NUTRITION IN PUBLIC HEALTH

DR CHIHURUMNANYA ALO
MBBS, DTM&H(IRELAND),FWACP
 OUTLINE
• Food classes and classification
• Functions of major food classes
• Nutrition and health
• Infection and nutrition
• Epidemiology and control of common nutritional
problems in Nigeria
• Food policy, hygiene and toxicology
• Assessment of nutritional status
• Nutrition education.
 HISTORY
• Humans have evolved as omnivorous hunter-
gatherers over the past 250,000 years.
• The diet of early modern humans varied
significantly depending on location and climate.
• The diet in the tropics tended to be based more
heavily on plant foods,
• Diet at higher latitudes tended more towards
animal products
• Analysis of postcranial
and cranial remains of
humans and animals
from the Neolithic,
along with detailed
bone modification
studies have shown that
cannibalism was also
prevalent among
prehistoric humans.
• Agriculture developed about 10,000 years ago in
multiple locations throughout the world,
• Mostly cultivated were wheat, rice, potatoes, and
maize, with staples such as bread, pasta, and tortillas.
• Farming also provided milk and dairy products, and
sharply increased the availability of meats and the
diversity of vegetables.
• The importance of food purity was recognized when
bulk storage led to infestation and contamination risks.
• Cooking developed as an often ritualistic activity,
– due to efficiency and reliability concerns requiring
adherence to strict recipes and procedures,
– and in response to demands for food purity and consistency
• The first recorded nutritional experiment is found in the
Bible's Book of Daniel.
• Daniel and his friends were captured by the king of
Babylon during an invasion of Israel.
• Selected as court servants, they were to share in the
king's fine foods and wine.
• But they objected, preferring vegetables (pulses) and
water in accordance with their Jewish dietary
restrictions.
• Daniel and his friends received their diet for 10 days and
were then compared to the king's men.
• Appearing healthier, they were allowed to continue with
their diet.
•Around 475 BC, Anaxagoras stated that food is absorbed by the
human body and therefore contained "homeomerics"
(generative components), suggesting the existence of nutrients.
•Around 400 BC, Hippocrates said, "Let food be your medicine
and medicine be your food."
•In 1747, Dr. James Lind, a physician in the British navy,
performed the first scientific nutrition experiment, discovering
that lime juice saved sailors who had been at sea for years from
scurvy, a deadly and painful bleeding disorder.
•The essential vitamin C within lime juice would not be identified
by scientists until the 1930s.
•Around 1770, Antoine Lavoisier, the "Father of Nutrition and
Chemistry" discovered the details of metabolism, demonstrating
that the oxidation of food is the source of body heat.
• In 1790, George Fordyce recognized calcium as necessary for fowl
survival.
• In the early 19th century, the elements carbon, nitrogen, hydrogen
and oxygen were recognized as the primary components of food,
and methods to measure their proportions were developed.
• In 1816, François Magendie discovered that dogs fed only
carbohydrates and fat lost their body protein and died in a few
weeks, but dogs also fed protein survived, identifying protein as an
essential dietary component.
• In 1840, Justus Liebig discovered the chemical makeup of
carbohydrates (sugars), fats (fatty acids) and proteins (amino acids.)
• In the 1860s, Claude Bernard discovered that body fat can be
synthesized from carbohydrate and protein, showing that the
energy in blood glucose can be stored as fat or as glycogen.
• In the early 1880s, Kanehiro Takaki observed
that Japanese sailors (whose diets consisted
almost entirely of white rice) developed
beriberi (or endemic neuritis, a disease
causing heart problems and paralysis),
• British sailors and Japanese naval officers did
not.
• Adding various types of vegetables and meats
to the diets of Japanese sailors prevented the
disease.
• In 1896, Eugen Baumann observed iodine in thyroid
glands.
• In 1897, Christian Eijkman worked with natives of
Java, who also suffered from beriberi.
• He observed that chickens fed the native diet of white
rice developed the symptoms of beriberi, but
remained healthy when fed unprocessed brown rice
with the outer bran intact.
• Eijkman cured the natives by feeding them brown
rice, discovering that food can cure disease.
• About two decades later, nutritionists learned that
the outer rice bran contains vitamin B1, aka thiamine.
• In the early 20th century, Carl Von Voit and Max Rubner independently
measured caloric energy expenditure in different species of animals,
applying principles of physics in nutrition.
• In 1906, Wilcock and Hopkins showed that the amino acid tryptophan
was necessary for the survival of rats.
• He fed them a special mixture of food containing all the nutrients he
believed were essential for survival, but the rats died.
• A second group of rats were fed an amount of milk containing vitamins ,
• Gowland Hopkins recognized "accessory food factors" other than
calories, protein and minerals, as organic materials essential to health,
but which the body cannot synthesize.
• In 1912, Casimir Funk coined the term vitamin, a vital factor in the diet,
from the words "vital" and "amine," because these unknown
substances preventing scurvy, beriberi, and pellagra, were thought then
to be derived from ammonia.
• The vitamins were studied in the first half of the 20th century.
• In 1913, Elmer McCollum discovered the first vitamins,
– fat soluble vitamin A, and
– water soluble vitamin B (in 1915; now known to be a complex of several water-soluble vitamins)
and
– vitamin C as the then-unknown substance preventing scurvy.
• Lafayette Mendel and Thomas Osborne also performed pioneering work on vitamins A
and B.
• In 1919, Sir Edward Mellanby incorrectly identified rickets as a vitamin A deficiency
because he could cure it in dogs with cod liver oil.
• In 1922, Elmer McCollum destroyed the vitamin A in cod liver oil, but found that it still
cured rickets.
• Also in 1922, H.M. Evans and L.S. Bishop discover vitamin E as essential for rat
pregnancy, originally calling it "food factor X" until 1925.
• In 1925, Hart discovered that trace amounts of copper are necessary for iron
absorption.
• In 1927, Adolf Otto Reinhold Windaus synthesized vitamin D, for which he won the
Nobel Prize in Chemistry in 1928.
• In 1928, Albert Szent-Györgyi isolated ascorbic acid, and in 1932 proved that it is vitamin
C by preventing scurvy.
• In 1935 he synthesized it, and in 1937, he won a Nobel Prize for his efforts. Szent-
Györgyi concurrently elucidated much of the citric acid cycle.
• In the 1930s, William Cumming Rose identified essential amino
acids, necessary protein components which the body cannot
synthesize.
• In 1935, Underwood and Marston independently discovered the
necessity of cobalt.
• In 1936, Eugene Floyd Dubois showed that work and school
performance are related to caloric intake.
• In 1938, Erhard Fernholz discovered the chemical structure of
vitamin E.
– It was synthesised by Paul Karrer.
• In 1940, rationing in the United Kingdom during and after World
War II took place according to nutritional principles drawn up by
Elsie Widdowson and others.
• In 1941, the first Recommended Dietary Allowances (RDAs) were
established by the National Research Co
 Nutrition
• Nutrition may be defined as the science of
food and its relationship to health
• nutrient or food factor is used for specific
dietary constituents such as protein or
vitamins.
• Good nutrition means “maintaining a
nutritional status that enables one to grow
well and enjoy good health
 Nutrition
(a) “a science that studies all the interactions
that occur between living organisms and
food. It includes the psychological, social,
cultural, economic and technological factors
that influence which food we choose to eat.
(b) It also studies the biological processes by
which we consume food and utilize the
nutrient it contains”(Smolin and
Grosvenor,2000).
 Why study nutrition?
Nutrition is one key to developing and maintaining a state of
health that is optimal.
2 Poor diet and sedentary lifestyle are risk factors
for life-threatening chronic diseases and death.
3 Cardiovascular disease, stroke, hypertension, diabetes and
some form of cancer
4 Not meeting nutrient needs in younger years predisposed to
suffering health consequences of poor nutrition in later years
e.g bone fractures from osteoporosis, iron deficiency anaemia
5 Too much intake of supplements e.g Vit A, Vit D, Vit
B6,calcium or copper can be harmful.
 Why do we eat or feed
(Is there a difference between eating and feeding)
1. Basal metabolism
2. Growth and development
3. Daily activity
4. Illness/disease/healing and recuperation
5. Specific dynamic actions (thermogenesis)
6. Others: social, religious, cultural
 Classification of food
• Ways to classify
• Based on origin
– Foods of animal origin
– Foods of vegetable origin
• Classification by chemical composition
– Proteins
– Carbohydrates
– Fats
– Vitamins
– minerals
 Classification contd.
• Classification by predominant fxn
– Body building foods, e.g meat, milk, poultry, fish,
eggs, pulses, groundnuts, etc
– Energy-giving foods, e.g cereals, sugars, roots and
tubers, fats and oils.
– Protective foods, e.g vegetables fruits, milk etc.
 Classification contd.
• Classification by nutritive value
– Cereals and millet
– Pulses (legumes)
– Vegetables
– Nuts and oil seeds
– Fruits
– Animal foods
– Fats and oil
– Sugar and jaggery
– Spices
– Miscellaneous foods
 NUTRIENTS
• They are organic and inorganic complexes
contained in food.
• There are about 50 different nutrient normally
supplied through food
• Each nutrient has specific fxn in the body.
• Most natural foods contain more than one
nutrient.
• They are usually divided into macronutrients and
micronutrients
• MACRONUTRIENTS
– Proteins, fats and carbohydrates. These make up
the bulk of the food
• MICRONUTRIENTS
– Vitamins and minerals.
– They are required in small amounts which vary
from micrograms to several grams.
 PROTEINS
• The word protein means that which is of first
importance
• They are complex organic nitrogenous
compounds
• Composed of carbon, hydrogen, oxygen,
nitrogen and sulphur in varying amount.
• Some also contain phosphorous, iron and
occasionally other elements
 PROTEINS
• Differ from chd and fats in that they contain
nitrogen (16%)
• Proteins constitute about 20% of body weight in
an adult.
• Made up of smaller units called amino acids
• Some 24 amino acids are needed by the body
• 9 are called essential because the body cannot
synthesize them in amounts corresponding to its
needs
 Proteins
• They must be obtained from dietary proteins
• They are leucine, isoleucine, lysine,
methionine, phenylalaninie, threonine, valine,
tryptophan, and histidine.
• Evidence is now accumulating that histidine is
essential even for adults
• Non-essential amino acids may be
synthesized by the body
 Proteins
• Both essential and non-essential amino acids
are needed for synthesis of tissue proteins
• The non-essentials are arginine, asperginic acid,
serine, glutamic acid, proline and glycine.
• Some of the essential amino acids have
important biological fxns e.g, the formation of
niacin from tryptophan or the action of as a
donor for the synthesis of choline folate and
nucleic acids
 Functions of proteins
• A protein is said to be complete when it contains all
the EAA in amounts that correspond to the body
needs.
• When a protein is lacking is one or more of the EAA, it
is said to be biologically incomplete
• The quality of dietary protein is dependent on the
pattern of amino acids.
• From nutritional point of view, animal proteins are
superior to vegetable protein because they are
biologically complete
 Fnxs of proteins
• Proteins are for
– Body building : this component is small when
compared with the maintenance component except
in the very young child and infant.
– Repair and maintenance of body tissue
– Maintenance of osmotic pressure
– Synthesis of certain substances as antibodies, plasma
proteins, enzymes, hormones and coagulation factors
– Formation of blood cells.
 Fxns of proteins
– Proteins are connected with the immune
mechanism of the body. The CMI immune
response and bactericidal activities of the
leucocytes have been found to be lowered in
severe forms of PEM.
– They can also supply energy ( 4kcal/1g) when
calorie intake is not adequate. This is not their
primary fxn.
 Sources of proteins
• Animal sources
– Milk, meat, eggs, cheese, fish, fowl
– These proteins contain all the EAA
– Egg considered the best among the
proteins because of high biological
value and digestibility.(reference
protein)
• Vegetable sources
– Pulses(legumes e.g groundnut, cowpea,
horse bean, kidney bean, lentil, pigeon
pea, soya bean seed, velvet bean),
– cereals(barley, millet, sorghum, wheat),
– nuts, oil-bean seed, almond, cashew
nut, coconut, melon seeds, pumpkin
seeds, sesame seed, sunflower seeds,
walnut etc.
 Assessment of protein nutrition status

• Many tests have been used to assess the state

of protein
• Arm muscle circumference
• creatinine-height index
• Serum albumin and transferrin
• Total body nitrogen
• The best measure of state of protein nutrition
is probably serum albumin concentration
 Serum albumin concentration
• It should be more than 3.5g/dl
• A level of 3.5g/dl is considered mild degree of
malnutrition
• A level of 3g/dl is severe malnutrition
• Serum albumin and transferrin asses the
ability of the liver to synthesize proteins
 Net protein utilization
• This is the measure of
proportion of ingested
protein that is retained in
the body under specified
conditions for the
maintenance and/or
growth of the tissues.
• This is a parameter for the
evaluation of biological
value of a protein.
 Fats and oils
• Fats are solids at 20 deg C
• They are called oils if they are liqud at 20 deg
C.
• They are concentrated sources of energy
• They are classified as
– Simple lipids e.g triglycerides
– Compound lipids e.g phospholipids
– Derived lipids e.g cholesterol
 Fats and oil
• The body can synthesize TGC and cholesterol
endogenously
• Most of the body fats(99%) in the adipose tissue
is in the form of TGC.
• In normal human subjects, the adipose tissue
constitutes between 10 – 15 % of the total body
weight.
• Accumulation of 1kg of adipose tissue
corresponds to 7700kcal of energy
 Fatty acids
• Fats undergo hydrolysis to yield fatty acids and
glycerol.
• Fatty acids are divided into
– Saturated and
– Unsaturated fatty acids
• saturated fatty acids are lauric, palmitic and
stearic acids
 Fatty acids
• Unsaturated fatty acids are further divided into
– Monounsaturated fatty acids such as oleic acid
– Polyunsaturated fatty acids such as linoleic acid and α-
linolenic acid
• PUFA are mostly found in vegetable oils and the
saturated fatty acids mainly in animal fats
• Some exceptions e.g cocoa nut and palm oil though
vegetable oils have extremely high % of sat fatty acids
• On the other hand, fish oils though not veg oils
contain poly and mono unsat fatty acids
 Essential fatty acids
• EFA are those that cannot be synthesized by
the body and can be derived only through
food.
• The most important one is linoleic acid, which
seves as a basis for the production of other
EFA (linolenic and arachidonic acids
• NB: all PUFA are not EFA
 Sources of fats
• Dietary sources may be classified as
– Animal fats: major sources are ghee, butter, milk,
cheese, eggs, fat of meat and fish
– Vegetable fats: groundnut, mustard seed, sesame,
coconut. They are sources of vegetable oil and
they store oil in their seeds.
– Other sources: small quantities of invisible fats are
found in most other foods such as cereals, pulses
and vegetables
 Functions of fats
• They are high energy foods providing as much as
9kcal for every gram. By supplying energy they
spare protein from being used for energy.
• They serve as vehicles for fat-soluble vitamins
• They support body viscera such as heart, kidney,
and intestine
• Fat under the skin provides insulation against cold
• Fats provide the palatability that is required in
food
 Functions of fats
• They are rich sources of EFA which are needed for
– body growth,
– structural integrity of cell membrane and
– decreased platelet adhesiveness.
• PUFA are precursors of prostaglandins; a group of
compounds now recognised as local hormones.
– They play major role in controlling many physiologic fxn in
the body such as
• kidney fxn,
• vascular homeostasis,
• acid secretion in the stomach GI motility,
• reproduction and
• lung fxn
 Fxns of fats
• Cholesterol is essential as a component of
membranes and nervous tissue and is also a
precursor for the synthesis of steroid
hormones and bile acids.
 Visible and invisible fats
• Visible fats are those that are separated from their
source e.g butter from milk, cooking oils from oil
bearing seeds
– It is easy to estimate their intake in the daily diet.
• Invisible fats are those which are not visible to the
naked eye
– They are present in every article of food, e.g cereals,
pulses, nuts, milk eggs.
– It is difficult to estimate their intake.
– They are the major contributors of fat.
 HYDROGENATION
• When vegetable oils are hydrogenated under
conditions of optimum temperature and
pressure in the presence of a catalyst, the
liquid oils are converted into semi-solid and
solid fat.
• During hydrogenation, unsat fatty acids are
converted into sat fatty acids and the EFA
content is drastically reduced.
 REFINED OILS
• This is done by treatment with steam, alkali,
etc
• Done to remove the free fatty acids and rancid
materials which may be present in them
• Refining does not affect the unsat fatty acids
content of the oil.
• It only improve the quality and taste of oils
 Fats and diseases
• Obesity : diet rich in fat can pose a threat to human
body by causing obesity with its attendant morbidities
• Coronary artery dx: high fat intake i.e dietary fat
representing 40% of the energy supply and containing
a high supply of saturated fats, has been identified as a
major risk factor for CDH
• Cancer : there is recent evidence that diet high in fats
increase the risk of colon cancer and breast cancer
• The skin lesion of kwashiorkor and EFA deficiency has
attracted attention.
 Carbohydrate
• This is the main source of energy in food providing
4kcals/gm
• They are also essential for the oxidation of fats and
for the synthesis of certain non-essential amino
acids
• Three main sources of chd
– Starches; basic to the human diet. It is found in
abundance in cereals, tubers and roots
– Sugars comprise of monosaccharide (glucose, fructose,
galactose)
 CHDs
– Disaccharides: ( sucrose, lactose and maltose)
• These free sugars are highly soluble and easily
assimilated. They constitute a major source of energy
– Cellulose which is the indigestible component of CHD with
scarcely any nutritive value contributes to the dietary fibre
• If the dietary chd do not meet with the energy needs
of the body, protein and glycerol from dietary and
endogenous sources are used by the body to
maintain glucose homeostasis
 Sources of chd
• Barley, maize, millet,
oats, rice, sorghum,
wheat, rye,
• Breadfruit, cassava,
plantain, potato(irish),
potato(sweet), yam
 Dietary fibre
• This a non-starch polysaccharide which is a
physiologically important component of diet.
• It is found in vegetables, fruits and grains
• Divided broadly into
– Cellulose and
– Non-cellulose polysaccharides which includes
pectin, inulin and plant gums. These are degraded
by the micro flora in the intestine
 Dietary fibre
• In the last few years, dietary fibre has
attracted a lot of attention
• It absorbs water and this increases the bulk of
the food and helps reduce the tendency to
constipate by encouraging bowel movement
• It is firmly established that dietary fibre lowers
the serum cholesterol levels
 Vitamins
• Class of organic compounds categorized as
essential nutrients
• Required in small amounts by the body
• Fall in category of micronutrients
• Enable the body to use other nutrients
• Body is unable to synthesise all vits. Therefore
must be supplied by food
 VITAMINS
• Two major groups
– Fat soluble vitamins
• A, D ,E ,K
– Water soluble vitamins
• B - GROUP, C
• Each group has a specific fxn
• Deficiency of any leads to a specific disease
 VIT A
• Preformed retinol
• Pro-vitamin – beta carotene
• Beta carotene converted to retinol in the
intestinal mucosa
 VIT A fnxs
• Indispensable for normal vision
– Contributes to the production of retinal pigments
needed for vision in dim light
• Necessary for maintaining the integrity and
normal functioning of glandular and epithelial
tissue which lines intestinal, respiratory and
urinary tracts, skin, eyes.
• Supports skeletal growth
 Fnxs cont.
• It is anti-infective
– Increased susceptibility to infection and lowered
immune response in vit A def.
• It may protect against some epithelial cancers
such as bronchial ca, but the data are not fully
consistent
 SOURCES OF VIT A
• Widely distributed in plants and animals, fortified
foods.
• Animal sources
– Liver, eggs, butter, cheese, whole , milk, fish, meat.
– Fish liver oils are the richest natural source of vit A.
• Plant sources
– Green leafy vegetables e.g spinach, amaranth. Others
are paw-paw, mango, pumpkin, carrots, tomatoes, etc
• Fortified foods: margarine, milk,
• Liver has capacity for storing vit A in form of
retinol palmitate
• A well fed person has sufficient stores to meet
his needs for about 6 – 9 months.
• Free retinol is toxic and is therefore
transported in the bloodstream in
combination with retinol binding protein.
• In severe prot. def, decreased prdxn of retinol
binding prot. Prevents mobilization of liver
retinol reserves.
 Vitamin A Def.
• Predominantly ocular signs
– Nightblindness, conjunctival xerosis, Bitot’s spot,
corneal xerosis and keratomalacia
• Nightblindness: inability to see in dim light
• Conjunctival xerosis: 1st clinical sign of vit A
def. Dry and non-wettable conjunctiva. It
appears muddy and wrinkled instead of
smooth and shiny.
 Vit A def
• Bitot’s spots:
– triangular, pearly white or yellowish foamy spots on
the bulbar conjunctiva
– Frequently bilateral
– In young children indicate vit A def.
– In older individuals, often sequelae of earlier dx
• Corneal xerosis: particularly serious
– Cornea appears dull, dry, non-wettable, opaque
– There may be an ulceration which may leave a scar
 Vit A def
• Keratomalacia: liquifaction of the cornea
– A grave emergency
– Cornea may become soft or may burst open
– If eye collapses, vision is lost.
• EXTRA-OCULAR MANIFESTATION
– Follicular hyperkeratosis
– Anorexia
– Growth retardation
 Treatment
• Treatment should be urgent
• Early stages can be reversed
• 200,000 IU or 110mg of retinol palmitate
orally, 2/7
• All children with corneal ulcers should recieve
vit A.
 PREVENTION
• 2 forms
– Improvement in people’s diet to ensure regular
and adequate supply of vit A.
– Reducing frequency and severity of contributory
factors as PEM, diarrhoea, RTI, measles.
• Nutrition education of the public and
community participation.
 VIT A RDA
• Adults • adolescents:
– Men: 600mcg – 13-19yrs:600mcg
– Women: 600mcg
– Lactation: 950mcg
• Infants: 350mcg
• Children:
– 1-6 yrs: 400mcg
– 7-12yrs:600mcg
 Toxicity
• Excess intake of retinol causes
– Nausea
– Vomiting
– Anorexia
– Sleep disorders
– Skin desquamation
– Enlarged liver
– Papiloedema
– May colour plasma and skin
 Vit D
• Nutritionally important forms of the vit are
– Calceferol (vit D2): may be derived by irradiation of
plant sterol, ergosterol
– Cholecalciferol( vitD3): naturally occurring, found
in animal fats and fish liver oil.
• Also derived from exposure to uv light which converts
thr cholesterol on the skin to vit D
• Vit D is largely stored in fat depots
 VIT D
• Metabolically inactive until it undergoes endogenous
transformation into several active metabolites
– 25,HCC in the liver
– 1,25 DHCC in the kidneys
• These metabolites are bound to specific transport proteins
and carried to target tissues – bone and intestine.
• Proposed to be a kidney hormone rather than a vit
• Not a dietary requirement in conditions of adequate sunlight
• In adequate amount by simple exposure tot sunlight for 5
mins/day.
 FXNS
• Intestine: promotes intestinal absorption of
calcium and phosphorus
• Bone: stimulates mineralisation, enhances
bone resorption, affects collagen maturation
• kidney: increases tubular reabsorption of
phosphate, variable effect on reabsorption of
calcium
• Other: permits normal growth
 Sources
• Sunlight
• Food: liver,
– egg yolk,
– butter,
– cheese,
– fish,
– human milk,
– and fortified foods
 VIT D Def.
• RICKETS: usually in children btw age 6mo and 2
yrs.
• Reduced calcification of growing bones
• Growth failure
• Bone deformity
• Muscular hypotonia
• Tetany and convulsion due to tetany
• Elevated conc of alakaline phosphate in the serum
 Vit D Def.
• Bone deformities • Developmental
– Curved legs milestones are delayed
– Deformed pelvis
– Pigeon chest
– Harrison’s sulcus
– Rickety rosary
– kyphoscoliosis
 Vit D def
• OSTEOMALACIA
• Deficiency in adults
• Mostly in women esp during pregnancy and
lactation.
 Prevention of vit D def
• Educating mothers to expose their children
regularly to sunshine
• Periodic dosing of young children with vit D
• Vit D fortification of foods
• RDA: adult- 100IU, children- 200IU, pregnancy-
400IU
• NB: excessive intake may result in anorexia,
nausea, vomiting, thirst and drowsiness, coma,
cardiac arrhythmia and renal failure.
 VITAMIN E
• Name for the tocopherols
• Alpha-tocopherol the most biologically potent
• Widely distributed in foods
• SOURCES
– Vegetable oils, cotton seed, sun flower, egg yolk
and butter
– Food rich in PUFA are also rich in vit E
 Vit E
• Role of vit E at the molecular level is still
poorly understood
• Usual plasma level is btw 0.8 and
1.4mg/1ooml.
• No doubt man requires tocopherol in diet
• But no clear indication of dietary def
• Cytotoxic to human lymphocyte in vitro at
high concentrations
 Vit K
• Occurs in two major forms
• Vit K 1 and K2
• Vit K 1 found mainly in green vegetables, some
fruits, cow milk > human milk
• Vit K2 is synthesized by intestinal bacteria,
• Vit K is stored in the liver
 Vit K
• Stimulates the production and release of coagulation
factors
• In vit K def, prothrombin content of blood is markedly
reduced and blood clothing time is considerably
prolonged.
• RDA is about 0.03mg/kg for adults
• Infants lack vit K at birth due to minimal store of
prothrombin at birth.
• Those at risk of vit K def should receive 0.5mg of vit K.
 THIAMINE
• VIT B1, water soluble
• Essential for utilization of carbohydrates
• Thiamine pyrophosphate, the conzyme of
carboxylase plays a role in activating
transketolase, an enzyme involved in the
direct oxidative pathway for glucose
• Deficiency leads to accumulation of pyruvic
and lactic acids
 Thiamine
• Sources
– Whole grain cereals, wheat, yeast, pulses, oil seeds
and nuts, especially groundnut.
– Meat, fish, eggs, vegetable and fruits contain small
amounts
– Milk is an important source for infants
• Thiamine is readily lost from rice during milling
• Further loss during cooking because it is water
soluble
 Thiamine
• Lost from fruits and vegetables during long
storage
• Destroyed by heat in toast and cereals cooked
with baking soda
• DEFICIENCY
– Beriberi
– Wernicke’s encephalopathy
 Vit B1 Def
• Beriberi
– Dry form xterized by nerve involvement
– Wet form xterized by heart involvement
– Infantile beriberi seen in infants btw 2 and 4 mo of age
• affected baby usually breast fed by a deficient mother
• Wernick’s encephalopathy is xterized by ophthalmoplegia,
polyneuritis, ataxia and mental deterioration.
• Minor degrees of manifestation include; loss of appetite,
absence of ankle and knee jerks, and presence of calf
tenderness.
 Prevention of B1 def.
• Educate people to eat balanced diet
• Stop alcohol
• Direct supplementation of high-risk group
– Pregnancy, dialysis, fasting, persistent vomiting
• RDA : 0.5mg per 1000kcal of energy intake
– the body content of B1 is placed at 30mg
 RIBOFLAVIN
• B2
• Involved in cellular oxidation
• Co-factor in a number of enzymes involved in
energy metabolism
• RDA : no real body stores
– 0.6mg/1000kcal of energy
 Sources of B2
• Richest natural source are
– Milk, eggs, liver, kidney, and green leafy
vegetables
– Meat and fish contain small amounts
– Cereals and pulses are relatively poor
 B2 deficiency
• Ariboflavinosis
• Lesions include: angular stomatitis, cheilosis,
glossitis, nasolabial dyssebacia
• Impaired neuromotor function, poor wound
healing, and increased susceptibility to
cattaract
• Def ususally occurs in association with other
B-complex vits
 NIACIN
• Nicotinic acid
• Essential for the metaboloism of chd, fat and prot
• For normal functioning of the skin, intestine and
nervous system.
• Tryptophan (an essential amino acid) serves as its
precursor
• Metabolised to N-methyl-nicotinamide and N-
methyl pyridones
 Sources of Niacin
• Liver • Milk is a poor source
• Kidney but its protein rich in
• Meat tryptophan
• Poultry • Niacin occurs in bound
form in maize and so
• Fish
unavailable to the
• Legumes consumer
• groundnut
 Deficiency of niacin
• Pellagra
• Xterized by the 3 Ds
– Diarrheoa
– Dermatitis
– Dementia
• Stomatitis and glossitis may occur
• Dermatits is often symetrical and found on
surfaces of body exposed to sunlight
• Mental changes (delirium, depression, irritability
 Prevention of niacin def
• Good mix diet
• Avoid dependence on maize
• A dx of poverty
• Given modern knowledge and opportunities,
it could be eliminated
 Vitamin B6
• Pyridoxine
• Exists in 3 forms
– Pyridoxine
– Pyridoxal
– Pyridoxamine
• Plays important role in metabolism of amino
acids, fats and chd
• Widely distributed in foods
 Sources of B6 and def
• Meat • Def
• Liver – Peripheral neuritis
• Egg yolk – Riboflavin def Impairs
optimal use of B6
• Fish
• INH is an antagonist
• Milk
• RDA: vary directly with
• Whole grain cereals protein intake
• Legumes – 2mg/day
• vegetables – Pregnancy/lactation:
2.5mg/day
 PANTOTHENIC ACID
• Existing realtionship • RDA : 10mg
btw pantothenic acid • 3 mg excreted daily in
and adrenal cortical fxn urine
• Biosynthesis of • All foods contribute to
corticosteroids dietary intake
• Mostly present in cells
as co-enzyme A
 FOLATE
• Recommended name: folate
• Alternative name: folacin
• Pharmacological prep is folic acid
• Occurs in food in 2 forms
– Free folate
– Bound folate
• Free folate is rapidly absorbed
• Bound folate is uncertain
 Folate
• Folate plays a role in synthesis of nucleic acid
• Normal development of RBCs in the marrow
SOURCES
• Liver, meat, dairy products, milk, fruits and
cereals, leafy vegetables
Overcooking destroys much of the folic acid
 Folate def.
• Def may occur from poor diet
• Commonly found in pregnancy and lactation
• Results in megaloblastic anaemia, glossitis,
cheilosis, and GI disturbances such as diarrhoea,
distension and flatulance
• Severe def can cause sterility
• Folate antagonist early in pregnancy can cause
abortions and or congenital malformations
• RDA ; 5-10mg
 VIT B12
• A compliex organometelic compound with a
cobalt atom
• Cyanocobalamine used therapeutically.
• It co-operates with folate in the synthesis of DNA,
so deficiency of any leads to megaloblastosis
• VITB12 has another role not related to folate in
the synthesis of fatty acids in myelin
• Absorption requires intrinsic factor in the stomach
and the complex absorbed in the terminal ileum
 Vit B12
• SOURCES
– Liver, kidney, meat, eggs, milk, cheese
– Not found in foods of vegetable origin
– Synthesized by bacteria in the colon
• It is relatively heat stable
• Liver is main storage site
• Body stores are sufficient to tide over 1-3 yrs
 Def and requirement
• Megaloblastic • Normal adult –
anaemia( pernicious 1mcg/day
anaemia) • Pregnancy – 1.5mcg
• Demyelinating • Lactation – 1.5mcg
neurological lesions • Infants and children –
• Infertility in animals 0.2mcg
• Def may arise among
vegeterians
 VITAMIN C
• Ascorbic acid,
• water soluble vitamin and the most sensitive to
heat
FUNCTIONS
• Plays a role in tissue oxidation
• Needed for formation of collagen which accounts
for 25% of total body protein
• collagen provides a supporting matrix for blood
vessels and connective tissue
 SOURCES and DEF
• The main dietary source • Scurvy, signs of which are
of vit C are swollen and bleeding gum,
– fresh fruits, e.g guava, subcutaneous bruising or
bleeding into skin and
lime, orange, tomato.
joints, anaemia and
– green leafy vegetables
weakness
as amaranth, cabbage,
• Estimated requirement is
spinach, cauliflower,
potatoes. from 40 – 60mg
 Minerals
• More than 50 chemical elements are found in
human body required for growth, repair and
regulation of vital body functions.
• Major minerals: calcium
– Phosphorous
– Sodium
– Potasium
– magnesium
• Trace elements: required by the body in small
quantities of less than a few mgs/day
• E.g are iron
– Iodine ,Flourine,Zinc,Copper,Cobalt, Chromium,
Manganese, Molybdenum, Selenium, Nickel, Tin,
silicon, and vanadium.
• Trace contaminants with no known function
– Lead, mercury, barium, boron, and aluminium
 CALCIUM
• Major mineral element
• Amount in blood usually abt 10mg/dl
• Equilibrium btw ca in blood and bone.
• This is maintained by vit D, PTH and calcitonin
• Developing foetus requires abt 30g
Functions SOURCES
• Formation of bones and • Milk and milk priducts,
teeth eggs, fish
• Coagulation of blood • Green vegetables,
• Contraction of muscles cereals and millet
• Limiting factor with
• Cardiac action
absorption of calcium
• Milk production from vegetables is the
• Relay of chemical and presence of oxalic acid.
electrical messages • Absorption is enhanced
• Metabolisim of by vit D and decreased in
hormones and enzymes the presence of phytates,
oxalates and fatty acids
 Calcium
• Deficiency
– No clear cut disease due to def, as long as Vit D
intake is optimal
– No deleterious effect has been observed in man
from prolonged intake of large quantities of
calcium
• RDA
– 400-500mg has been suggested for adults
 Iron
SOURCES
Functions • Two source
• Formation of hb – Haem-iron
– Non-haem iron
• Brain devpt and fxn
• Haem-iron; liver, meat,
• Regulation of body temp poultry, fish
• Muscle activity • They promote absorption of
• Cathecholamine iron
metabolism • Non-haem iron: vegetable
origin as vegetables, legumes,
• Binding oxygen to the nuts oilseeds, cereals,
blood cells • Their bioavailability is poor
due to phytates, oxalates and
carbonates
IRON DEF
• 3 stages of deficiency
– First stage xterised by
decreased storage without any
other detectable abnormality
– Intermediate or latent iron def.
Iron stores are exhausted but
anaemia has not yet occurred.
– Third stage of iron def with
decrease in the conc of hb
• End result is nutritional anaemia.
• Impaired CMI, reduced resistance
to infection, increased morbidity
and mortality
ABSORPTION
• Mostly from the duodenum and
upper small intestine
• Rate of absorption is influenced
by iron reserves, presence of
inhibitors, and promoters, and
disorders of duodenum
IRON LOSSES
• Daily loss in men-1mg,
menstruating women- 2mg.
• Loss through haemorrhage,
hookworm, haemorrhoids,
peptic ulcer
• Basal losses e.g urine, sweat,
bile, desquamated surface cell,
some IUCDs
IRON EVALUATION
• Hb of 10 – 11mg/dl defined as
early anaemia
• < 10mg/dl, marked anaemia
• Hb conc used to evaluate
anaemia, not a sensitive index of
nutritional anaemia.
• Serum iron conc,more useful
index. < 0.8 – 1.8mg/L.
• Serum ferritin: single most
sensitive tool, reflects iron stores
of body, useful in pop where the
prevalence of fe def is not high, <
10mcg/L indicate absence of
stored iron.
• Serum transferrin saturation;
values should be above 16%.
REQUIREMENT
• Infants (5-12 mo) –
0.7mg/day
• Children(1-12 yrs) – 1mg
• Adolescents(13-16 yrs)
-1.8mg/day for males and
2.4mg/ for females
• Adult males – 0.9mg/day
• Adult females
– Menstruating- 2.8mg
– Pregnancy
• First half- 0.8mg
• Second half- 3.5mg/day
– Lactation – 2.4mg
– Postmenopausal – 0.7mg/day
 IODINE
• An essential micronutrient SOURCES
• Required for the synthesis • Best source- sea foods e.g
of thyroid hormones sea fish, sea salt, cod liver oil
• Needed in minute • Smaller amount in milk,
amounts for growth, meat, vegetables, cereals
development and well • Iodine content of fresh
being water is small
• Blood level is about 8- • Iodine content in soil
determines the presence in
12mcg/dl
water and locally grown
foods
• DEFICIENCY
GOITROGENS
• Goitre
•
• Chemical substances
Hypothyroidism
• Retarded physical leading to goitre
development and mental • Interfere with iodine
function utilization by the
• Increased rate of spontaneous thyroid gland
abortion and still birth
• Neurological cretinism
• E.g cabbage,
including deaf-mutism cauliflower,
• Myxedematous cretinism • Most important dietary
including dwarfism and severe goitrogens are
mental retardation
•
cyanoglycosides and
Endemic goitre now replaced
by iodine def disorders thiocyanates
 PHOSPHORUS
• Essential for the formation of bones and teeth
• Plays important role in all metabolism
• Widely distributed in food stuff
• Deficiency rarely occurs
• Intake as much as calcium.
• Adult human body contains about 400-
700mcg of phosphorus as phosphate.
 SODIUM
• Found in all body fluids
• Adult human body contains about100g of sodium
ion
• Occurs in many foods and also added during
cooking in form of salt
• Lost from the body through sweat, and urine
• Requirement depend upon climate, occupation
and physical activity
• Adult requirement is about 10-15g
 POTASSIUM
• The adult human body contains about 250g of
potassium
• Widely distributed in foods
• Little likelihood fro deficiency to develop
• Daily requirement not yet determined
accurately
 MAGNESIUM
• A constituent of bone
• Present in all body cell
• Essential for normal metabolism of calcium and
potassium
• Deficiency may occur in chronic alcoholics, cirrhosis of
liver, toxaemia of pregnancy, PEM, and malabsorption
syndrome
• Clinical symptoms of def. Include irritability,
hyperreflexia, tetany, and occasionaly hyporeflexia,
• RDA: estimated to be 200-300mg per day.
 Trace elements
• Zinc
• Copper
• Cobalt
• Chromium
• Selenium
• Molybdenum
• Fluorine
• Read up!!!!!
 NUTRITION AND HEALTH
• Healthy food is necessary for
• promoting and maintaining good health in
adults;
• promoting optimal growth in infants, children
and adolescents;
• preventing many chronic diseases (like heart
disease and diabetes) and treating others; and,
• speeding recovery from injuries and surgery.
 Nutrition and health
• A balanced diet comprising of diverse and healthy foods is
key to promoting good health.
• After all, we are what we eat
• Research continues to prove that eating healthy food
promotes good health and unhealthy food habits lead to a
diseased body.
• Foods contain vital nutrients that aid our body’s metabolic
function.
• A lack of consumption of these nutrients or feeding upon the
wrong kinds of food leads to an accumulation of toxins
within the body, resulting in chronic diseases in the long run.
 Nutrition and health
• A nutritious diet while ensuring overall well
being, helps to
– maintain a healthy Body Mass Index (BMI),
– reduces the risk of several debilitating diseases
like cancer, cardiovascular ailments, diabetes,
osteoporosis and stroke.
• Thus a nutritious & healthy diet is important in
the prevention and cure of various diseases.
 Nutrition and health
• Adults need to maintain a healthy body weight,
• Men in particular should be wary of excess weight.
• In men, extra pounds tend to be stored around the
tummy.
• Sometimes referred to as abdominal fat, this increases
the risk of developing heart disease and diabetes to a
greater extent than fat stored on the hips and thighs,
which is more typical for women.
• This risk of abdominal obesity is even greater for men
of Afro-Caribbean and Asian origin.
 Nutrition and health
• Prostate cancer
• A recent review of risk factors for cancer found that
foods containing lycopene might help to reduce the risk
of prostate cancer in men.
• Tomatoes are a rich source of lycopene, but it's not
currently clear whether there are other compounds
present in tomatoes - and other foods - that might be
acting in conjunction with lycopene to achieve this
protective effect.
• So, rather than focusing your attention on eating
nothing but tomatoes, try increasing your overall intake
of all fruit and vegetables.
 Nutrition and health
• The physical demands of pregnancy and breastfeeding place extra
nutritional demands on women.
• Women are also at higher risk of developing iron deficiency anaemia
than men.
• How diet can alleviate the symptoms of premenstrual tension (PMT)
and the menopause is also the focus of much interest among scientists.
• Supplements of linolenic acid, vitamin D or calcium have been reported
to help with PMT symptoms, and soya-rich diets may also be beneficial.
• Many of the studies in this area are not conclusive, so women should
follow the principles of healthy eating and be wary of taking large doses
of single supplements.
• A review of risk factors for cancer found strong evidence of a link
between alcohol intake and breast cancer. This gives women another
reason to stay within safe alcohol limits.
 Nutrition and health
• Although their growth is slower than in infancy,
school-aged children still have high nutritional
needs but fairly small appetites.
• So it's crucial all meals and snacks continue to be
rich in nutrients and energy.
• The food choices children make during the crucial
years of development can influence their future
health risk and can also influence food habits in
later life.
• A structured eating plan with regular meals and
snacks is important to establish good eating habits.
 Nutrition and health
• Ensure there's also plenty of variety.
• A limited number of foods makes it difficult to obtain the full
range of nutrients.
• Children should have a range of foods based on each of the
main food groups.
• Important food groups for children include
– Energy giving foods
– Proteins
– Calcium
– Iron
– folate
 Nutrition and health
• The nutritional needs of older adults are
difficult to neatly categorise into absolute
age groups.
• Dietary needs depend on current health
– while many older people are fit and
active, some others who are younger
may be frail and require additional care.
 Nutrition and health
• Healthy Food Groups
No single food group can nourish the body with all
the vital ingredients it requires
• it is important that we consume a variety of healthy
foods to derive the nutrition our body needs.
• There are five main food groups, they are:

• Fruits
• Vegetables
• Cereals and Pulses
• Dairy
• Poultry, Fish and Meat products
 Nutrition and health
• A healthy balanced diet of these five food groups ensures
essential vitamins, minerals and dietary fiber.
• The food group serving size will depend upon various factors
like
– age, activity level, body size and gender.
• It is also important that one eats a variety of healthy foods
from within and across the food groups.
• This is because some foods from within a food group
provide more nutrients than others.
• This will ensure that one gets the maximum recommended
nutrition from the food group;
• Food variety will make for an interesting meal.
 Nutrition and disease
• Diseases can be linked to what we eat
• They include heart disease, hypertension,
some cancers, and diabetes
• Eating a diet that contains 5 to 9 servings of
fruits and vegetables as part of a healthy,
active lifestyle lowers the risk of some of these
diseases
 Epidemiology and control of common
nutritional problems in Nigeria
• Malnutrition is linked to poverty, low level of
education, and poor access to health services
including MCH &FP
• Nutritional deficiencies contribute to high
rates of disability, morbidity and mortality in
Nigeria
• In 1990, anthropometric survey of children
revealed prevalence of 15% to 52%
• Stunting prevalence ranging from 14% to 46%
• Recently, 42% of children are stunted, 25%
underweight, and 9% wasted.
• Incidence of low birth weight is 14%
• Both LBW and PEM are considered leading causes
of infant mortality
• 2003 survey showed 29.5% of children under 5
have Vitamin A deficiency
• VAD contributes up to 25% of infant, child and
maternal mortality in Nigeria because of reduced
resistance to PEM, ARIs, measles, malaria and
diarrhoea
• Micronutrient malnutrition is more prominent
in rural areas as compared to urban areas.
• Nutrition anaemia is another common
problem among children and women.
• Estimated prevalence of 20-40% in adult
females
• 20-25% in children
• Iodine deficiency has estimated prevalence
from 24 to 36%.
PROTEIN-ENERGY MALNUTRITION

• Aetiology
– in Nigeria, an interplay of complex
factors eventually result in the many
cases of PEM, that are common in our
rural areas.
CLASSIFICATION OF PEM.

There are many classification systems

with each system basing it’s
classification method on one or
more anthropometric indicators
and using different cut-off points.
KWASHIORKOR

• IN CHILDREN BETWEEN ONE AND THREE YEARS OF AGE.

• PRESENTING COMPLAINTS:
– FAILURE TO THRIVE,
– ANOREXIA,
– REFUSAL OF FEEDS,
– VOMITING,
– DIARRHEA,
– SKIN,
– HAIR AND
– MUCUS MEMBRANE CHANGES, OEDEMA.ETC.
KWASHIORKOR

PHYSICAL FINDINGS

• POOR GROWTH

• OEDEMA

• MUSCLE WASTING

• MENTAL CHANGES

THESE FOUR CARDINAL FEATURES ARE ALWAYS PRESENT.

KWASHIORKOR

OTHER FEATURES:

• SKIN CHANGES

• HAIR CHANGES

• MOON FACE

• SIGNS OF MICRONUTRIENT
DEFICIENCIES

• HEPATOMEGALY

• INTRACTABLE DAIRRHOEA
MARASMUS

• IN MUCH YOUNGER CHILDREN UP TO THREE AND A

HALF YEARS.

• COMMONER IN FIRST YEAR OF LIFE IN COMPARISM

TO KWASHIORKOR.

• NEAR ABSOLUTE DIETARY INADEQUACY.

• ASSOCIATED WITH FAILURE OF BREASTFEEDIND,

INFECTIONS, AND CONGENITAL MALFORMATIONS.
MARASMUS

MAIN SIGNS

• POOR GROWTH.

• MUSCLE WASTING.

• MENTAL ALERTNESS.

• APPETITE INTACT (TO VORACIOUS).

• DIARRHOEA.

• SKIN AND HAIR CHANGES.

• ANAEMIA.

• OEDEMA-ABSENT.
MARASMIC KWASHIORKOR

• PRESENTS WITH THE COMBINED FEATURES OF

MARASMUS AND KWASHIORKOR.
 National food policy
• A statement of objectives, priorities and
decisions taken on (a) food, and (b) social,
cultural, economic conditions related to
nutrition which are made as part of national
development plan for the population for a
specified period of time.
• National policy on food and nutrition was adopted
in 1998 and launched in Nov 2002
• Serves as a framework to guide the identification
and development of intervention programmes
aimed at addressing problems of food and
nutrition in Nigeria
• Universal salt iodization in overcoming iodine
deficiency diseases
• Vitamin A fortification of flour, sugar and vegetable
oil to combat VAD.
• Iron tablets for pregnant women to control for iron
deficiency anaemia
• National committee on food and nutrition
primarily to coordinate nutrition activity across
the sectors and to mobilize resources for
nutrition.
• Development of the Nigeria PROFILE. A
computer based nutrition policy analysis and
advocacy tool, primarily to make an effective
case to generate attention and resources for
combating malnutrition.
 Food hygiene/ safety
• Scientific discipline describing
– production of food,
– Handling of food
– Distribution of food
– Serving of food
in ways that prevent food borne illnesses and
health harzards.
 5 key principles of food hygiene
• Prevent contamination from pathogens spreading
from people, pests, and pets
• Separate raw and cooked food to prevent
contamination of cooked food
• Cook foods for the appropriate length of time
and at the appropriate temperature to kill
pathogens
• Store food at the proper temperature
• Use of safe water and cooked materials
 Food poison and toxicology
• Illness acquired through the consumption of
contaminated food
• Contaminants could be
– Bacteria
• Salmonella species
• Staph. Aureus
• Clostridium welchi/botulinium
• Vibroparahaemolyticus
• Bacillus cereus
• Chemical – Sea food poison
– Arsenic – Mushroom poison
– Lead • Food antigen allergy
– Cyanide
– Sensitisation to milk and
– Insecticide
egg.
• Plants/ animals
– Lathyrism (lathyrus sativus)
– Epidemic dropsy (argemone
oil in mustard seed oil)
– Aflatoxicosis (aspergillus
flavus)
 Assessment of nutritional status
• PHYSICAL EXAMINATION
– Measurement of height and weight to determine BMI
– inspection of body fat distribution
– anthropometric measurements of lean body mass.
(TSF AND MAC)
– signs of specific deficiencies
– signs of conditions that could predispose to
nutritional deficiencies (eg. dental problems)
– assessment of mental status
 LABORATORY INVESTIGATIONS

• Depend on the index case.

• Serum albumin.

• Total lymphocyte count.

• CD4 + t- lymphocytes.

• Skin antigen testing.

• Vitamin and mineral assays

 Nutrition education
• Objectives
– To establish food habits and practices consistent
with what the body needs
– To motivate people to adopt food consumption
within cultural patterns and available food
resources int the locality
– To strengthen food practices that are good, and
modify those that are likely to cause ill health
 Factors that affect success of nutrition
education
• Tradition e.g when it the male that determines
what food should be eaten in the home
• Taboo: meat, egg, for children causing “high taste”
• Idiosyncrasy; rejecting food because of colour,
taste, odour or aesthetic value
• Religion
• Availability
• Health beliefs.