural and religious
groups throughout the year.
• Iodized salt is also a preventive and corrective
measure for iodine deficiency and is the most
effective low cost, long-term solution to a major
public health problem.
388
How long do we need to use iodized salt?
• Iodized salt has to be used on a daily basis as

long as one lives in an iodine deficient
environment.
• This is the only safe and long-term solution to a
problem that affects many People.
389
The benefits of iodized salt
• Universal Salt Iodization can lead to an increase

of the average intelligence of the entire school
age population.
• The Iodization of salt will mean saving hundreds
of thousands of children.
• Iodine enhances intellectual and cognitive
development of whole generations.
390
The major consequences of iodine
deficiency
• Mental retardation • Decreased average
• Defects in the intelligence
development of • Loss of memory
nervous system • Inability to produce
• Goiter enough milk for
• Physical sluggishness offspring
• Reduced work • Lower birth weight
capacity • Growth retardation
• Impaired work
performance
391
The major consequences of iodine
deficiency
• � Dwarfism
• � Deaf-mutism
• � Cretinism
• � Reproductive failures (abortion, prematurity,
stillbirth)
• � Increased childhood morbidity and mortality
• � Economic stagnation and
• � Impotency.
392
Water helps to maintain many bodily
functions.
• Lubricates your joints and mucous
membranes.
- Enables you to swallow and digest foods.
- Absorb other nutrients, and eliminate
wastes.
- Perspiration helps maintain normal body
temperature.
• Water makes up around 65% of the body.
• It’s important to drink at least 8 cups of
water a day to maintain health.
Importance of water
• Water, next to oxygen is the body’s most

urgent need. It is more essential than
food.
• Without water, nutrients are of no value to
the body.
• Failure to understand the role of body
water contributes to health problems such
as indigestion and constipations and even
to needless death.
394
Importance of water
• Infant and children have a greater
proportion of water than old persons, and
obese persons have proportionately less
water than lean persons,
• Water is taken in the form of water itself,
beverages, such as coffee, tea, fruit
juices, and milk; and soups,
• Solid foods contribute the next largest
amount of water, as much as 25% to 50%
of water requirements, 395
Importance of water
• Fresh vegetables and fruits are 80% to

90% water; meat is 50% to 60% water,
and even bread is about 35% water,
• The sensation of thirst usually is a reliable
guide to water intake.
• Except in infants and sick persons,
especially comatose person who cannot
respond to the thirst stimulus.
396
Importance of water
• If losses are not replenished, heat exhausting
and possibility heat stroke may occur,
• Dehydration can occur rapidly in comatose
patients and in disabled or elderly persons
with brain impairment that are unable to
respond to the sensation of thirst,
• Other conditions, such as fever, diabetes
mellitus, vomiting, diarrhea, and the use of
drugs such as diuretics also increase water
need. 397
Body water
• About half of the adult body weight is

water 55% for man and 47% for woman.
• About 2000 to 2500 cc of water is
eliminated every day from the body
carrying waste products with it.
398
Body water
• The lost water has to be replaced in the

form of fluid or foods containing water.
• Although some water is formed, as end
products of food metabolism, from 6 to 8
glass of water should be drunk every day,
399
Water in relation to body function.
• It is an essential component of blood and

lymph and the secretion of the body, as
well as the more solid tissues.
• Moisture is necessary for the normal
functioning of every organ in the body.
400
Water in relation to body function
• Water is the universal medium in which

the various chemical changes of the body
take place.
• As a carrier water aids in digestion,
absorption, circulation and excretion.
• It is essential in the regulation of body
temperature.
401
Water in relation to body function
• Lubrication of joints and movement of the

viscera in the abdominal cavity
• Waste products are transported to the
blood in watery solution and eliminated by
the kidneys.
402
Table. 7. Body water components in the reference man
403
Normal loss of water
• • From the skin, as perspiration

• • From the lung, as water vapor
• • From the kidney, as urine
• • From the intestine, in the faeces
404
Abnormally
• Due to kidney disease

• If there is excessive perspiration due to
high environmental temperature.
• Due to diarrhea and vomiting
• Due to hemorrhage and burn
405
Dehydration
• The term dehydration implies more than

changes in water balance.
• There are always accompanying changes
in electrolyte balance.
• When the water supply is restricted or
when losses are excessive the rate of
water loss exceeds the rate of electrolyte
loss.
406
Dehydration
• Then the extra cellular fluid becomes

concentrated and osmotic pressure draws
water from the intra-cellular fluid into the
extra-cellular fluid to compensate.
• This condition is called extreme thirst and
dehydration.
407
Basal Metabolism
• Basal metabolism: is the energy required to

carry on vital body processes at rest, which
include all the activities of the cells, glands,
skeletal muscles tone, body temperature,
circulation, and respiration.
• In persons who are generally inactive physically,
basal metabolic needs make up the largest part,
about two thirds, of the total energy requirement .
409
Factors affecting basal metabolism
• Size and shape:

The greater the skin area, the greater will be
the amount of heat lost by the body and, in
turn, greater the necessary heat
production by the individual. E.g. tall
person needs more food than short
person with
the same weight.
410
Age and growth:

They are responsible for normal variation in
basal metabolism.
The relative rate is highest during the first
and second years and decreases after that,
although it is still relatively high through the
ages of puberty.
During adult life there is a steady decrease
in rate with a marked drop in old age.
411
• Sex:
Sex probably has little effect on metabolism.
Women have a lower metabolism than
men. Women usually have a less fat and
less
muscular development than men.
412
• Climate:
Climate has little effect on BMR, which is
always measured in a room temperature.
413
• Racial:
Differences in metabolism have been noted.
Eskimos have been reported to have a
BMR above accepted standards.
414
• State of nutrition:
In starvation or under nutrition the BMR is
lower.
415
• Diseases:
Diseases such as infection or fevers raise
the BMR in proportion to the elevation of
the body temperature.
The internal secretion of certain glands such
as the thyroid and the adrenal, affect
metabolism. Hyperthyroidism accelerates
metabolism by increasing production of
thyroxin.
416
• Sleep:
Sleep varies depending on individuals,
some are restless and others are quiet.
417
• Pregnancy:
After four months of gestation the BMR will
increase.
418
Are You Eating A Balanced Diet?
Product labeling advertise a food’s nutritious value. Some
common used terms are light, less, free, more, rich, rich in, lean, or excellent
source of. Many food products have open dates on their label. Examples are
expiration date, freshness date, pack date, and sell-by date.
1. Food Allergy - a condition in which the body’s immune
system reacts to substances in some foods.
•Allergies to peanuts, tree nuts, eggs, wheat, soy, fish,
and shellfish.
•A simple blood test can can indicate whether a person
is allergic to a specific food.
•These reactions may include rash, hives, or itchiness
of the skin; vomiting, diarrhea or abdominal pain; or
itchy eyes and sneezing.
2. Food Intolerance - a negative reaction to a food or part of
a food caused by a metabolic problem.
•The inability to digest parts of certain foods or food
components.
•May be associated with certain foods such as milk or
wheat, or even with some food additives.
•Common symptoms include nausea, vomiting,
diarrhea, and fever.
3. Food borne Illness – A term that means a person has food
poisoning.
•To prevent foodborne illness you should clean,

separate, cook and chill food when handling it.
•A foodborne illness can result from eating foods
contaminated with pathogens or poisonous
chemicals.
•The symptoms from the most common types of
food poisoning generally start within 2 to 6 hours
of eating the food responsible. That time may be
longer (even a number of days) or shorter,
depending on the toxin or organism responsible
for the food poisoning. The possible symptoms
include: nausea/vomiting, abdominal cramps,
diarrhea, weakness, fever and headache.
Growth And Development
• It is worth remembering that the fetus

development in 40 weeks from the two cells
joined at conception into an independent infant
with a functioning nervous system, lungs, heart,
stomach, and kidneys.
• To support this rapid growth and development
major changes takes place in the mother’s body.
• Under normal conditions the mother’s weight
increases by 20 per cent during pregnancy.
423
Components of weight gain during pregnancy.
•Fetus, placenta, amniotic fluid 4750gms

•Uterus and breasts 1300gms
•Blood 1250gms
•Water 1200gms
•Fat 4000gms
Total 12500gms
424
Causes for low weight gain during pregnancy
• Low food intake,

• Many women continue to do hard physical
activities like carrying wood and water,
and do other strenuous jobs until
childbirth.
425
Causes for low weight gain during pregnancy
• Many factors cause variation in weight at

birth, but in developing countries the
mothers' health and nutritional status and
her diet during pregnancy are probably
most important. Low birth weight (LBW) is
defined as being below 2.5kg.
426
There are two main reasons for L.B.W:
• Premature or early delivery

• Retarded fetal growth
427
Causes of premature delivery
• � Poor maternal nutrition,

• � High maternal blood pressure
• � Acute infections
• � Hard physical work
• � Multiple pregnancies
• � In many cases the cause is unknown
428
Causes of retarded fetal growth
• Fetus, due to infections such as Rubella

and syphilis
• Placenta, if it is abnormally small or with
blockage
• Mother, maternal nutrition and health
• Anemia
• Acute or chronic infections such as TB
429
NB:
• Mothers are often the key care takers for

the children in the household.
• They have to be healthy and need the
time, the knowledge and the right
environment to carryout their duties.
430
Proper care of children
• Appropriate hygiene and sanitation
• Safe food preparation and storage
• Successful breast feeding and adequate
weaning practice
• Psychosocial care such as attention,
affection and encouragement
• Equitable health services and a healthy
environment,
• Spacing of child birth.
431
Children at risk
• High risk factors which often have

influences on a child's nutritional states
are the followings:
• � Low birth weight
• � Twins or multiple births
• � Many children in the family
• � Short intervals between births
• � Poor growth in early life
432
Children at risk
• High risk factors which often have

influences on a child's nutritional states
are the followings:
• Early stopping of breast milk < 6 moths
• Introduction of complementary feeding
either too early or too late
• Many episodes of infections
• Illiterate mothers,
433
Children at risk
High risk factors which often have influences

on a child's nutritional states are the
followings:
•Resources scarcity,
•Recent migration of mother to the area,
•Children with single parent.
434
435
Unit: Three
Assessment of nutritional status
• Nutritional assessment is the process of
estimating the nutritional position of an
individual or groups, at a given point in
time, by using proxy measurement of
nutritional adequacy.
• It provides an indication of the adequacy
of the balance between dietary intake and
metabolic requirement.
436
Uses of Nutritional Assessment
• It should aim at discovering facts to guide

actions intended to improve nutrition and
health.
437
Diagnostic tool; (individual and group)
• Does a problem exist – identify

• Type of problems
• Magnitude of the problem
• Who are affected by the problem
438
Monitoring tool (individuals and group)
• Requires repeated assessment over time

• Has the situation changed?
• Direction and magnitude of change
439
Evaluation tool (individual or group).
• To what extent has the intervention,

treatment, or programme had the intended
effect (impact)
440
Anthropometrics assessment
• It is the measurement of the variation of

physical dimensions and the gross
composition of the human body at
different age levels and degrees of
nutrition.
441
Anthropometrics assessment of growth
Common measurements include;

•– Stature (height)
•– Body weight
•– Skin fold
•– Mid Upper Arm Circumference (MUAC)
442
Indices derived from growth measurements;
• – Weight-for-height,
• – Height-for-age,
• – Body Mass Index (BMI) = Weight in Kg
divided by Height in metre square that is
Wt/(Ht)2
443
The Waterlow Classification
• Waterlow pointed out two different types of
deficit: a deficit in WEIGHT-FOR-HEIGHT
(wasting) and a deficit in HEIGHT-FOR-AGE
('stunting').
• 1. Waterlow has suggested classification
based on wasting (current malnutrition) or
stunting (chronic malnutrition)
• WFH = 80% of the Reference standard or
• –2.5D below the median
• HFA = 90% or – 2.5D below the median 444
Table: 8. Waterlow classification
Weight
Above Below
Above Normal Acute malnutrition
Height
Below Nutritional Chronic

Dwarfism Malnutrition
445
Identification malnutrition superficially
• Changes in the superficial tissues or in

organs near the surface of the body, which
are readily seen or felt upon examination.
These include
• changes in:
• – Eyes
• – Skin
• – Hair
• – Thyroid gland 446
Common indicators
• � Edema
• � Dyspigmentation of the hair
• � Angular Stomatits
• � Corneal lesions
• � Swelling (enlargement) of glands
447
Nutritional Surveillance
• Nutritional surveillance: is defined as the

measurement of the frequency and
distribution of nutrition related diseases or
problems using regularly collected and
available information.
• It comprises the compelling and analysis
of nutrition information for decision making
• relative to national or regional polices or
programme planning.
449
Nutritional Surveillance
•Nutritional surveillance could be concerned

with everything that affects nutrition, from
food production, distribution, and intake to
health status itself.
450
Objectives of nutritional surveillance
• To provide information so that decision

can be more favorable to nutrition
• To increase the allocation of resources to
improve the nutrition of the malnourished
in drought and famine condition.
451
Potential users of Nutritional Surveillance
Information (N.S.I)
• � Ministry of health
• � Ministry of agriculture,
• � Government and nongovernmental
organizations.
452
Nutritional outcome indicators
• Prevalence of malnutrition among preschool

children (<80% WFH)
• Prevalence of birth weight infants (<2.5kg)
• Prevalence of stunting in school entrants
(<90% HFA)
• Estimate of infant and/or child mortality rate.
• Quality of housing
• Water supply
• Sanitation and literacy rate.
453
Unit: Four
Nutrition throughout the
Life-cycle
Course: Public Health Nutrition
Lecturer: Saad Ahmed Abdiwali(MPH)
Aim of this Unit
 Describe importance of proper nutrition

throughout the lifecycle,
Learning Objectives
By the end of this unit, the students should

be able to;
 Discuss nutrition issues at different life

stages,
 Understand intergenerational link of

malnutrition,
Introduction
 Nutrition challenges continue throughout the

life cycle,
 Poor nutrition often starts in utero
 extends into adolescent and adult life, (girls and
women)
 Spans generations
 Undernutrition during childhood,
adolescence, and pregnancy,
 additive negative impact on birth weight of infants
Intrauterine (foetal) Life
 Low birth weight infants,

 Intrauterine growth retardation (IUGR),
 High risk of neonatal or infant mortality,
 Less likely to catch-up significantly,
 High risk of developmental deficits,
 More likely to be underweight or stunted,
 Consequences extend into adulthood,
 “foetal origins of disease hypothesis”
Figure 1. Nutrition throughout the Lifecycle
Infancy and Childhood
 Frequent, prolonged infections,

 Inadequate intake of nutrients
 Energy, protein, vitamin A, zinc, iron
 Exacerbate effect of fetal growth retardation,
 Most growth faltering, resulting in stunting

and underweight, occurs during first two
years of age,
Child Malnutrition by Age Group,
Ethiopia DHS 2006.
75
50
Stunting
Underweight
25
0
0 12 24 36 48 60
Age (months)
 Undernutrition in early childhood has serious
consequences;
 More severe illness (diarrhea, pneumonia, etc.)
 Strong exponential association between severity
of underweight and mortality,
 54% of 11.6million child deaths in 1995 in

developing countries associated with underweight,
 Most deaths attributable to mild-moderate
undernutrition,
Causes of Death among Ethiopian
Children 0-5 Years Old
Other 2%
Measles 4%
AIDS 1%
Neonatal 25%
Diarrhea 20%
Malnutrition
53%
Malaria 20%
Pneumonia
28%
22
School-age Children
 Health-nutrition received attention recently,
 Assumed to have passed critical stage, and
no longer vulnerable ?
 Little data on health-nutrition (school children)
 Many infections affecting preschool children
persist into the school years,
 Malnutrition widespread in school children,
 Adversely affect
 school attendance,
 performance, learning
 Determinants of physical growth
 Environmental + genetic factors
 Poor food consumption pattern,
 Illness,
 Lack of sanitation,
 Poor health and hygienic practices,
 Potential for catch-up growth among stunted
children is limited after age two,
 Particularly when children remain in poor environment,
 Stunting at age two years associated with later
deficits in cognitive ability, regardless of catch-up,
 School feeding (breakfast, lunch)
 Improves school performance (hunger alleviation),
 Malnourished children benefited most,
 Cost-effective interventions
 Mass application of antihelminthics,
 Micronutrient supplementation (iron, iodine),
 Treatment of injuries and routine health problems,
 Enormous educational and economic gains,

 Achieved from improving health and nutrition of children
Adolescent Nutrition
 Transition between childhood-adulthood,
 Accelerated growth in height (hormonal changes)
 Second period of rapid growth
 Window of opportunity for compensating for early childhood
growth failure,
 Limited potential for significant catch up,
 Effects of early childhood undernutrition on cognitive
development and behavior may not be fully redressed,
 Stunted girl most likely to become a stunted adolescent

and later a stunted woman => LBW
 Better nourished girls have higher premenstrual
growth velocities and reach menarche earlier,
 Malnourished girls grow slowly but for longer,

menarche is delayed,
 May not finish growing before their first pregnancy,
 Growing adolescents give birth to smaller baby,
 Poor placental function,
 Competition for nutrients
 Adolescent pregnancies;
 High risk of maternal and infant mortality,
 Preterm delivery
 Less likely to use antenatal and obstetric services
 Maternal mortality ratios for 15-19 year olds

twice as high as those 20-24 year olds
(Bangladesh)
Adult undernutrition
 Economic livelihood of populations depends on
health and nutrition of adults,
 Continuous gradient in working capacity and
productivity, linked to body weight,
 Progressive increase in mortality and morbidity

 individuals with a BMI<18.5 (dev’g countries)
 Higher mortality rates among Nigerian adults with
CED;
 Mild 40%, moderate 140%, severe 150% greater
 Women’s health and nutrition
 Productivity and quality of women’s life,
 Survival and development of children
 Nutrition policy and interventions

 Aimed at reducing young child malnutrition
 Pregnant or lactating women
 Target but not intended beneficiary
 Nutrition interventions in pregnancy and early
childhood,
 improvements in body size and composition in adolescents
and young adults,
 Improvements in physical and intellectual performance
 Investing in maternal and childhood nutrition,

 Short- and long-term benefits (economic, social),
 Reduced health care costs through the lifecycle,
 Increased educability and intellectual capacity,
 Increased adult productivity,
Intrauterine Growth Retardation
 Foetal growth constrained by inadequate

nutritional environment in utero,
 Newborn that has not attained its growth
potential,
 Difficult to determine gestational age in
developing countries,
 Low birth weight (<2500) often used as a
proxy for intrauterine growth retardation
(IUGR)
 Three types of IUGR
 Group 1:
 Born after 37 weeks of gestation and weight less
than 2,500 g at birth,
 Group 2:
 Newborns are preterm and weigh less than the
10th percentile at birth,
 Group 3:
 Weigh less than the 10th percentile, but have a
birth weight greater than 2,500 g.
Figure 2. Different types of IUGR
Epidemiology of IUGR
 In 2000, an estimated 11.0% f newborns in

developing countries, or 11.7 million infants,
have low birth weight at term,
 In Asia, 20.9% of newborns are affected, and

sub-region accounts for 80% of all affected
newborns worldwide,
 IUGR affects more newborns than who have
low birth weight; about 24% or 30 million
newborns per year in developing countries,
 Major global human development problem

with profound short- and long-term
consequences for individuals, communities,
and whole populations,
Causes of IUGR
 Developing countries, mainly nutritional;

 Inadequate maternal nutritional status before
conception,
 Short maternal stature,
 undernutrition and infection in childhood,
 Poor maternal nutrition during pregnancy,
 low gestational weight gain (inadequate dietary intake)
 Infections, diarrheal diseases, intestinal
parasitosis, respiratory infections, malaria, etc.
 Cigarette smoking
 Underlying and basic causes
 Care of women,
 Access to and quality of health services,
 Environmental hygiene and sanitation,
 Household food security,
 Educational status,
 Poverty,
 Industrialized countries,
 Cigarette smoking is the most important
determinant of IUGR,
 Low gestational weight gain,
 Low pre-pregnancy body mass index
 Pre-eclampsia, short stature, genetic factors,
alcohol and drug use during pregnancy,
 Established etiological roles, but quantitatively less
important
 Etiologic role of micronutrieints
 Remain to be clarified;
 RCT required to define possible effects of folate,
iron, calcium, vitamins D and A, magnesium, and
zinc, especially in developing countries,
 Use of multiple vitamin and mineral supplements
by women in developing countries is an important
strategy to improve micronutrient status and
benefit women’s health, pregnancy outcome, and
child health,
Consequences of IUGR
 Risk of neonatal death for term infants weighing
2,000-2,500 g at birth is four times higher than for
infants weighing 2,500-3,000 g, and ten times higher
than for infants weighting 3,000-3,500 g,
 In developing countries with a high prevalence of
low weight at birth, IUGR infants account for the
majority of neonatal deaths,
 Risk of mortality due to IUGR extends beyond
neonatal period,
 Increased risk of morbidity due to diarrhea, ARI,
Long term consequences of IUGR
 Less likely to catch-up during first two years

of life,
 Neurodevelopmental outcomes;
 Neurological dysfunction associated with
 Attention deficit, hyperactivity, clumsiness, poor school
performance,
 Cognitive development and behavior,
 Deficit in cognition
 Impaired immune function,
 Related to extent of foetal growth retardation
Barker’s foetal origins of disease
hypethesis
 Evidence of association between retarded

foetal growth & chronic diseases in adult life;
 Blood pressure,
 Noninsulindependent diabetes,
 Coronary heart disease,
 Cancer
Barker’s foetal origins of disease
hypethesis, …. Cont’d
 Adult consequences of early undernutrition

may be accelerated by the nutrition transition;
 Shifts in dietary patterns and lifestyle related to

urbanization and rapid economic development,
 Life-cycle approach
 Analysis of nutrition problems,
 Choice of interventions
 Emphasis on
 nutritional status, unlike disease, as cumulative over
time and not an isolated incident,
 Centrality of nutrition in maintaining women’s health
 Birth weight is a critical indicator of lifecycle
of malnutrition (maternal-child-adult),
 The life cycle provides a strong framework for

discussing the challenges facing human
nutrition
Nutrition of Older People
 World population is aging;

 1950: 200 million people over 60 years,
 2025: 1.2 billion, 70% live in dev’ng countries,
 Demographic transition in 20th century
 High birth and death rates to low fertility and mortality
 Majority of poor older people in developing

countries enter old age after a lifetime of poverty
and deprivation, poor access to health care, a diet
usually inadequate in quality and quantity
 Poverty, lack of pension, death of younger
adults from AIDS, and rural to urban
migration of younger people compel older
people to continue working,
 Adequate nutrition, healthy ageing, and

ability to function independently are essential
components of a good quality of life,
 Conventional BMI cut-offs for defining CED
may not be appropriate for older people
above 70 years,
 Age related changes in body composition,
 Practical problems in obtaining accurate height
measurements, (curvature of spine)
 Nutritional status in elderly related to;
 functional ability,
 Psychomotor speed and coordination,
 Mobility,
 Ability to carry out activities of daily living
 Research needed on elderly;
 Magnitude of malnutrition (+ micronutrient status),
 Refine techniques of anthropometric methods,
 Nutrient requirements,
 Age related changes leading to reduced/altered intake,
 Physiological changes in sense of taste,
 Poor appetite associated with loneliness, social
isolation, depression, medications,
 Physical factors such as absent or ill-fitting dentures,
 limited ability to procure or prepare food,
 chronic diseases,
Unit: Five
Nutritional problems of Public
Health importance
Overview of micronutrient
deficiency disorders and
clinical signs
Objectives
 Overview of major micronutrient deficiencies
• Iron
• Iodine
• Vitamin A
• Zinc
 Clinical features
 Biochemical assessment
 Treatment
 Micronutrient deficiencies in emergencies
What is Malnutrition?
 Malnutrition = “lack of nutrients / poor nutrition”
 Two principle constituents:

• Protein-energy malnutrition
• Deficiency in micronutrients
Zinc Vitamin D Cobalt
Iodine Thiamin Riboflavin
Vitamin B6 Vitamin E Magnesium
Manganese Iron Seleniu
Folate Vitamin B12 m
Niacin
Vitamin A Phosphorus Vitamin K
Vitamin C Cobalamin Chromium
Micronutrient deficiencies are common throughout the world

including in most emergency-affected populations….
Overview of Micronutrient Deficiencies
• Common when dependent on relief food

• Preventable, BUT
– Food sources not common and are expensive
– Fortification adds to cost of relief food
• Difficult to recognize
– Symptomatic cases often represent tip of iceberg
– Laboratory assessment difficult & expensive
• Lack of 1 micronutrient typically associated with deficiencies of other
micronutrients
• Highest risk groups
– Young children
– Pregnant Women
– Lactating women
4 Major Micronutrient Deficiencies
• Iron  Anemia
• Iodine  Iodine Deficiency
Disorders (IDD)
• Vitamin A  Xeropthalmia
• Zinc  Multiple disorders
Anemia
• Most common global nutrition problem

• Common causes of anemia
– Iron deficiency anemia (IDA)
– Infections (malaria, hookworm, HIV)
– Other vitamin deficiencies
– Hemoglobinopathies
• Health impact
– Perinatal & maternal mortality
– Delayed child development
– Reduced work capacity
Anemia- Risk Factors
•Low dietary intakes

• Diet poor in iron-rich
foods/animal foods
• High intake of inhibitors (Tea)
• Infections (malaria, helminthes

infection, schistosomiasis)
• Blood loss
Anemia- Signs & Symptoms
• Tiredness and
fatigue
• Headache and
breathlessness
• Pallor: pale
conjunctivae,
palms, tongue, lips
and skin
Anemia- Assessment
• Blood can be tested for anaemia using different methods which
look at the colour of the blood, the number of blood cells, or use
a chemical which reacts with the haemoglobin.
– Hemoglogin (Hemocue)
– Hematocrit
• Defined by WHO as:
– Hb <11.0 g/dL – children
– Hb <12.0 g/dL – women
– Hb <12.0 g/dL - Men
Indicators of Iron Status
Lab
Price, Complexity of Test

• Soluble transferrin receptor (sTfR)
• Ferritin (FER)
• Iron (Fe) and total iron binding capacity (TIBC)
• Zinc protoporphyrin (ZP)
• Hemoglobin (Hb) Field

Anemia- Treatment
• Dietary diversification
– Foods that are rich in iron include:
• Meat
• Fortified cereals
• Spinach
• Cashew nuts
• Lentils and beans
• Fortification
• Iron supplements
Iodine Deficiency Disorders (IDD)
• Significant cause of preventable brain damage in children
• Health effects:
– Increased perinatal mortality
– Mental retardation
– Growth retardation
• Preventable by consumption of adequately iodized salt
Iodine Deficiency Affects
the Brain
Cretinism
Goiter
Reduced
intellectual
performance
*Goiter manifests only a small portion of IDD

IDD- Risk Factors
• Low iodine level in food
– products grown on iodine-poor soil
– erosion, floods
– mountainous areas
– distance from sea (low fish intake)
• Non-availability of iodized food (salt)

IDD- Assessment

• Measure urinary iodine excretion (UIE)
• Measure levels of thyroid hormones in blood
• Measure degree of goitre
Grade 0 No Goitre
Grade 1 Palpable Goitre
Grade 2 Visible Goitre

Salt Iodine Measurement
Titration Lab
Price, Complexity of Test

Gold standard
WYD Iodine Checker

Single wavelength (585 nm) spectrophotometer
Measures iodine level (ppm) in salt based on the
absorption of the iodine-starch blue compound
Rapid Kit
Qualitatively measures iodine content in salt
Highly sensitive but not specific
Field
Inexpensive
Vitamin A Deficiency (VAD)
 Leading cause of preventable blindness among pre-school

children
 Also affects school age children and pregnant women
 Weakens the immune system and increases clinical

severity and mortality risk from measles and diarrhoea
 Supplementation with vitamin A capsules can reduce child

mortality by 23%.
 WHO (2002) estimates that 21% of all children suffer from

VAD, mostly in Africa and Asia
VAD- Signs & Symptoms
• Clinical deficiency is defined by:

– night blindness
– Bitot’s spots
– corneal xerosis and/ or ulcerations
– corneal scars caused by xerophthalmia
WHO Classification of Xerophthalmia
1N Night blindness
2B Bitot’s spots
X3 Corneal xerosis
2B X3
X4 Corneal
ulcerations
-Keratomalacia
X5 Corneal scars
- permanent X4 X5
blindness
VAD- Risk Factors
• Low availability of
vitamin A-rich foods
• Lack of breastfeeding
• High rates of infection
(measles, diarrhoea)
• Malnutrition
VAD - Assessment
• Clinical assessment for night blindness
• Biochemical assessment
– Retinol
• Serum analyzed by HPLC
• Cutoff: < 0.7 µmol/L
– Retinol-binding protein (RBP)

• Serum or DBS analyzed by ELISA
• Cutoff: ~ < 0.7 µmol/L
Dried Blood Spots for RBP
• Quick and easy field friendly technique

• Collection through venipuncture or finger stick
• Fasting not necessary
• DBS should completely dry and be protected from humidity
• Storage of DBS at –20oC only for short term, –70oC for long
term
• Shipping of DBS cards on frozen ice packs to the laboratory
Poor Quality DBS
VAD- Treatment
• Supplementation
– Capsules given during immunization days
• Food Forms
– As pre-formed vitamin A in foods from animals
• Liver, fish
– As pro-vitamin A in some plant foods
• red palm oil, carrots, yellow maize
• Fortified blended foods (CSB or WSB)
High dose oral supplements of vitamin
A
• Rapid and targeted
• Highly effective in lowering

mortality in infants and
children in third world
communities
• Highly effective in reducing

complications in measles
• Reduced prevalence of
malaria in children in Papua
New Guinea
Zinc Deficiency
 Zinc essential for the function of many enzymes

and metabolic processes
 Zinc deficiency is common in developing countries
with high mortality
 Zinc commonly the most deficient nutrient in
complementary food mixtures fed to infants during
weaning
 Zinc interventions are among those proposed to
help reduce child deaths globally by 63% (Lancet,
2003)
Zinc Deficiency- Signs & Symptoms
 Hair loss
 Skin lesions
 Diarrhea
 Poor growth
 Acrodermatitis enteropathica
 Death
Zinc Deficiency- Assessment
 No simple, quantitative biochemical test of zinc status

 Serum Zinc
• Can fluctuate as much as 20% in 24-hour period
• Levels decreased during acute infections
• Expensive
 Hair zinc analysis
Zinc Deficiency- Treatment
 Regular zinc supplements can greatly reduce common

infant morbidities in developing countries
• Adjunct treatment of diarrhea
 20mg /day x 10 days
• Pneumonia
• Stunting
 Zinc deficiency commonly coexists with other micronutrient
deficiencies including iron, making single supplements
inappropriate
 Dietary diversification
• Animal protein (oysters, red meat)
Zinc Vitamin D Cobalt
Iodine Thiamin Riboflavin
Vitamin B6 Vitamin E Magnesium
Manganese Iron Seleniu
Folate Vitamin B12 m
Niacin
Vitamin A Phosphorus Vitamin K
Vitamin C Cobalamin Chromium
What do the micronutrients in red have in common?

Micronutrient deficiencies in
emergencies
Deficiencies of:
• Vitamin C  scurvy
• Niacin (vitamin B3)  pellagra
• Thiamin (vitamin B1)  beriberi
…usually associated with situations where

populations are fully dependent on limited
commodities for their food needs.
Vitamin C - Ascorbic Acid
• Humans are among the few species that cannot
synthesize vitamin C and must obtain it from
food
• Manufacture of collagen
– Helps support and protect blood vessels, bones,
joints, organs and muscles
– Protective barrier against infection and disease
– Promotes healing of wounds, fractures and bruises
• Sources
– Citrus fruits, strawberries, kiwifruit, blackcurrants,
papaya, and vegetables
Scurvy – Signs & Symptoms
• Small blood vessels fragile
• Gums reddened and bleed easily
• Teeth loose
• Joint pains
• Dry scaly skin
• lower wound-healing, increased susceptibility
to infections, and defects in bone
development in children
Thiamin – Vitamin B1
• What it does in the body
– energy production and carbohydrate and fatty
acid metabolism
– vital for normal development, growth,
reproduction, healthy skin and hair, blood
production and immune function
• Deficiency due to diets of polished rice
Beri Beri- Signs & Symptoms
• Develop within 12 weeks
• Dry Beriberi  peripheral neuropathy
– Difficulty walking and paralysis of the legs
– Reduced knee jerk and other tendon reflexes, foot and
wrist drop
– Progressive, severe weakness and wasting of muscles
• Wet Beriberi  cardiopathy
– Edema of legs, trunk and face
– Congestive heart failure (cause of death)
Wrist & foot drop: Edema:
Dry Beri Beri Wet Beri Beri
Riboflavin Deficiency
• Deficiency is rare and often occurs with

other B vitamin deficiencies
• Several months for symptoms to occur

– Burning, itching of eyes
– Angular stomatitis
– Cheilosis
• Swelling and shallow ulcerations of lips
– Glossitis
Riboflavin deficiency
Angular stomatitis Glossitis

Niacin – Vitamin B3
• Essential for healthy skin, tongue, digestive
tract tissues, and RBC formation
• Processing of grains removes most of their
niacin content so flour is enriched with the
vitamin
Pellagra – Signs & Symptoms
• ‘three Ds’: diarrhea, dermatitis and dementia
• Reddish skin rash on the face, hands and feet
which becomes rough and dark when exposed
to sunlight (pellagrous dermatosis)
– acute: red, swollen with itching, cracking, burning,
and exudate
– chronic: dry, rough, thickened and scaly with
brown pigmentation
• dementia, tremors, irritability, anxiety,
confusion and depression
Pellagra Dermatitis
Summary
• Major risk factors for micronutrient deficiency
diseases include poor dietary intake, infection,
disease and sanitation
• The 4 major MDD are anemia, iodine

deficiency, vitamin A deficiency, and zinc
deficiency
• Treatment for MDD include dietary

diversification, supplementation, and food
fortification
Unit: Six
Nutrition Intervention
• When there is a nutritional problem in a
community, if the magnitude and the
causes of the problem are known, we will
plan to do intervention.
544
Methods of nutrition intervention
• � Food fortification
• � Food for work
• � Price subsidization
• � Supplementation
• � Family planning
• � Integration of nutrition with health
• � Price policy
545
Mechanisms of nutrition interventions
• There are five principal mechanisms

through which all interventions work.
546
1) Availability of food at local or regional
level. Making the required foods more
available with the respect to place and
time.
547
2) Accessibility to food and availability of
foodstuff at the household level. Making the
required foods more accessible and
available to the households
548
3) Food utilization at household level.
Making better use of available foods. Food
processing such as fermentation, preparing
weaning food.
549
4) Distribution within the household.
•􀂾 Intra household distribution of food
•􀂾 Supplementation
•􀂾 Education
550
5) Physiological utilization
•Health service activities and environmental
sanitation
•Primary health care
•Environmental health
551
Criteria used for successful interventions
• Relevance of the intervention to solve the

problem at hand
• Feasibility
• Integratability
• Effectiveness
• Ease in targeting
• Cost effectiveness
• Ease in evaluation
• Long-term continuation 552
553
Essential Nutrition Actions Approach
• An action oriented approach to nutrition...

• If we use ENA approach to nutrition,
estimated decrease of child mortality is
25%.
• The seven essential actions and the six
contact points should be included in the
curricula of all health science students.
554
There are seven action areas:
1. Promotion of Breastfeeding:
Key messages
• Timely initiation of breastfeeding (1 hour of birth)
• Exclusive breastfeeding until six months
• Breastfeed day and night at least 10 times
• Correct positioning & attachment
• Empty one breast before switching to the other
•Estimated decrease of child mortality is 13% if the
child is optimally breastfed
555
2. Appropriate Complementary Feeding

Key messages:
• Introduce appropriate complementary
foods at 6 months
• Continue breastfeeding until 24 months &
more
556
• Increase the number of feeding with age

• Increase density, quantity and variety with
age
• Responsive feeding
• Ensure good hygiene (use clean water,
food and utensils)
557
3. Feeding of the sick child

Key messages:
• Increase breastfeeding and complementary
feeding during and after illness
• Appropriate Therapeutic Feeding.
558
4. Women's nutrition:
Key messages:
•During pregnancy and lactation Increase
feeding
􀂾Iron/folic Acid Supplementations
􀂾Treatment and prevention of malaria
• De-worming during pregnancy
• Vitamin A Capsule after delivery 559
5. Control of Vitamin A Deficiency:

Estimated decrease of child mortality is 2%
Key messages:
• Promote breastfeeding: source of vitamin A
• Vitamin A rich foods
• Maternal supplementation
• Child supplementation
• Food fortification
560
6. Control of Anemia
Key messages:
• Supplementation of women and children
(IMCI)
• De-worming for pregnant women and
children (Twice/year)
• Malaria control
• Iron rich foods
• Fortifications 561
7. Control of Iodine Deficiency Disorders:

Key messages
•Access and consumption by all families of
iodized salt
How the Essential Nutrition Actions expands
coverage of nutrition support in the health
sector:
562
There are six critical contact points in the lifecycle
1. During Antenatal Care

•• Pregnancy: TT
•• Antenatal visit, Iron/Folic Acid
•• De-worming
•• Maternal diet
•• EBF
•• Risk signs, FP, STI prevention
•• Safe delivery, iodized salt
563
There are six critical contact points
in the lifecycle
2. Delivery;
•• Safe delivery,
•• EBF,
•• Vitamin A, Iron/Folic Acid
•• Diet, FP and STI, Referral
564
in the lifecycle
3. Postnatal and Family Planning:
•• EBF, Diet, Iron/Folic Acid
•• FP, STI prevention
•• Child's vaccination
565
in the lifecycle
4. Immunizations:
•• Vaccination, Vitamin A
•• De-worming
•• Assess and treat infant's anemia
•• FP, STI, Referral
566
in the lifecycle
5. Well child and GMP:
•• Monitor growth
•• Assess and counsel on feeding
•• Iodized salt
•• Check and complete vaccination
•• Vitamin A/de-worming
567
in the lifecycle
6. Sick child:
•• Monitor Growth
•• Assess and treat per IMCI
•• Counsel on feeding
•• Assess and treat for anemia,
•• Check and complete vitamin A
•• Immunization/de-worming
568
Need to integrate ENA into other
health programme
1. a) Child survival EPI+
•b) Community IMCI
•c) Health facilities IMCI
2. a) Reproductive Health
•b) Women's Nutrition
•c) Lactational Amenorrhea Method
569
Need to integrate ENA into other
health programme
3. a) National immunization Days Polio and
Measles
4. a) Nutrition programme positive deviance
community GMP
5. a) Infectious Diseases, Control of Malaria,
Tuberculoses HIV/AIDS (PMTCT)
•How the Essential Nutrition Actions expand
coverage outside the health sector?
570
Need to integrate ENA into other sectors
1. a) Schools, Adolescent nutrition

•b) De-worming
•c) Iron supplementation
•d) School lunch
571
2. a) Agriculture, food diversification

•b) Food security
•c) Women's farmers clubs
•3. a) Emergency women to women support
572
4. a) Sanitation, clean water & sanitation

•b) Public health education
•c) Prevention of diarrhoea, malaria, ARI
•5. a) Micro-credit, income generation
•b) Nutrition education
573
NB:
• The most visible evidence of good
nutrition is a taller, stronger, healthier child
who learns more in school and become
productive, happy adults who participate in
society.
• Malnutrition dose not need to be severe to
pose a threat to survival.
574
NB:
• Worldwide, fewer than 20% of deaths
associated with childhood malnutrition
involve severe malnutrition; more
than 80% involve only mild or
moderate malnutrition.
575
Unit: Seven
Nutrition and Development
Why invest on
nutrition?
576
Nutrition and
Development
Why invest on nutrition?

577
Nutrition in the MDGs
MDG Relevance of nutrition
Eradicate extreme poverty Contributes to human capacity and productivity

and hunger throughout life cycle and across generations
Achieve universal primary Improves readiness to learn and school achievement
education
Promote gender equity and Empowers women more than men
empower women
Reduce child mortality Reduces child mortality (over half attributable to
malnutrition)
Improve maternal health Contributes to maternal health thru many pathways
Addresses gender inequalities in food, care and
health
Combat HIV/AIDS, malaria Slows onset and progression of AIDS
and other diseases Important component of treatment and care
Ensure environmental Highlights importance of local crops for diet diversity
sustainability and quality
Develop a global partnership Brings together many sectors around a common
for development problem 578
Trends in stunting (low height for age) in children < 5 yrs, by region and year
75
50
% stunted
25
0
1980 1990 1995 2000
SS Africa Asia South America

579
4th Report on World Nutrition Situation, ACC/SCN
Rates of stunting in children < 5 years have increased
or remained high in Africa
60
40
%
20
1980 1990 2000
East and Southern West North

580
De Onis et al, 2000 - WHO Global Databank
The number of stunted children is rising
dramatically in Africa
Number of children in millions
60
40
20
0
1980 1990 2000
East and Southern West North Total
581
De Onis et al, 2000 - WHO Global Databank
%
G
10
20
30
40
50
60
0
ab
on
N
am
ib
ia
G
ha
na
Be
ni
n
K
en
C
am ya
er
M oo
n
au
rit
a
Ta n i a
nz
an
ia
E
rit
re
a
M
a
N li
Bu ige
rk ria
in
a
Fa
so
U
M g an
oz
am da
bi
qu
e
C
ha
R d
wa
nd
Et a
hi
op
i
Za a
M m
years, in selected east African countries
47
ad b
ag ia
as
ca
M r
Prevalence of stunting in children under five
al
aw
i
582
The Global conceptual framework for the causes of
malnutrition Reduced educability, lost
Functional
productivity, mortality, morbidity consequences
Nutritional Status Manifestation
Immediate
Diet Health Causes
Household Environ. Health, Underlying

Care of Mother
Food Security Hygiene & Sanitation Causes
and Child
Human, Economic, and Institutional

Resources, manmade & natural calamities
Political and Ideological Structure Basic

Ecological Conditions Causes
Adapted from 583
Potential Resources
UNICEF
Malnutrition: Hidden Problem

Majority (80%)
mild & moderate
UNICEF/94-1173 Pirozzi

Victims not aware
584
Child Malnutrition by Age Group
Percentage
75
50
Stunting
Underweight
25
0
0 12 24 36 48 60
Age (months)
585
Source:: EDHS 2005
What are the developmental
consequences quantitatively?
Current scientific data
Profiles Model
Functional Consequences 586

Assumptions & Data Sources
 Period: 2006-2015

UN Medium Population Projection
 EDHS 2005, National Surveys & MOH

Reports
 Targets: National Micronutrient

Guidelines and National Nutrition
Strategy
587
Four Functional Consequences

Mortality
 Illness
 Intelligence loss

Reduced productivity
588
Malnutrition
and
•
Child Survival
589
Child Mortality (2006-2015)
UNICEF/C-56-19/Murray-Lee
1.3 million child deaths 590
Breastfeeding Practices
100
75 Exclusive Complementary
Breastfeeding Feeding
49 50
% 50
UNICEF/93-COU-0173/Lemoyne
25
0
0-6 months 6-9 months
591
Infant Deaths due to Poor
Breastfeeding Practices
18%
592
Poor Breastfeeding Practices
50,000
infant deaths
UNICEF/93-COU-0173/Lemoyne
every year
593
Vitamin A Deficiency
 Night blindness
 Ulceration of the cornea
 Permanent blindness
594
Children with Vitamin A
Deficiency (VAD)
Permanent blindness
Xerophthalmia
Night blindness
Sub-clinical
Vitamin A deficiency
595
Low Birth Weight
13.5%
• 2006-2015: 0ver 600,000 infant
deaths
596
The Intergenerational
Cycle of Malnutrition
Child growth failure
Low birth Early Low weight and

weight babies pregnancy height in teens
Small adult women
597
ACC/SCN, 1992
Key Actions
to Improve
Maternal Nutrition
598
Control of iodine deficiency
disorders
 Ensure access to
and consumption of
UNICEF/90-058/Goodsmith
salt fortified with iodine
in every household
599
Control of vitamin A
deficiency
 Distribute a
high-dose of
vitamin A within
six weeks after
delivery
600
Control of iron
deficiency anemia

Distribute
iron
supplements
during the
last six
months
601
Improve access to
family planning services
 Delay
first pregnancy,

Increase birth
intervals
602
Increase food intake
 Incr ease food intake
during pr e gnancy &
lactation:

Pr e gnancy (at least 1
additional meal /
200kcal)

lactation (at least
2 additional 603
Decrease energy expenditure
in the mother
UNICEF/93-COU-0931/Ethiopia/Thomas
 Access to labor saving devices 604
Care in emergencies
 • Promote proper
caring practices
UNICEF/90-008/Lemoyne
during emergency
situations

including
HIV/AIDS
605
Integrate food security &
nutrition
•
 Implement food
security activities
along with
LINKAGES Ethiopia
nutritional 
interventions
606
Key Actions to Improve
Child Survival, Growth, and
Development (0-24 Months)
607
Breast Feeding
 Promote
exclusive,
on-demand
breastfeeding
UNICEF/D0192-0060/Johnson
until 6 months
608
Complementary Feeding

Promote
appropriate
feeding
practices
from 6
to 24
months
609
Sick Child Feeding

Promote appropriate child feeding practices
during and after illness
610
Prevention of vitamin A
defciency
 Distribute vitamin
A supplements
to children
6-59 months
611
Improve access to
preventive health
interventions
 Immunization
 Malaria
control( use bed
nets)

Safe water

Sanitation 612
Unit: Eight
Nutrition in emergencies
By
Saad Ahmed Abdiwali
Overview
• Of all the deaths that occur in major humanitarian
emergencies about 33 - 50% are associated with
malnutrition.
• in emergencies, the mortality rate is closely associated
with the severity of malnutrition.
• Malnutrition is already the highest risk factor for
illness and death in Africa.
• Four to five million children die in Africa each year
from malnutrition-related problems 620
Overview…
• These deaths are because of a
combination of factors, such as
• gross poverty
• gross under-development in the form
of
-high illiteracy,
-unclean water, and
-inadequate health facilities
621
Food security
means all people having access at all
times to the food needed for an active and
healthy life.
• Three things are required for overall food
security:
1. Adequate and stable food availability or a
consistent food supply in the affected area.
2. Food access, or the ability of the displaced
population to get to the food and be able to
afford it. 622
3. Bio-utilization
Food security…
 Food insecurity, may exist at any level:
national, community, or household level.
• When a large number of people experience food
insecurity, a food emergency may occur.
• is not common during natural disasters that occur
suddenly
• Decreased rainfall ,,,,,,the early signs of a food
emergency……decline in food supply and an
increase in food prices.
623
Food security…
• The final stage of a food emergency is a

nutritional emergency in which reduced
access to food is associated with actual or
threatened increases in morbidity and death.
624
Food Security in Famine, Drought,
and Conflicts
• A famine is a condition of a population

in which a considerable increase in
deaths is associated with inadequate
food consumption.
• Most famines occur when large
numbers of people in a region, who are
already undernourished, cannot obtain
enough food
625
Causes of famine include
• War, civil conflict, or social upheaval.
• Failure of a harvest due to climatic or other
environmental conditions, such as drought,
flood,
• collapse of the food-distribution network
and/or the marketing system,
• Lack or disruption of an emergency food-
support system that ensures the rural poor
have access to food during shortages
626
consequences of famine
• Physiological — a significant increase in
deaths, which is mainly due to malnutrition.
• Psychological — altered patterns of behavior
• Social — weakened family ties Social bonds

grow weak as people begin to care only for
themselves.
627
drought
• is any unusual, prolonged dry period that is severe
enough to reduce soil moisture and water supplies
below the minimum level necessary for sustaining
plant, animal, and human life.
Effects of drought
• Immediate — occurs due to overtaxing and drying
up of water supplies; this results in loss of crops,
livestock, and other animals and no water for
628
washing, bathing, and drinking
Drought…
• Secondary — occurs due to a depletion of

crops and grazing for livestock
o Causes temporary migration of families to
areas with better grazing for remaining
livestock, or to cities for alternative sources
of income.
629
Conflicts and Complex
Emergencies
conflicts can create famine as well as disrupt famine-
relief operations in the following ways:
 by disrupting the agricultural cycle
 by driving farmers from the land
 by interfering with the marketing processes
 by destroying stores of harvested foods
 by decreasing access to displaced persons

630
Complex emergencies
 may be caused by multiple factors.
e.g., war and drought in Ethiopia then

Refugees and internally displaced persons
(IDP) have a high risk of becoming
malnourished.
631
Malnutrition
A condition in which health is impaired
due to a lack , imbalance, or excessive
intake of one or more nutrients.
For the sake of this presentation
• Malnutrition encompasses a range of
conditions, including acute malnutrition,
chronic malnutrition and micronutrient
deficiencies.
632
The impact of an emergency on nutrition
TRIGGERS
Natural disaster War Political/economic

(flood, drought, earthquake) shock
IMPACT ON POPULATION
Destruction of
Large-scale Breakdown of Loss of property Social
infrastructure
migration essential services and business disruption
(roads, markets
(health, water, (houses, land,
etc.)
sanitation etc.) animals, stock
etc.)
IMPACT ON HOUSEHOLDS
Reduced Residence in Lack of Loss of earnings Families
access to food overcrowded water, and access to split
settlements hygiene, health services
sanitation
IMPACT ON INDIVIDUALS
Malnutrition Disease
DEATH
633
Advances in nutrition in emergencies

Effects of Malnutrition and
Micronutrient Deficiencies
• Through interfering with their normal growth
and development, causing permanent
disability or reducing their ability to work….
Wasting and/or Edema (Acute Malnutrition)

Stunting (Chronic Malnutrition)
Micronutrient Deficiency Disorders
634
Wasting and/or Edema
• Sign of Acute Malnutrition

• Wasting results from rapid weight loss or
failure to gain weight due to inadequate food
intake or disease,
• The risk of death is high among
malnourished children with edema.
• The emotional and social development of
these children may also be affected
635
clinical forms of severe acute malnutrition
Marasmus
Wasting, hunger, old-man appearance
Hunger, old-man appearance
Kwashiorkor
Edema, poor appetite, flaky paint
dermatitis, moon face, sparse,
loose, straight hair, irritable
Marasmic kwashiorkor
Wasting + edema
636
Stunting (Chronic Malnutrition)
• result from long-term nutrition problems that
existed before the emergency.
• Children may look normal but have a low
height for their age.
• Stunting in women increases the risks of
childbirth complications and death of the
mother and the baby.
637
Micronutrient Deficiency
Disorders
• lack of certain vitamins and minerals.
• lead to severe disability or even death.
• They often co-exist with acute malnutrition
• but emerge only during treatment of or
recovery from severe malnutrition
638
micronutrient deficiency disorders can
occur among displaced populations
 Iron deficiency anemia:
 Vitamin A deficiency
 Zinc deficiency
 Niacin deficiency, or pellagra
 Thiamin (vitamin B1) deficiency
 Vitamin C deficiency, or scurvy
 Iodine deficiency
639
Nutritional Assessment in
emergencies
Definition: - Nutritional assessment is an
interpretation of anthropometric, biochemical
(laboratory), clinical and dietary survey data to
tell whether a person/ group of people is well
nourished or malnourished (Over nourished or
under nourished).
640
Anthropometric Assessments
Anthropometry
is the measurement of human growth and
body size to obtain information about an
individual’s health status in terms of his
intake of nutrients and past illness.
641
Anthropometric indicators of
Malnutrition
• Median WFH less than 80% indicates wasting
• Median HFA less than 90% indicates stunting
• Median WFA less than 80% median indicates underweight
• MUAC less than 12.5 cm indicates wasting
• BMI less than 17 indicates wasting in adults
• Malnutrition rate is the proportion of children aged 6 months to
5 years who are below –2 Z-scores or the median 80% of the
reference value.
642
Clinical Assessments
Anthropometric measurements do not
reveal all the signs of nutritional
deficiencies that affect mortality or
productivity.
a. Presence of nutritional oedema
b.Signs of vitamin deficiencies
c. Signs of mineral deficiencies
d.Signs of infectious diseases
643
Food Security Assessments
• Food Security indicators — markets,
food production, livestock, household
assets, employment, food gathering,
sufficiency of food and fuel, food
preparation and consumption,
breastfeeding, endemic micronutrient
deficiencies, etc.
644
Food Security Assessments...
• Public Health indicators — disease
patterns, access to health services and
feeding centres, nutrition education,
environmental risk factors, hygiene
measures, traditional medicinal practices,
etc.
645
Food Security Assessments...
• Social and Care Environment indicators
— especially with respect to vulnerable
populations (such as minority or separated
groups, pregnant women, breastfeeding
mothers), infant and young child feeding
practices, shelter and overcrowding, and
social support systems.
646
NUTRITIONAL SURVEILLANCE
• It is system organized to monitor the food

and nutrition situation of a country or a
region within a country on a continuous and
regular basis.
• Methods
– Active surveillance
– Passive surveillance
– Sentinel Surveillance
647
The Early warning signs(EWS)
This includes data on :
– Crop assessments
– Epidemic diseases
– Nutritional status of vulnerable groups
– livestock conditions
– Impact of precipitation on crops and
livestock
– Market situation
– Magnitude of food shortages and measures
taken for mitigation.
648
Early warning signs(EWS)
Food crises
Production patterns
Market prices
Food stocks(food balance sheets)
Rainfall pattern
649
EWS cont…
Prevalence of malnutrition(PEM)
Wt/age, wt/ht,
BMI
Children’s growth
 Infectious disease rates
Food intake relative to need
650
EWS cont…
Household food security
Employment levels
Market prices
Changes in real income and
purchasing power
Dietary energy supply
651
EWS cont…
Caring capacity
Maternal education
Literacy rates
Maternal employment
Public expenditure
Breast feeding(duration and percentage
652
EWS cont…
Malnutrition-infection complex
Incidence of diarrhea
EPI coverage
availability of clean water
Children’s wt for age
653
EWS cont…
Micronutrient deficiencies
Iron deficiency(rates of anemia
Vitamin A Deficiency (Night blindness) in
children
IDD(goiter, cretinism)
654
Source of data
1. Agricultural data food balance sheet
2. Socio-economic data(marketing, distribution
& storing
3. Food consumption pattern(Antropocultural )
4. ABCD studies
5. Vital and health statistics
655
The TRIPLe A’ CyCLe
• Surveillance should be followed by intervention
action in a cyclic manner
Assessment
of the nutrition
Situation of
A country or
A region
Action based Analysis of the

on analysis cause of nutritional
and available Problems
resources
656
Emergency Nutrition
Intervention
• Direct Intervention
• Indirect Intervention
657
1. General Rations
• This is the distribution of food
commodities in sufficient quantities to
meet a family’s basic nutritional
requirements.
• The general ration usually consists of
– basic foods
– Complementary foods
658
GFD if 1>
• Unusual severe decline in food availability

or affordability
• Coping mechanisms are, or will be,
insufficient
• There is a high prevalence of malnutrition
• The GR should include a nutritionally
balanced combination of cereals, pulses
and edible oil.
659
The daily general ration should include
660
Based on this nutrient composition, the
recommendation in Ethiopia is for the complete
ration/full basket:
661
2. Selective Feeding Programs
• include a combination of a blended food, a

high-energy source and sugar (optional),
which are distributed in addition to the
General Ration
• Blended Foods: Various cereal-based
Corn-Soy Blend, Famix, Faffa and
Unimix.
662
Selective Feeding Programs…
• Two types of selective FP
1. supplementary feeding and
2. therapeutic feeding.
• When the GR being provided is not
adequate, leading to an increase in
malnutrition
1.Targeted
2.Blanket
663
1. supplementary feeding
programme
1.1 Blanket SFP
For vulnerable group(U5,pregnant &
lactating mothers, elderly and those with
chronic disease.
1.2 Targeted SFP
For moderately malnourished group
664
SFP carried out
1. Take Home or Dry Rations

2. On-Site Feeding or Wet Rations
665
Nutrient Composition
666
Nutrient Composition…
667
668
669
670
Aggravating Factors
• poor household food availability and accessibility, GFR
below mean energy requirement
• CMR >1 per 10,000 per day
• epidemic of measles, whooping cough (pertussis), cholera,
shigella and other important communicable diseases
• high prevalence of respiratory or diarrhoeal disases
• high prevalence of HIV/AIDS
• outbreaks of diseases (malaria, etc.)
• low levels of measles vaccination and vitamin A
supplementation
• inadequate safe water supplies and sanitation
• inadequate shelter
• war and conflict, civil strife, migration and displacement 671
2. Therapeutic Feeding Programs
(TFP)
Provide a rehabilitative diet together with
medical Rx for diseases and complications
associated with the presence of SAM.
When to Establish TFP?
• The number of SAM individuals exceeds the

capacity of the local health system/facility OR
• When the prevalence of SAM is > 3%
672
When to close TFP
⇒ Decrease in admissions to TFP over 2
consecutive months AND the number of
inpatients in the TFC/Phase I of TFP is within
the capacity of the local health system
⇒ Prevalence of SAM is following a downward

trend and must be evaluated in the context of
population size and capacity of local health
system
673
When to close TFP…
⇒ Prevalence of GAM is < 10% in presence
of aggravating factors
⇒ Referral facility for TF available

⇒ Presence of targeted SFP for
referral/follow-up of TFP participants
⇒ Under-five mortality rate < 2/10,000/day

674
Therapeutic Feeding Programs
(TFPs)
TFPs may be administered through:
• Therapeutic Feeding Center (TFC)

• Nutrition Rehabilitation Unit (NRU) at a
hospital or health facility
• Community-Based Therapeutic Care
(CTC/OTP) program
675
Other Emergency Interventions
1. Promoting Breastfeeding and Safe Infant
Feeding
2. Nutrition Education
3. Disease Control Measures
676
M&E FOOD AND NUTRITION
PROGRAMS
• Document the effectiveness of the program

in meeting its goals, objectives, and targets
• Monitor the use of the food aid distributed
• Monitor the impact of the program on the

food security status of the target population
677
Indicators for which data should
be collected:
• Monthly attendance
• Proportion of exits – recovery rate, death
rate, defaulter rate, transfer rate
• Mean length of stay
• Average rate of weight gain
678
679
Evaluating Food and Nutrition
Programs
• Evaluating food and nutrition programs is
important because it measures their
effectiveness, identifies lessons for future
preparedness, mitigation, and assistance,
and promotes accountability.
• All programs should be evaluated in terms

of set objectives and agreed standards.
680
681
682
Unit: NINE
Food security
Saad Ahmed Abdiwali, (MPH)
11/21/15 683
Outline
 What is food security?
 Dimensions
 Realities and myths around hunger
11/21/15 684
What is food security?
 Food security describes a situation in

which people do not live in hunger or fear of
starvation.
11/21/15 685
food security
 Food security exists when all people, at all
times, have access to sufficient, safe and
nutritious food to meet their dietary
needs and food preferences for an active
and healthy life (FAO)
 Food security for a household means

access by all members at all times to
enough food for an active, healthy life.
11/21/15 686
Dimensions
Food security includes at a minimum

• the ready availability of nutritionally adequate
and safe foods, and
• an assured ability to acquire acceptable foods in

socially acceptable ways (that is, without
resorting to emergency food supplies,
scavenging, stealing, or other coping strategies).
11/21/15 687
Food sovereignty
is the right of peoples
 to define their own food preferences and agriculture/food
production system;
 to protect and regulate both domestic agricultural production

and trade in order to achieve sustainable development
objectives;
 to determine the extent to which they want to be self-reliant; to

restrict the dumping of products in their markets; and
11/21/15 688
 Rosset (2003) argues that "Food sovereignty goes beyond the
concept of food security… [Food security] means that…
[everyone] must have the certainty of having enough to eat each
day[,] … but says nothing about where that food comes from or
how it is produced."
 Food sovereignty includes support for smallholders and for

collectively owned farms, fisheries, etc., rather than
industrializing these sectors in a minimally regulated global
economy
11/21/15 689
 Food sovereignty” “right of peoples to define their
own food, agriculture, livestock and fisheries systems”,
in contrast to having food largely subject to
international market forces.
 Food sovereignty is the right of peoples to healthy and

culturally appropriate food produced through
ecologically sound and sustainable methods, and their
right to define their own food and agriculture systems.
11/21/15 690
Viewpoint: Hunger is not a myth, but myths
keep us from ending hunger
 World Hunger: 12 Myths, 2nd Edition,

by Frances Moore Lappé, Joseph Collins
and Peter Rosset, with Luis Esparza. )
 Source:
http://www.food first.org /pubs/ backgrdrs/ 1998/ s98v5n3.htm
)
11/21/15 691
Myth 1: Not Enough Food to Go Around
 Reality
 Enough food is available to provide at least
2.15 kg of food per person a day worldwide.
 The problem is that many people are too poor

to buy readily available food.
11/21/15 692
Myth 2: Nature's to Blame for Famine
 Reality
 It's easy to blame nature.
 Food is always available for those who can afford it.

 Human-made forces are making people increasingly
vulnerable to nature's vagaries
 The real culprits are an economy that fails to offer

everyone opportunities, and a society that places
economic efficiency over compassion.
11/21/15 693
Myth 3: Too Many People
 Reality
 Although rapid population growth remains a
serious concern in many countries, nowhere does
population density explain hunger.
 For every Bangladesh, a densely populated and

hungry country, we find a Nigeria, Brazil or Bolivia,
where abundant food resources coexist with hunger
11/21/15 694
Myth 4: The Environment vs. More Food?
Reality
 Efforts to feed the hungry are not causing the
environmental crisis.
 Large corporations are mainly responsible for deforestation-
creating and profiting from developed-country consumer
demand for tropical hardwoods and exotic or out-of-season
food items.
 Most pesticides used in the Third World are applied to
export crops, playing little role in feeding the hungry.
11/21/15 695
Myth 5: The Green Revolution is the Answer
 Reality
 production advances of the Green Revolution
are no myth
 Great production increases were achieved
through the green revolution but hunger has
persisted
 Increasing production alone cannot alleviate
hunger.
 Fails to alter the distribution of economic
power that determines who can buy the
additional food.
11/21/15 696
Myth 6: We Need Large Farms
 Reality
 Small farmers typically achieve at least four to
five times greater output per acre than large-
scale farmers, in part because they work their
land more intensively and use integrated, and
often more sustainable, production systems.
 Secure land tenure is needed, to give farmers
incentives to invest in land improvements, to
rotate crops, or to leave land fallow for the
sake of long-term soil fertility.
11/21/15 697
Myth 7 The Free Market Can End Hunger
 Reality
 The trade promotion formula has proven an
abject failure at alleviating hunger
 Export crop production squeezes out basic
food production
11/21/15 698
Myth 9
Too Hungry to Fight for Their Rights
 Reality
 Bombarded with images of poor people as
weak and hungry, we lose sight of the
obvious: for those with few resources, mere
survival requires tremendous effort
 If the poor were truly passive, few of them

could even survive.
11/21/15 699
Myth 10 More U.S. Aid Will Help the Hungry
 Reality
 Foreign aid can only reinforce, not change, the
status quo.
 Our aid is used to impose free trade and free
market policies, to promote exports at the
expense of food production
11/21/15 700
Myth 11 -We Benefit From Their Poverty
 Reality
 Low wages-both abroad and in inner cities at
home-may mean cheaper bananas, shirts,
computers and fast food for most Americans
 Enforced poverty in the Third World
jeopardizes U.S. jobs, wages and working
conditions as corporations seek cheaper labor
abroad.
11/21/15 701
Myth 12: Curtail Freedom to End Hunger?
 Reality
 we see no correlation between hunger and
civil liberty ??
 freedom taken as the right to unlimited
accumulation of wealth-producing property
and the right to use that property however
one sees fit-is in fundamental conflict with
ending hunger
11/21/15 702
Steps proved to be most effective at achieving
food security? seven pro-poor action areas
1. Investing in Human Resources

2. Improving Access to Productive Resources and
Remunerative Employment
3. Improving Markets, Infrastructure, and Institutions
4. Expanding Appropriate Research, Knowledge, and
Technology
5. Improving Natural Resource Management
6. Good Governance
7. Pro-poor National and International Trade and
Macroeconomic Policies
11/21/15 703
Unit: TEN
Infant and young child feeding
in emergencies situation
By
SAAD AHMED ABDIWALI
704
“Breast feeding is the most precious gift
a mother can give her infant. When there
is illness or malnutrition, it may be life
saving gift; when there is poverty, it may
be the only gift.” Ruth Lawrence, MD
705
PRACTICAL STEPS
on how to ensure appropriate infant and
young child feeding in emergencies.
1. Endorse or Develop Policies
• Each agency should, at central level, endorse or develop a
policy
• Policies should be widely disseminated and procedures at all
levels adapted accordingly.
2. Train Staff.
• ensure basic orientation for all relevant staff (at national and
international level) to support appropriate IYCF
• health and nutrition program staff and
• Specific expertise on breastfeeding counseling and support will
require technical training
706
Cont…
3. Co-ordinate Operations
an agency or group of agencies should responsible for:
• Policy co-ordination:
• Intersect oral co-ordination:
• Development of an action plan for the emergency operation
• Dissemination of the policy and action plan to operational
and non-operational agencies including donors
4. Assess and Monitor
 determine the priorities for action and response
 Obtain key information through RA & by informed observation
and discussion includes :
• Demographic profile: women, infants and young children,
pregnant women, un accompanied children
• predominant feeding practices
707
Cont…
5. Protect, Promote and Support Optimal IYCF with
Integrated Multi-Sectoral Interventions
• Ensure demographic breakdown at registration of children under five
with specific age categories:
0-<12months, 12-<24 months, 24-59 months to identify the size of
potential beneficiary groups
• Establish registration of new-borns within two weeks of delivery to
ensure timely access to additional household ration entitlement
6. Minimizes the Risks of Artificial Feeding as much as
possible.
• Procurement, management, distribution, targeting and use of breast
milk substitutes, other milks, bottles and teats should be strictly
controlled and comply with the International Code.
708
Introduction
• In emergencies, children under five are more
likely to become ill and die from malnutrition
and disease than anyone else.
• In general, the younger they are, the more
vulnerable they are.
• Inappropriate feeding increases their risks.
• Malnutrition during the early years of life has
a negative impact on cognitive, motor-skill,
physical, social and emotional development.
709
Risks of death highest for the youngest
Around the world, in non-emergency situations
• two thirds of under-five deaths occur during
the first 12 months of life.
• Whether this proportion changes in an
emergency depends in part on how infants
are fed.
• up to 10%of the malnourished children
admitted were under six months old, most
deaths were among younger children.
710
Increased illness (morbidity)
 Lack of food, adequate water and shelter,
 overcrowding,
 inadequate sanitation,
 separation of parents and children, and
 trauma
are characteristic of emergencies.
Many of these increase child illness
711
Risks of death higher for
malnourished children
• Malnourished infants are much more likely to
die than are well-nourished infants.
• An underweight child who falls ill is much
more likely to die.
• Anemia and other micronutrient deficiencies
make children even more vulnerable.
• Low birth weight due to malnutrition of
pregnant mothers also is associated with
higher infant mortality
712
10.5 million deaths among children under 5
years old in all developing countries, 1999
• About 51% of deaths of children under five years
old are due to pneumonia, diarrhoea, measles
and malaria.
• over half of the deaths, about 54%, are
connected with underlying malnutrition.
• For that reason, a major part of both prevention
and treatment is to improve infant and young
child feeding as well as maternal nutrition.
713
714
Breast feeding protects infants in famine
• In the early 1980s, several years of drought
and crop failures triggered famine in the
Darfur region of Sudan during 1984-85.
• A survey in eight villages showed deaths
were closely related to age.
• Children of one to four years were six times
as likely to die as adults.
• But they were also three times as likely to die
as the infants under one year, a difference
that might be correlated with the almost
universal breastfeeding.
715
Recommendations
There is consensus on recommendations for
the best, the optimal infant feeding for
ordinary conditions. These are not changed
for emergencies.
 Start breast feeding within one hour of birth.
 Breast feed exclusively for six months.
 From six months,add adequate
complementary foods.
 Continue breastfeeding up to two years or
beyond.
716
Infant feeding
• Breastfeeding is the best way to feed an infant
• It the best quality food for infants, in emergencies or
non-emergencies
• BF has many Advantages to infant, mother & society
These include health, nutritional, immunologic,
developmental, psychological, social, economic, and
environmental benefits.
• Substitutes are inferior to breast milk
• The infant under six months benefits most from
exclusive breastfeeding.
717
Protection by BF is greatest for the youngest
infants even in non-emergency settings
• Not to breastfeed increases the risk of dying
by six times in infants less than two months
old, and
• even between 9 and 11 months the risk is
increased by 40%.
• Breastfeeding continues to provide the best
quality of food during the second year, and to
reduce the impact of illness.
718
Challenges to infant feeding in
emergencies
• In both ordinary life and emergencies, women
may sometimes have difficulties with
breastfeeding.
• These may have physical or social causes, or
simply be due to lack of confidence.
• These difficulties can in most cases be prevented
and overcome.
• If alternatives are unavoidable, it is important to
reduce the risks of using them as much as
possible.
719
Common concerns about BF
 “Malnourished mothers cannot breastfeed.”
 “The mother thinks she is not producing
enough milk to feed her baby.”
 “Stress prevents mothers from producing
milk.”
 “The mothers may have HIV and transmit it
through breastfeeding.”
720
Main tasks to do:
• Gives accurate information to correct

misconceptions & answer questions
• Builds the mother’s confidence
• Makes sure that the mother is supported
721
Alternatives to breast milk
and their problems
For use of alternatives to mother’s milk
 wet-nursing
 milk banks
 infant formula
 animal milk
 powdered full cream milk
If artificial feeding is given, use of feeding
bottles should be avoided.Cup feeding is
possible from birth and a safer option.
722
For use of alternatives to mother’s milk
 Mother has died or is unavoidably
absent.
 Mother is very ill.
 Mother is relactating.
 Mother tests HIV positive and chooses
to use a breast milk substitute.
 Mother rejects infant.
 Infant dependent on artificial feeding
723
Problems in artificial feeding in emergency
• lack of water
• poor sanitation
• inadequate cooking utensils
• shortage of fuel
• daily survival activities take more time and
energy
• uncertain, unsustainable supplies of breast
milk substitutes
• lack of knowledge on preparation and use of
artificial feeding
724
Conditions to reduce dangers of
artificial feeding
􀂾 Infant formula with directions in users’
language
􀂾Alternatively, ingredients and knowledge
for home-prepared formula
􀂾 Supply of breast milk substitutes until at
least six months or until relactation
achieved.
􀂾 Milk and other ingredients used within
expiry date
725
Additional requirements
• Easily cleaned cups, and soap for cleaning them
• A clean surface and safe storage for home
preparation
• Means of measuring water and milk powder (not
a feeding bottle)
• Adequate fuel and water
• Home visits to lessen difficulties preparing feeds
• Follow-up with extra health care and supportive
counseling
• Monitoring and correction of spillover
726
Some important points from International Code of
Marketing of Breast milk Substitutes
 no advertising or promotion to the public

 no free samples to mothers or families
 no donation of free supplies to the health care
system
 health care system obtains breast milk
substitutes through normal procurement
channels, not through free or subsidized
supplies
 labels in appropriate language, with specified
information and warnings
727
Thank you!
728
References:
1. Interagency working group on Infant and young child feeding in emergency.
Operational Guidance for emergency Relief staff and programe manager:
Nov.2001.
2. Draft material developed through collaboration of UNCHR, UNICEF, LINKAGES,

IBFAN, ENN and additional contributors, Module 1 for emergency staff. Manual
for orientation reading and reference: November 2001
3.Graeme A. Clugston. Nutrition for Health and Development World Health:

Organization Geneva, Switzerland
3. Ethiopian nutrition coordination unit of the Early Warning Department of the

Disaster Prevention and preparedness commission. Emergency Nutrition
Intervention Guideline: A. A, Ethiopia. August 2004
4. LINKAGES Project. Recommended Feeding and Dietary Practices to Improve

Infant and Maternal Nutrition: Academy for Educational Development1825
Connecticut Avenue NW Washington, DC 20009, Feb. 1999
729

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GOLLIS UNIVERSITY

DEPARTMENT OF PUBLIC HEALTH

Lecturer: Sa’ad Ahmed Abdiwali

4. Nutrition through the lifecycle

5. Nutritional problems of public health importance

Enable the student acquire theoretical

• Course delivery modalities;

The science of Nutrition:

• Nutrition studies the interaction between the

• Study of food in relation to man, and study of

• Science of food as it relates to optimal health

• Human Nutrition is a scientific discipline,

– Biological actions of essential nutrients

• Public Health Nutrition focuses on issues

• The emphasis is on promoting health and

• A pathological state resulting from a

– Protein−energy malnutrition (PEM),

• are the most common serious nutritional problems

– Fulfills energy needs (macronutrients)

– Provides sufficient amounts of essential

– Reduces risk of disease

– Is safe to consume (low contaminants or

• Malnutrition, is not a simple problem with a

• Multiple and interrelated determinants are

• Causes could be categorized as:

• The interplay between the two most significant

• A malnourished child, whose resistance to

• Children who enter the malnutrition-infection

• Malnutrition lowers the body’s immune-response

Weight loss Disease:

• Infections cause loss of appetite,

• These, in turn, increase the body’s

• Three clusters of underlying causes lead

– is defined as sustainable access to safe

• In rural areas, HHFS may depend on access to land

• In urban areas, where food is largely bought on the

• Other potential sources of food are by exchange, gifts

• HHFS depends on access to food -

– Families should have a health centre within a

– Inadequate care for children and women, the third

• Care is manifested in the ways a child is

• Nutritionally, care encompasses all

• In communities where mothers are

• Among the range of caring behaviors that

– Good caring practices need to be grounded in good

• Protecting children’s health:

– Breastfeeding affords the best early occasion

– Verbal stimulation by caregivers is particularly

– Ill or malnourished children who are in pain

– Adolescent pregnancy is a major risk factor for both

– It is often said that poverty at the family level

– Political, legal and cultural factors at the

• A wide variety of policies and programs can

• Could be seen as short or long-term

• Several short route interventions can improve

• Community-based nutrition and health services

• Facility-based nutrition and health services (health and

• Micronutrient supplements, Micronutrient fortification

• Targeted food aid

• Conditional cash transfers

• Maternal nutrition, knowledge, and care-seeking during

• Infant and young child feeding

• Promoting healthy life styles (increase physical activity;

• To facilitate glucose transport to the

• Milk and milk

Vegetables are poor source of protein.