NUTRITIONAL PROBLEMS

INTRODUCTION

Nutrition is a basic human need and a pre-requisite for a healthy life. A proper diet is essential
from early age of life for growth, development and active life.

Preventing under nutrition has emerged as one of the most critical challenges to India planners
in recent time.

Despite substantial improvement in health and well-being since the country’s independence,
under nutrition remains a silent emergency in India, where almost half of all children under the
age of three are underweight, 52% women, 74%of children are anaemic,30% of newborn with
low birth weight.

PREVALENCE OF UNDER NUTRITION

Prevalence of under nutrition is highest in Madhya Pradesh 55%, Bihar 54%, Orissa 54%,
Uttar Pradesh 52% and Rajasthan 51% while Kerela 37% and Tamil Nadu 27% have lower
rates.

DEFINITION

According to WHO

Nutrition is a critical part of health and development. Better nutrition is related to improved
infant, child and maternal health, stronger immune systems, safer pregnancy and child birth,
lower risk of non-communicable diseases (such as diabetes and cardiovascular disease) and
longevity.

NUTRITIONAL DEFICIENCY DIESEASES

Nutritional deficiency diseases are those diseases which occur when there is absence of
nutrients which are essential for growth and health and another cause for a deficiency disease
may be due to structural or biological imbalance in the individual’s metabolic system.

NUTRIENTS

Nutrients are the constituents in food that must be supplied to the body in suitable amounts,
these includes proteins, fats, carbohydrates, vitamins, minerals and fiber.
DEVELOPMENT OF DEFICIENCY

Body store \ tissue level depletion

Inadequate Intake

Physiological dysfunction

Impaired absorption Clinical signs and symptoms

Morbidity and mortality

FACTORS AFFECTING NUTRITIONAL STATUS

Nutritional problem or malnutrition is a man-made disease having ecology being directly or

indirectly related to humans as discuss below:

(i)Conditional influences

Infectious diseases are important conditioning factors responsible for the malnutrition,
especially in small children. Diarrhea, measles, whooping cough and malaria all contribute to
malnutrition.

(ii)Cultural influences

Lack of food is not only the cause of malnutrition. People choose poor diet when good ones
are available due to cultural influences related to:

Food habits, custom, beliefs, tradition and attitudes:

-Rice is a staple food cereal in eastern and southern state of India and wheat in northern
India.
-Green leafs, rice and fruits are avoided by nursing mothers in Gujrat.
Religion
Religion has a powerful influence on food habits of the people:
-Hindu do not eat beef, Muslim do not eat pork.
-Some Hindu do not eat meat, fish, egg and certain vegetables like onion.
Food feds
Personal like and dislike play an important role in the selection of the foods.
Cooking practices
 Draining away rice water at the end of the cooking, prolonged boiling in open pans,
peeling of vegetables, all affect nutritional value of food.
Child-rearing practices
These vary from region to region and influence the nutrition status of the infant and
children. The examples of this is the curtailment of the infants for breastfeeding,
adoption of bottle feeding & refined foods.
Miscellaneous
In some countries men eats first and women and children are severely affected.
Chronic alcoholism is another factor leading to serious malnutrition.

(iii)Socio Economic factors

Malnutrition is largely the product of poverty, ignorance, illiteracy, inadequate sanitary

conditions, large family size etc. The speed with which the population is growing in many
developing countries is another important factor leading to poverty and thus to malnutrition.

(iv)Heredity and constitution

Some related diseases are genetically determined, examples obesity, diabetes etc.

(v)Biological factors

Communicable and parasitic diseases (such as hookworm, round worm, malaria).

(vi)Environmental Factors

Geographical location, climate, soil, agricultural development and population density play an
important role in determining nutritional status.

For example rickets occurs in those areas where there is less exposure to sun, goiter is endemic
in the foothills of Himalayas. Lathyrism or neurolathyrism is a neurological disease of humans
and domestic animals caused by eating certain legumes of the genus lathyrus.

TYPES OF NUTRITIONAL DISORDERS

Malnutrition has been defined as pathological state resulting from relative or absolute
deficiency or excess of one or more essential nutrients. Malnutrition can result from under
nutrition or from over nutrition. It comprises of four forms:

(i)Under nutrition

This is the condition which results when insufficient food is eaten over an extended period of
time.
(ii)Over Nutrition

This is the pathological state resulting from the consumption of excessive quantity of food over
an extended period of time.

(iii)Imbalance

It is a pathological state resulting from a disproportion among essential nutrients with or

without the absolute deficiency of any nutrients.

(iv)Specific Deficiency

It is a pathological state resulting from a relative or absolute lack of an individual nutrient.

(v)Under Nutrition

It is defined as a pathological state resulting from an absolute or relative deficiency of one or

more essential nutrients. It includes:

(i) PEM

(ii) LBW

(iii) Nutritional Anemia

(iv) Lathyrism

(v) Endemic Goiter

(vi) Endemic Fluorosis

(vii) Xerophthalmia

(viii) Keratomalacia

1) PEM (Protein’s Energy Malnutrition)

It refers to a form of malnutrition where there is inadequate protein and calorie intake.
It is considered as a primarily nutritional problem in India.
It occurs in children in the first five years of life.
It is not only an important cause of childhood mortality and morbidity but also leads to
permanent physical and mental impairments in those who survive.
The incidence in India is 1-2% in preschool population. In India, the incidence is more
common in Maharashtra, Andhra Pradesh and Odisha.

Causes
  Inadequate intake of food in both quality and quantity.
 Infections: Diarrhea, respiratory infections, measles and intestinal worms, which
increase requirements for calories, proteins and other nutrients while decreasing their
absorption and utilization.
 Poor environmental conditions
 Large family size
 Poor maternal health
 Lactation failure
 Delayed supplementary feeding
 Adverse cultural practices relating to child rearing and wearing, such as the use of over
diluted cow’s milk and discarding water from cereals.

Protein energy malnutrition leads to two types of disease.

(a)Kwashiorkor

(b)Marasmus

(a)Kwashiorkor

Kwashiorkor is an acute form of childhood protein energy malnutrition characterized of

edema, irritability, anorexia ulcerative dermatoses and enlarged liver with fatty
infiltrates.
Kwashiorkor is the most common and widespread nutritional disorders in developing
countries. It is a form of malnutrition caused by not getting enough protein in the diet.

(b)Marasmus

Marasmus is a severe form of malnutrition that consists of the chronic wasting away of
fat, muscle and other tissue in the body.
Malnutrition occurs when the body does not get enough protein and calories.
This lack of nutrition can range from a shortage of certain vitamins to complete
starvation.
Marasmus is one of the most serious forms of protein energy malnutrition in the world.

(c)Marasmic Kwashiorkor

A malnutrition disease primarily of children resulting from the deficiency of both

calories and protein. The condition is characterized by severe tissue wasting
dehydration, loss of subcutaneous fat, lethargy and growth retardation.
 Kwashiorkor and Marasmus – A comparative chart

Kwashiorkor Marasmus

(i) Acute illness, infections, measles, (i) Severe prolonged starvation chronic,
Trauma, age, sepsis are some causes. recurring infection.
(ii) Protein is principal nutrient. (ii) Calories and protein are principal
(iii) 8 months to 3 years. nutrients.
(iv) Rapid, acute onset. (iii) 6 months to 2 years.
(v) Some weight loss. (iv) Chronic, slow onset.
(vi) High mortality (v) Severe weight loss.
(vi) Low mortality unless related to
underlying disease condition.

Comparison of clinical features

(i) Edema, pot belly, swollen legs. (i) No edema

(ii) Mild to moderate growth retardation. (ii) Weight loss up to 40%.

(iii) Weight mashed by edema. (iii) Severe growth of failure.

(iv) Muscle wasting sometimes hidden by (iv) Muscle wasting present.

abdomen fat.
(v) Fat wasting severe loss of
(v) Fat wasting often retained. subcutaneous fat.

(vi) Mental changes irritable, moaning (vi) Quiet and apathetic.

apathetic.
(vii) Wrinkled face old man face).
(vii) Round face (moon face)

Gomez Classification

Parameter: Weight for age.

Reference Standard (50th percentile) WHO chart

 If the weight > 90% of the expected weight = no malnutrition.

 1st degree = weight is 75-90% of the expected weight.
  2nd degree = weight is 60-75% of the expected weight.
 3rd degree= weight <60% of the expected weight.

Physical Examination

 Muscular tone, muscle wasting, delayed walking.

 Abdomen - hepatomegaly, oedema.
 CVS – Cardiomegaly, o edema.
 CNS – Apathy, confusion, psychosis, depression.

Developmental Milestones:

 7 months = Shuts mouth, shakes head to refuse foods.

 9 months = Finger feeding.
 10 months = Drinks from cup.
 12 months = Hold spoon unable to get food to mouth.
 15 months = Control spoon + cups.
 18 months = Play with food.

Laboratory test

 Full blood counts.

 Blood glucose profile.
 B tool and urine for parasites and germs.
 Electrolytes, calcium & serum proteins.
 Mantoux test.

Diagnosis of PEM

1) History – including detailed dietary history.

2) Anthropometric measurements.
3) Weight
4) Length/ height
5) Mid upper arm circumference MUAC
6) Chest circumference
7) Head circumference
8) Anthropometric measurements of nutritional status

(i) Weight

At 5-6 months double of birth weight.

At 3years weight 5 times double of birth weight.

At 6years weight 6 times double of birth weight.

(ii) Height At 1year 72-75cm.At 2years 88 – 90cmAt 4years 100cm

(iii) Mid upper arm circumference

Measurement Color Indication

MUAC less than (11cm) Red color Severe Malnutrition

Between(11-12.5cm) Orange Moderate

Between 12.5 – 13.5cm Yellow At risk or mild

Over 13.5 Green Well nourished

Prevention Of Malnutrition

I. Primary Prevention
 Health education to mothers about good nutrition and food hygiene.
 Exclusive breast feeding for months.
 Immunization for infants and children.
 Growth monitoring on growth charts specially of all children under 3 years of age.

II. Secondary Prevention

 Mass screening of high risk populations, using simple tools like weight for age or
MUAC.

III. Tertiary Prevention

 Good nutrition, supplementary feedings.

 Counseling of mother regarding family planning and spacing of birth.

2) Low Birth Weight

Low birth weight has been defined by WHO as weight at birth of < 2500grams.
Causes

(i) Preterm birth

About two thirds of all low birth weight babies are preterm, or born before the 37 weeks of
pregnancy.

(ii) Genetics

Chromosomal abnormalities, along with heart defects can cause IUGR and LBW.

(iii) Gaining less than the recommended amount of weight during pregnancy can result in a
baby born at LBW.

(iv) Substance abuse

During alcohol, smoking, using illicit drugs during pregnancy can inhibit a baby’s growth in
womb leading to low birth weight baby.

(v) Maternal illness/ infection.

Prevention

I. Identification of mother at risk – malnutrition, heavy work load, infection, disease and high
blood pressure.

II. Increasing food intake of mother, supplementary feeding, distribution of iron

and toxic acid tablets.

III. Avoidance of smoking.

IV. Improving sanitation method.

V. Early detection and treatment of medical disorders – diabetes, hypertension.

VI. Controlling infections like UTI, Rubella, malaria, syphilis.

MICRO NUTRIENTS DEFICIENCY

-VITAMIN A

-VITAMIN B

M VITAMINS - -VITAMIN C
I -VITAMIN D
C
R -VITAMIN K
O
-CALCIUM
N
U MAJOR MINERALS - PHOSPHORUS
T
-SODIUM
R
I MINERALS - -POTASSIUM
E
-MAGNESSIUM
N
T TRACE ELEMENTS – IRON
S
-IODINE

-FLUORINE

-ZINC

(1) VITAMIN A DEFICIENCY

 Vitamin A is necessary for good eyesight. In children vitamin A deficiency causes loss
of eye sight. If this deficiency is severe it may lead to permanent blindness. Vitamin A
deficiency symptoms are seen more severely in children of age group 1 to 5 years.
 Nyctalopia (Night Blindness) is one of the first sign of vitamin A deficiency.

(i)Xeropthalmia

The term xeropthalmia means dryness of eye. Development of the condition passes through
various stages that may ultimately lead to irreparable damage.

Clinical Features

 Corneal ulcers
 Softening of cornea
 Keratomalacia
  Bitot spot

Signs Of Vitamin A Deficiency

 Dry skin
 Dry eyes
 Night blindness
 Poor wound healing
 Acne and Breakouts
 Delayed Growth
 Throat and Chest Infection

Recommended Dietary Allowance For Vitamin A

 In infants – 375 microgram/dl

 0 – 3 years – 600mg or 2000IU
 4 – 8 years – 900mg or 3000IU
 9 – 13 years – 1700mg or 5665IU
 14 – 18 years – 2800mg or 9335IU
 19 + years – 3000mg or 10,000IU
 In pregnancy – 1000microgram/dl
 In lactation – 1300microgram/dl

Prevention Of Vitamin A Deficiency

i. Eat foods which are rich in vitamin A. Fish, cod liver oil, milk, butter, carrots, tomato,
green leafy vegetables, papaya, guava, yellow fruits containing carotene and vegetables
such as pumpkin are rich in vitamin A.
ii. Milk, egg, fish oil etc are rich in vitamin A. Leafy vegetables like carrot and fruits like
papaya and mangoes are good sources of vit A.
iii. One spoon of vit A syrup to children of 1 – 5years age group once in 6 months also
prevents vitamin A deficiency to a certain extent.
iv. When the child is given vitamin A syrup once in 6 months up to 5years of age, vitamin
A gets retained in the liver and is available in sufficient quantities till the next dose is
administered.
v. Pregnant women should take nutritious food that contains vitamin A. This helps the
child in the womb to get vitamin A from its mother.

Treatment
Mild to moderate cases of deficiency can be treated by daily oral dose of 10,000IU of fat
soluble vitamin A for 10days. In severe cases, large dose of 50,000 IU is recommended for 01
week.

(2)Vitamin D Deficiency

Vitamin D is a fat-soluble vitamin that plays an important role in calcium homeostasis and
bone metabolism.

(i) Rickets
 Rickets is a condition that affects bone development in children. It causes bone pain,
poor growth and soft, weak bones that can lead to bone deformities.
 Adults can experience a similar condition, which is known as Osteomalacia.
(ii) Causes
A lack of vitamin D or calcium is the most common cause of rickets.

(iii)Clinical Manifestation

 The child tends to be miserable, closer examination will reveal the flabby toneless state
of the muscles that causes a pot - belly.
 The first main feature is a swelling at the growing ends of the long bones. This swelling
may be first found at the wrist, radius is also affected.
 Once a child with rickets begins to stand, walk and become active, they develop new
deformities because of the soft weak character of the bones. The most common
deformity is bow legs, less frequently knock knees are seen. More serious are
deformities of spine.

(iv)Rickety Rosary

 A row of beadlike prominence at the junction of a rib and its cartilage (i.e.enlarged
costochondral joints) resembling a rosary.

(v)Treatment

 The basis of treatment is to provide vitamin D and calcium.

 Vitamin D may be given as cod – liver oil three teaspoon three times a day will supply
about 3000 IU
 Calcium is best given as milk at least half liter a day cow’s milk contains 120mg calcium
per 100L.
 While the child is being treated, the mother should be educated regarding the importance
of sunlight.
  Vitamin D rich foods are as follows:
Fatty fish such as salmon, tuna, and mackerel.
Beef liver, cheese, mushrooms, egg yolks, milk, orange juice, other dairy products such
as yogurt.
 Recommended dietary allowance for vitamin D is 5 – 10 microgram/dl.

Vitamin B Deficiency

Vitamin B are a group of water – soluble vitamins that plays important role in cell metabolism.
Vitamin B supplements are referred to by the specific name of each vitamin(e.g. B1, B2, B3
etc.)

1) Beri Beri
 It is a nervous system ailment caused by a thiamine deficiency (deficiency of Vitamin
B1) in the diet. Thiamine is involved in the breakdown of energy molecules such as
glucose and it is also found on the membranes of neurons.

Prevalence

 Beri – Beri is rare in developing countries because most foods are now vitamins
enriched.

Causes

 Beri – beri is caused by a lack of thiamin (vitamin B1). Thiamin occurs naturally in
unrefined cereals and fresh foods particularly whole grain bread, fresh meat, legumes,
milk, fruit, green vegetables etc. Beri – beri is therefore, common in people whose diet
excludes these types of nutrition.
 Beri –beri may be found in people whose diet consists mainly of polished white rice,
which is very low in thiamin bearing husk has been removed.
 It has been seen in chronic alcoholics. Drinking alcohol heavily can lead to poor
nutrition and excess of it makes it harder for the body to absorb and store thiamin.
 Wernickle – korsakoff syndrome causes alteration in cellular metabolism, results in
blockage of thiamin use which results in thiamin deficiency without any dietary
shortfall.
 Undergoing dialysis and taking high doses of diuretics can raise the risk of beri–beri.

Clinical Manifestation

 Weight loss
 Emotional disturbances
  Impaired sensory perception (wernickle encepahalopathy)
 Pain in the limbs.
 Irregular heart rate.
 Edema.
 Disease may cause heart failure and death.

Types Of Beri – Beri

The main types of Beri – Beri

1) Wet Beri – Beri

2) Dry Beri – beri
3) Infantile beri – beri
1) Wet Beri – Beri
Wet beri – beri affects the cardiovascular system, it is sometimes fatal and causes a
combination of heart failure and weakening of the walls, which causes the peripheral
tissues to become edematous. It is also characterized by:
 Vasodilation leading to increased arteriovenous shunt.
 Peripheral edema
 Awakening at night short of breath.
 Increased heart rate.
 Shortness of breath with activity.
 Swelling of the lower legs.
2) Dry Beri – Beri
Dry beri – beri and wernickle – korsakoff syndrome affect the nervous system. It causes
wasting and partial paralysis resulting from the damaged peripheral nerves. It is also
referred to as neuritis. It is characterized by:
 Difficulty in walking.
 Tingling or loss of feeling (sensation) in hands and feet.
 Loss of muscle function or paralysis of the lower legs.
 Mental confusion/speech difficulties.
 Involuntary eye movement (nystagmus)
 Vomiting
3) Infantile Beri – Beri
This type of beri – beri is commonly found in children in developing countries. Obvious
signs and symptoms are cry loudly and without tears. Untreated, it can prove fatal with
in 24hours.

Signs And Symptoms

  Difficulty breathing
 Enlarged heart
 Pneumonia
 Rapid heart rate
 Swelling in both lower legs
 Confusion, memory loss, delusions and lost sensitivity to vibrations may be witnessed
on late-stage patients.

A Neurological Examination May Show Signs of

 Changes in the gait.

 Coordination problems.
 Decreased reflexes.
 Dropping of the eyelids.

Treatment

Good nutrition is the first line of defense against Beri – beri.

 Thiamin rich diet include sunflower seeds, beans, fish, pork yogurt, seafood, diary
products, meat etc
 Recommended dietary allowance of thiamin is 1.2mg daily for men and 1.1mg for
women, 1.4mg in pregnancy. During pregnancy there is increased risk of deficiency.
 Treatment of acute thiamin deficiency with cardiovascular or neurologic
signs/symptoms.
 200mg intravenous or orally thiamin three times daily until symptoms resolve or
improve.
 10mg/day oral thiamin until expected recovery is complete.
 Acute crisis 50mg administered intramuscular for 2 – 4 days, followed by oral
maintenance therapy.
 Treatment of thiamin deficiency with suspected WKs.
 500mg IV thiamin infused over 30min three times on day 1 and 2 of therapy.
 250mg thiamin IV or intramuscularly on day 3 or 5 of therapy.
II. PELLAGRA
 It is vitamin deficiency disease most commonly caused by a chronic lack of niacin
(vitamin B3) in the diet.
 It can be caused by decreased intake of niacin or tryptophan, and possibly by excessive
intake of leucine.
 Pellagra can be common in people who obtains most of their food energy from maize
(often called ‘corn’) notably rural areas south America where maize is a staple food.
Maize is a poor source of tryptophan as well as niacin.
Clinical Manifestation
Pellagra is classically described by the “four D’s”: - diarrhea, dermatitis, dementia and
death. A more comprehensive list of symptoms includes:
 High sensitivity to sunlight
 Dermatitis, alopecia, edema
 Red skin lesions
 Weakness
 Ataxia, paralysis of extremities
 Peripheral neuritis
 Dilated cardiomyopathy
 Aggression
 Insomnia

Treatment

 Admission to hospital and rest are desirable for serious cases. Milder cases may be
treated as outpatient.
 The patient should be given 50mg of niacin (nicotinic acid) three times a day orally.
 The diet should contain at least 10mg per day of good protein (if possible meat, fish,
milk or eggs, if not ground nuts, beans or legumes) and should be high in energy (3000
to 3500kcal per day).

Prevention

The following steps can help in prevention of pellagra.

 Diversity in the diet is important. Reliance on maize as the sole staple foodstuff should
be discouraged and the consumption of other cereals in place of part of maize should be
encouraged.
 Production and consumption of food known to prevent pellagra, that is those rich in
niacin such as ground nuts and those rich in tryptophan such as eggs, milk, lean meat
and fish should be increased.
 Niacin tablets should be administered as a prophylaxis in prisons and institutions in
areas where pellagra is endemic, and to refugees.
 Nutrition education should be provided to teach people what foods can prevent what
foods can prevent the disease.
 VITAMIN ‘C’

Vitamin ‘C’ is also known as ascorbic acid. Vitamin C helps to protect cells and keeping
them healthy, maintaining healthy skin, blood vessels, bones and cartilage, helping with
wound healing.

Sources Of Vitamin C

Citrus fruit such as oranges and orange juice peppers, strawberries, black currants, broccoli,
Brussels sprouts, potatoes etc.

 Scurvy resulting from a deficiency of vitamin ‘C’.

 Recommended dietary allowance for vitamin C is 40 mg/dl and 80mg/dl in lactation.
 Scurvy leads to the formation of spots on the skin, spongy gums, and bleeding from the
mucous membranes. The spots are more abundant on the thighs and legs and a person
with ailments looks pale, feels depressed and is partially immobilized.
 In advanced scurvy there are open, suppurating wounds and loss of teeth.

Causes

 Scurvy caused by lack of vitamin ‘C’.

 Scurvy rarely present in adults although infants and elderly people are affected in
modern western society.
 Vitamin C is destroyed by the process of pasteurization so, babies fed with ordinary
bottled milk sometimes suffer from scurvy, if they are not provided with adequate
vitamin supplement.
 Virtually all commercially available baby formulas contain added vitamin C for this
reason, but heat and storage destroy vitamin C.
 Human breast milk contains sufficient vitamin C if the mother has an adequate intake.
Clinical Manifestations
The following symptoms & signs may occur
 Tiredness and weakness
 Swollen gums which bleed easily at the base of the teeth
 Hemorrhages in the skin
 Other hemorrhage e.g. nosebleeds, bleed in wine or feces, splinter hemorrhage below the
fingernails
 Delayed healing of wounds
 Anemia
Treatment
 Scurvy is treated with vitamin C rich diet.
  250mg ascorbic acid by month four times a day as well as plenty of fresh fruit and
vegetables rich in vitamin C.
Prevention
 Scurvy can be prevented by a diet that include certain citrus fruit such as orange or
lemons, black currant, guava, kiwi, papaya, tomatoes, cabbage, spinach, carrot, broccoli,
lemon juice and many animal products including liver contain vitamin C.

Vitamin ‘k’

 Vitamin K refers to group of fat – soluble compounds. Vitamin K involved in

coagulation, bone development and cardiovascular health.
 According to the national academy of science food and nutrition board, the dietary
requirements are based on the intake of healthy adults and the adequate intake is 120 and
90 mg/day for men & women respectively.
 Vitamin K deficiency bleeding (vkdb) in newborns can separate in to three categories
based on timing of the presentation.
(i) Early VKDB present within 24hours after birth.
(ii) Classic VKDB present within the first week.
(iii) Late VKDB present between one to twelve week of life.

Etiology

 Vitamin K deficiency occurs in the neo natal period, in hereditary combined vitamin k
dependent clotting factors deficiency (VKDB).
 Inadequate uptake from diet
 Chronic disorder (Gastrointestinal bleeding) (cystic fibrosis)
 Pregnant mother on anticonvulsants.
 Celiac disease.

Vitamin deficiency can contribute to significant bleeding, poor bone development,

osteoporosis and increased risk of cardiovascular disease, easy bruising and excessive bleeding
from wounds, epitasis, hematuria.

Treatment

(i) Prophylaxis in newborns 1mg of vitamin K1 by intramuscular injection within 01 hour of

birth.
(ii)VKDB: 1 to 2 mg vitamin K1 by slow intravenous or subcutaneous infusion. Severe
bleeding may require fresh frozen plasma at a dose of 10 – 15ml/kg.
 Vitamin K deficiency due to malabsorption: Dependent on the disease. Malabsorption
requires daily administration of high doses of oral Vitamin K1 0. 3 to 15mg/day. If oral
dosing is in effective, parental vitamin K1..Vitamin K nutritional deficiency in adults: - At
least 120 and 90 mg/day for men and women respectively by diet or oral
supplementation.

MINERAL DEFICIENCY

1.GOITER

Iodine, a trace-elements found in soil, is essential components of the thyroid hormones

involved in regulating the body metabolic process.

Iodized salt and seafood’s are the major dietary sources of Iodine.

Iodine is essential for synthesis of thyroid hormone.

Deficiency of iodine can lead to Goiter.

EPIDEMOIOLOGY

In India goiter was found to a significant extent in the HIMALAYA GOITER BELT which is
the world biggest goiter belt.

It affects Northern states of Jammu & Kashmir, Himachal Pradesh, Punjab, Haryana, Delhi,
Uttar Pradesh, West Bengal, Manipur, Mizoram, Nagaland.

District GONDA of Uttar Pradesh is highly endemic.

SYMPTOMS

Iodine deficiency causes abnormal enlargement of the thyroid gland, which is situated in neck.
In children, iodine deficiency causes reduced thyroid functioning which results in retarded
physical and mental growth.

IODINE RICH FOODS

Iodine is found in animal protein foods and vegetables, seaweeds(nori,kelp,kombu,wakame),

fish, shellfish , iodized salt, eggs, beef liver, chicken, Dairy (milk , cheese ,yoghurt), fortified
infant formula.

PREVENTION

 Using Iodized table salt to prevent from goiter caused by Iodine Deficiency.
 Regular check-up of thyroid gland function.
 Avoidance of radiation exposure of thyroid gland.
 Adult require 150micrograms per day and Pregnant, breastfeeding women need 200mcg per
day.

DISORDERS OF FLOURINE

 Flourine deficiency can lead to dental caries and possibly Osteoporosis.

 Fluoride is contained in bones and teeth is necessary for the formation and health of bones
and teeth.
 Flouride strengthen Bones.

SOURCE

The main source of fluoride is fluoridated drinking water.

TOXICITY

Excess fluorine can accumulate in teeth and bones, causing Fluorosis. Drinking water
containing >10 ppm is a common cause of this. Permanent teeth that develop during high
fluoride intake are most likely to be affected. The earliest signs are chalky white, irregularly
distributed patches on the surface of enamel, tis patches became yellow or brown stain,
producing mottled appearance. Severe toxicity weakens the Enamel. Treatment involves
reducing fluoride intake. (Example in areas with high fluoride intake water levels patient
should not drink fluoridated water or take fluoride supplement). Children should always be told
not to swallow fluoridated toothpastes.

PREVENTION OF FLOURIDE DEFICIENCY

1)TOOTHPASTE

Toothpaste is one source of fluoride that contains at least 1250ppm (parts per million) of
fluoride.

2)FOOD

Sea food such as crab and oysters and potatoes high in fluoride.

3)DRINK

Some drinks are high in fluoride. Black tea and white wine are good source of fluoride.

4)A dental fluoride application

For history of cavities, dentist apply fluoride directly to teeth in the form of gel, foam or
varnish.

OSTEOPOROSIS

Osteoporosis is a disease of bones that leads to an increased risk of fracture. Osteoporosis

means ‘porous bone’. In Osteoporosis the bone mineral density (BMD) is reduced.
Osteoporosis is most common in women after Menopause.

CAUSES

 Steroids are used to treat various conditions. They can affect the production of bone by
reducing amount of calcium absorbed from gut and increasing calcium loss through
kidney.
 Poor diet, Deficiency of vitamin D or calcium.
 Family history
 Smoking and alcohol reduce ability to make bone.

Signs And Symptoms

 Osteoporosis itself has no specific symptoms. Its main consequence is the increased risk
of bone fractures.
 Typical fragility fractures occur in the vertebral column, ribs, hips and wrist.

Prevention

 Nutrition: Proper nutrition includes a diet sufficient in calcium and vitamin D. Patients at
risk for osteoporosis (e.g.steroid use) are generally treated with vitamin D and calcium
supplements.
 Exercise
 Lifestyle modification.

Nutritional Anemia

Nutritional Anemia is a condition where the hemoglobin content of blood is lower than normal
as a result of a deficiency of one or more nutrients, regardless of the causes of such deficiency.

Age Group Normal (Hemoglobin)

 Adult male  13.5 to 17.5gm/dl
 Adult Female  12.1 to 15.1gm/dl
 Pregnant Women  11 to 12gm/dl
 Children  11 to 16gm/dl
Causes

 Inadequate diet
 Insufficient intake of iron
 Iron malabsorption (e.g.Celiac disease, previous gastric surgery)
 Pregnancy
 Excessive menstrual bleeding
 Hook worm infestation
 Malaria, G1 bleeding, phletotomy, hemolysis.

Clinical Manifestation

 Lethargy
 Fatigue
 Malaise
 Weakness
 Headache
 Anorexia
 Mood swings
 Exercise in tolerance
 Shortness of breath
 Pallor may be evident in sclera and palmar surfaces.
 Iron deficiency in young children increases the risk of development delays and
behavioral disturbances.

Diagnosis

 Laboratory testing
Complete blood count reveals low hematocrit and hemoglobin concentration, serum
ferritin test reflect total body iron stores.
 PBS examination.
 Non – enteric oral supplements are the first line of therapy. Ferrous sulfate is most
commonly used. Recommended dose of iron is 100 to 200mg of elementary iron per
day.
 Dairy products should be avoided because they interfere with the absorption of oral Iron.
 Intake of ascorbic acid increases absorption of iron. For example, a glass of orange juice
contains sufficient vitamin C to significantly increase iron absorption from foods.
 In case of poor absorption, intramuscular and intravenous iron treatments are available.
 Adequate iron intake before pregnancy can help prevent anemia.
  Encourage mother for exclusive breast feeding. Cow milk consumption by infants and
toddlers is associated with iron deficiency. Unfortified infant formula contains about
20% of the iron found in breast milk where as fortified formula has more than twice the
iron concentration.

Over Nutrition

It is defined as a pathological state resulting from an absolute or relative excess of one or more
essential nutrients.

Obesity

 Obesity is common in both males and females and adults and children.
 Obesity is an epidemic disease, which consist of body weight that is in excess of that
appropriate for a person’s height and age standardized to account for differences,
leading to an increased risk to health related problem.

Causes

 When over a prolonged period more energy is ingested in food than is expended by
physical exercise, work and basal metabolism, weight will be gained and obesity result.
 Metabolic studies shows that diet high in fat are more likely to induce body fat
accumulation than diets high in carbohydrates.
 Obesity is rarely due to endocrine dysfunction.
 Obesity is due to an imbalance between energy intake and energy expenditure and
underlying causes are endocrine disorders, genetic factors.
 Obesity is common in children as well as adults. Obese children generally become
overweight adults. Infant who are bottle feed with infant formula are likely to become
obese than the baby who are breastfeed.

Manifestation

 Obesity refers to excess accumulation of body fat or adipose tissue leading to more than
20% of desirable weight.
 Over weight is usually judged on the basis of the weight in relation to height of the
person taking into consideration the person gender and age group.
 Weight for height is calculated by using BMI (Body Mass Index). BMI is calculated as
follows.

BMI = Weight in kg
 Height in (m2)

Criteria Of Obesity Based on BMI

BMI Obesity
20 – 24.g Normal
25 – 29.9 Obesity Grade 1
30 – 40 Obesity Grade 2
Greater than 40 Obesity grade 3

Nutritional Status Indication By BMI

BMI Nutritional Status
<16 Under nourished
16 – 18.5 Possibly undernourished
18.5 – 25 Probably well nourished
25 – 30 Possibly obese
>30 Obese

Obesity And Health Program

 Various health risks are associated with obesity.

 Diabetes
 Hypertension and cardiovascular disease
 Disease of gall bladder
 Arthritis

How To Reduce Weight

 Eat less fried food.

 Eat more fruits and vegetables.
 Eat more fiber rich food items like whole grains, grams and sprouts
 Regular exercise to keep the body weight within normal limit.
 Slow and steady reduction in weight.
 Severe fasting may lead to health hazards. Enjoy a variety of foods needed to balance
your physical activity.
 Eat small and frequent diet.
 Cut down sugar, fatty foods and alcohol.
 Use low fat milk.
 Weight reducing diet must be rich in protein and low carbohydrate and fat.
 Nutrition During Pregnancy

Demand for nutritious diet is high during pregnancy extra food is required to meet the need
of the foetus and the pregnant women.

 Maternal malnutrition leads to high prevalence of low birth weight infants and high
maternal and infant mortality.
 Additional foods are required to improve the birth weight and to increase mother’s body
fat deposits.
 Lactating women need more nutritious food for optimum milk input.
 Dietary requirements of pregnant women.
 Proteins: 1g/kg weight per day plus 10g extra.
 Calories: Additional 300 – 400Kcal
 Fat: 20 – 40mg/day
 Iron: 40mg/day
 Folic acid: 400mg/day
 Diet of pregnant women has a direct influence on the weight of the baby at birth.
 Pregnant women need an additional 300kcal of energy, extra 15g of protein and 10g of
fat from mid pregnancy onwards.
 During pregnancy and lactation additional amount of calcium is required for proper
formation of bone and teeth and also for secretion of breast milk.
 Iron deficiency anemia during pregnancy increases maternal mortality and incidence of
low birth weight. Hence, consuming iron rich food is essential.

Nutritional Assessment
A Risk Factors

There are numerous risk factors for poor nutritional status, including major trauma, burns,
sepsis, substance abuse, sudden weight loss and many gastrointestinal disorders. The factors
listed below may place a patient at risk for developing or may denote the presence of nutrients
deficiencies.

 Age < 18years or >65years (increased risk age>75years)

 Weight loss is calculated as follows:
 Percent weight loss= (UBM – (BW)/UBW
 Where usual body weight, (BW = current body weight).
 Excessive alcohol intake, other substance abuse.
 Homelessness, Limited access to food.
 Limited capacity for oral intake (dysphagia, odynophagia, stomatitis, muscositis)
  NPO>3days.
 Increased metabolic demands: extensive burns, major surgery, trauma, fever, infection,
wound, fistula, pregnancy.
 Chronic disease (especially AIDS, diabetes, cancer, stroke)
 Protracted nutrients losses: malabsorption syndromes, short gut syndrome, draining
absers, wounds, fistula, effusion, renal dialysis.
 Intake of catabolic drugs: corticosteroids, anti-neoplastics, immunosuppressants.

Diet History

 A detailed diet history provides insight into a patient baseline nutritional status and may
detect subclinical nutrients deficiencies or toxicities.
 Assessment includes questions regarding chewing or swallowing problems, avoidance of
eating related to abdominal pain, changes in appetite, taste, or intake as well as use of a
special diet or nutritional supplements.

Medical History

 A review of past medical history includes identifying existence of conditions resulting in

increased metabolic needs, altered gastrointestinal function and absorptive capacity,
chronic disease state, organ failure and levels of physical activity.

National Nutrition Program And Schemes

 National Nutrition Policy 1993

 National Iodine Deficiency Disorders control Program
 Vitamin A prophylaxis program
 National nutritional anemia prophylaxis program
 Mid day meal program
 Integrated child development services (ICDS)

Nationwide Celebration of events

 World Breast feeding Week(1- 7 august)

 National Nutrition week (1 – 7 September)
 World food day (16th October)
 Global Iodine Deficiency Disorder(IDD) prevention day
 Universal children Day (14th November)
 International Women’s Day(8th March)

Nursing diagnosis related to the client having nutritional problems.

Nursing Diagnosis

 Altered nutritional less than body requirements.

Nursing Interventions

 Arrange a meeting with the dietician.

 Discuss the food option for the client.
 Have a planned food chart prepared for the client.
 Arrange for more proper timing of meals.
 Monitor the client weight and biochemical status.
 Initiate the diet therapy according to the disease conditions:
 For example, protein – restricted diet in acute renal failure.
 High protein diet in older clients.
 High calcium diet to prevent osteoporosis.
 High iron diet for anemia.
 Start with clear liquid diet, then progress to semi – solid and then solid.
 Provide assistance with feeding.
 TPN can be given if unexplained and prolonged diarrhea is there.
 It provides carbohydrates in the form of dextrose, fat in special emulsified form,
protein in the form of amino acids, vitamin, mineral and water.
 It prevents subcutaneous fat and muscle protein from being catabolized by the body
for energy.

Summary:

We learnt about nutritional deficiencies, factors affecting nutritional problems, types pf

nutritional disorders, mineral deficiencies, vitamin deficiencies, nutritional assessment and
nursing diagnosis.

Conclusion:

To perform different functions and processes, the body needs various types of nutrients, which
also play a major role in keeping the body fit and healthy. Most of these nutrients are obtained
through food. However, a large number of people in India do not get enough nutrients, which
results in various disorders, including anaemia, osteoporosis, night blindness, and so on.
According to the Food and Agriculture Organisation report, 190.7 million people suffered
from nutritional problems in India from 2014-2016.Since independence, India has witnessed
the ‘white revolution’ and ‘green revolution’ and made immense progress in food production.
The Government has also launched several schemes to boost the nutritional status of the
people. However, millions of citizens still suffer from malnutrition.