100

95

75

25

0
 Section 6 : Nutrition in Public Health
127 Introduction to Nutrition in Public health Rajul K Gupta 712
128 The Proximate Principles and Energy Rajul K Gupta 717
129 Micronutrients : The Vitamins Rajul K Gupta 725
130 The Micronutrients : Minerals Rajul K Gupta 734
131 Major Foods and their Nutritive Value Rajul K Gupta 741
Nutritional Requirements of Special Groups:
132 Rajul K Gupta 750
Mothers, Children and the Elderly
133 Nutritional Deficiency Diseases of Public Health Importance Rajul K Gupta 758
Public Health Aspects of Food Hygiene & Sanitary
134 Rajul K Gupta 771
Regulation of Eating Establishments
135 Nutritional Programmes in India Rajul K Gupta 778
136 Nutritional Assessment and Surveillance of a Community Rajul K Gupta 783
Food Processing, Food Adulteration, Food Additives,
137 Rajul K Gupta 791
Preservatives, Food Toxicants and Food Fortification
Nutrition during Special Situations : Disasters, Fairs
138 Rajul K Gupta 798
and Festivals, Community Feeding of Children
139 Nutrition Tables Rajul K Gupta 804
 therapeutic regimens. For instance, his dietetic prescriptions
Introduction to Nutrition in
127 Public health
reveal a close relationship of effects of individual foods on both
sick and the well. Pulses, he said, should be eaten with cereals.
The obese should be advised to labour much, drink little….
Rajul K Gupta Remedial foods have been suggested for fever, ‘hot intestines’,
dysentery, melancholic disorders etc. (4, 5). Ancient Indian
texts give adequate indication of the importance that diet and
The term ‘Nutrition’ is derived from a Latin word nutritic,
nutrition were accorded during ancient times (Box - 2).
meaning nourishment (1). Nutrition can be considered to be the
foundation of good health and freedom from disease. ‘Nutrition
Box - 2 : Aahara, Vichara, Yoga and Ayurveda : The
science’ has been comprehensively defined by Robinson as ‘The
Ancient Indian wisdom
science of foods, nutrients and other substances therein; their
action, interaction and balance in relationship to health and Aahara or the dietary philosophy has been central to the
disease; the processes by which the organism ingests, digests, concept of ancient Indian system of medicine, Ayurveda.
absorbs, transports and utilizes nutrients and disposes off their Prudent food with a strict dietary discipline was the
end products…” (2). Simply put the word nutrition is used to hallmark of ancient Indian lifestyle and one of the secrets
refer to the processes of the intake, digestion and assimilation of a long and healthy life which the Indians enjoyed in the
of nutrients and the application of this knowledge to maintain Vedic times. As per the principles of Ayurveda, the diet is
health and combat disease. See Box - 1. supposed to change with the time of the day and seasons.
‘Hot’ and ‘cold’ temperaments of the food are supposed to
Box - 1 : Significance of nutrition be balanced with the weather, seasons and climate. These
dictums were ingrained in the lifestyle along with good and
Adequate nutrition is required for growth, development and
noble thoughts (vichara) and the discipline of life (Yoga) for
maintenance of normal functions
a long lasting good health and the ultimate union with the
Under nutrition contributes to 60% deaths amongst under supreme power. Can we learn something from this traditional
five children (WHO, 2002) Indian wisdom!
More than 85% children in India suffer from malnutrition
(44% Mild malnutrition, 38% moderate malnutrition and 4.6% The phrase ‘science of nutrition’ was first used probably by Count
severe malnutrition) (Gomez classification, NNMB 2007) Rumond in an essay on feeding poor people in 1795 (6). During
the same period Lavoisier who was working on combustion and
About 55% men and 75% non pregnant non lactating women respiratory metabolism, is said to have established nutrition as
are anaemic a science (7). In 1753 James Lind published the first edition of
Epidemiological data shows strong association between A Treatise on the Scurvy which elaborated how 110 men were
under nutrition and morbidity / mortality disabled by scurvy and were miraculously cured by an Indian
Chronic degenerative disorders such as coronary artery remedy (the infusion of the needles of an evergreen tree). Lind
disease, hypertension, type 2 diabetes, certain cancers, etc was also the first one to study experimentally the value of
are related to diet and nutritional status different substances in the treatment of scurvy, and proved
that dietary lemons and oranges cured scurvy (5).
Obesity is associated with higher risk of developing cancer
In 1839, a Dutch physician Gerrit Mulder claimed that complex
breast, colon, endometrium, gallbladder, esophagus,
nitrogen compounds like egg albumin, serum albumin, fibrin
pancreas, etc.
and wheat gluten all contained a common radical, ‘protein’ (8).
Consumption of foods rich in dietary fibre and antioxidants Marasmus was described in the year 1877 by Jules Poirot from
is associated with reduced risk of certain cancers France under the term “athrepesie”.
Under nutrition during foetal and early childhood is known The science of nutrition bloomed during the 20th century.
to be associated with chronic degenerative disorders in later Vitamins and amino acids were discovered, human nutritional
life requirements were established and the relationship between
diet, nutrition and the human body in health and disease were
Good nutrition is a fundamental requirement for positive recognized. These scientific advances evolved through several
health, functional efficiency and productivity. Nutritional phases. Lafayette B. Mender (USA) identified the nutritive
status is internationally recognized as an indicator of national value of proteins during 1909-1928. In due course, various
development. Nutrition is both an input into and an output of, experiments and observations by different workers pointed
the developmental process (3). towards some unknown food factors that were vital for the
Nutrition is an extremely dynamic subject that changes every very sustenance of life. JBA Dumas (1871) was the earliest man
day. Continuous research and a constant study into nutrition of science to question the adequacy of diet composed only of
therefore remains a subject of contemporary interest. proteins, carbohydrates, fats and salts. He had published his
observations on the health of infants of Paris made during the
History
siege by the Germans. Pekelharing demonstrated in 1905 the
It is believed that Hippocrates, the Father of Medicine, paid existence of unidentified nutrients in milk and why they were
strict attention to the diet of his patients as a feature of his absolutely essential for survival of mice in minute quantities.

• 712 •
In 1912 Casimir Funk (Poland) propounded the theory that research on animal nutrition, communicable disease and
beriberi, scurvy, pellagra and possibly rickets were caused food safety. The bird flu endemic has once again opened the
by deficiency of “special substances which are of the nature Pandora’s Box : ‘Are the non-vegetarian foods safe enough?’
of organic bases” and coined the term ‘vitamine’. Thus the (9). Fierce research is on, to answer these questions through
new concept of dietary deficiency diseases was born. In 1926 the integrated effort of multidisciplinary forces… medicine,
Goldberger and Lillie described malnutrition in rats also virology, veterinary medicine, nutrition, food technology, public
featuring growth arrest, ‘ophthalmia’, hair loss on ears, neck, health, epidemiology, genetics, biotechnology, mathematical
chest and forearms etc. Fur became matted and fell exposing modelling, information technology…. These and many other
denuded pale pink skin. Oral and lingual ulcers and fissuring advances in nutritional sciences represent the ceaseless effort,
were also noticed. Diarrhoea was also seen in some rats. The genuine initiative and devotion of many pioneer scientists all
condition was diagnosed as rat pellagra. Lean meat and yeast over the world through out the ages.
cured it. The curative agent was designated by Goldberger and Food and Nutrients : Major Categories of Foods and
Lillie as pellagra-preventive (P-P) factor. However, later it was
Nutrients
found that this condition (in rats) was not analogous to human
pellagra, but was caused due to the deficiency of riboflavin. Food : Food is a substance eaten or drunk to maintain life and
growth. The foods are generally classified into cereals (wheat,
The dangerous disease Pellagra was earlier described in
rice, maize etc.), legumes (pulses and peas), nuts and oilseeds,
Northern Spain in 1735 by Casal. However, scientific world had
vegetables, fruits, milk and milk products and flesh foods (fish,
to wait till Goldberger undertook a study in 1915. He studied
meat and chicken and egg). Diet, on the other hand is what a
the diets of patients and medical staff in State Asylums in
person habitually eats and drinks.
South Carolina, Georgia and Mississipi. This study proved that
the disease was caused by a deficiency rather than a poison Nutrients : The nutrients are chemical substances that
or infection. The search for the pellagra preventing factor are present in the food we eat. The important nutrients are
travelled through high proteins, yeast and liver and ended with proteins, fats, carbohydrates, vitamins and minerals. Foods
the isolation of nicotinic acid from rice polishings by Funk in contain various nutrients in different proportions. Depending
1912. Many other workers also isolated this chemical from on the relative concentration of various nutrients foods can be
other food stuffs (5). classified into protein, carbohydrate or fat rich foods.
Verner McCollum (USA) discovered a fat soluble soluble factor Why do we eat food? - Functions of food : We eat to satisfy
that was essential for growth (Vitamin A) in l916 (6). Chick, hunger (satiety) and to get energy for our day to day functioning.
Windaus and Hess worked on Vitamin D, Evans and Bishop Food serves many functions in the body :
on Vitamin E, King and Gyorgy on Vitamin C, Dam on Vitamin a) Food builds body tissues : The structural materials of food,
K, Mitchell, Snell and Williams on folic acid and Hodjkin on proteins, minerals, vitamins and water are needed for growth
Vitamin B. and development. The food is also needed for the maintenance
McCance, Mac Kay, Widdowson, McLaren and Woodruff did of the cells and tissues.
pioneering work on iron deficiency. Ciceley Williams (England) b) Food regulates body processes : Many a body processes
described Kwashiorkar in 1933. Kerpel Fronuis, Gomez and are regulated by the ‘fuel’ supplied through food e.g.
Cravioto also worked on protein calorie deficiency. temperature control of the body (calories), control of osmotic
Great debate started in the sixties and seventies on the causation pressure (proteins and electrolytes), maintenance of hydrogen
and relationship between marasmus and kwashiorkor where ion concentration (pH through electrolytes), solvent power
eminent nutritional scientists, Waterlow, Gopalan, Scrimshaw, of fluids (proteins and water), nerve conduction (minerals),
McLaren and others participated. Various studies on protein muscle elasticity (minerals), innumerable metabolic processes
and energy requirements, the role of infection, metabolic and (vitamins and minerals).
endocrine changes, and adaptation were carried out. Derrick c) Food supplies energy : The macronutrients (carbohydrates,
Jelliffe, a pioneer in nutrition introduced the term ‘protein- proteins and fats) supply energy. These provide constant source
calorie’ malnutrition, which was later modified to protein of fuel to the body. It is measured in terms of a kilo calorie.
energy malnutrition and adopted by the FAO/WHO committee d) Food gives us enjoyment : We want to enjoy food and
in 1971 to describe both kwashiorkor and marasmus. entertain our guests with tasty food.
Into the 21st century : The era of interdisciplinary These requirements may be met by various combinations of the
coordination three major food constituents : carbohydrates, proteins & fats,
Agriculture cannot be kept away from nutrition. Great advances taken in different proportions. Although the actual distribution
in agriculture were achieved with the green revolution in of each one of these nutrients in our daily diet is vital for
India. The introduction of genetically engineered food during good health, one hardly considers their proportion, as long as
the last decades of the twentieth century was followed by an he enjoys the food. It must be appreciated that our lifestyle
ongoing international scientific debate. Parallel advances were governs all facets of our life including our eating habits.
achieved in animal nutrition and veterinary medicine, which The community faces major nutritional problems from the
increased animal food production. The relationship between consumption of inadequate or imbalanced diet. This is true
mad cow disease and animal food as well as its relationship to for both healthy and sick. Economic prosperity and affluence,
Cruetzfeld Jacob disease in the humans is stimulating further at least in a section of the society, are now threatening the

• 713 •
community through over nutrition and its related hazards. attacks of acute respiratory or acute diarrhoeal infections are
From Under-Nutrition to Over-Nutrition notorious to lead to a malnourished state. Measles is another
dangerous condition that has a lasting negative effect on
Within the past few decades, there has been a significant the system through compromised immunity, micronutrient
reduction in cases of nutritional deficiencies. Classical deficiency and severe malnutrition.
nutritional deficiency syndromes of florid pellagra, beriberi,
scurvy or kwashiorkor have almost disappeared. We do not Malnutrition in childhood diminishes the proper development
come across the famines any more. This improved scenario is a of the immune response mechanism. The cellular immune
result of multiple inputs namely, smaller families, better food responses are markedly impaired leading to a higher mortality
security, economic development, improved health systems, from the seemingly common infections.
conquest of infections, better health awareness and accountable Variability in Nutritional Requirements
governance. It is seen that malnutrition among preschoolers Even though there is a concept of standard requirements and
has reduced appreciably and nutritional status of adults too intakes, it must not be forgotten that each person has unique
has improved significantly. There is not only a major reduction nutritional requirements. This is because each one of us has
in malnutrition, but over the past decade or so we have stepped a unique genetic make up and body biochemistry. A nutrient
into the realm of over nutrition. The number of overweight intake sufficient for one person may be inadequate for other.
and obese is steadily and alarmingly rising in India. This is There are many references in literature where it is quoted that
owing to the rapid lifestyle changes that have swept India. where 2 mg Vitamin B6 is normally adequate for most but there
Mechanization, motorization, static entertainment (television are individuals with inherited defects in B6 metabolism and
and computers), sedentary life, low physical activity and the need 30 to 100 times that amount. Similarly the absorption
fast food culture has taken its toll. The situation is so alarming and daily requirements of Calcium varies 3 to 5 folds in various
that there is a recommendation to redrawn BMI standards with normal individuals. The same can be said for Vitamin D and
a more stringent ‘pen’, in a hope to stall the rapid progression Iron where metabolic differences in handling these nutrients
of lifestyle diseases - diabetes, hypertension and the coronary alter their requirement.
artery disease.
Besides these genetic differences, many other factors can also
The Interplay between Malnutrition and Infection alter daily requirements, including age, environment and life
There has been a close association between malnutrition and style choices. Factors as diverse as pregnancy, lactation, sports
infections (Fig. - 1). It is a vicious cycle that is difficult to training, smoking and pollutants can cause nutritional needs
break in the setting of poverty, ignorance and lack of health to vary. Some of these factors are summarized in the Box - 3.
services.
Box - 3 : Factors altering the daily requirement of
Fig. - 1 : The vicious cycle of malnutrition and infections nutrients
Severe Biochemical individuality Genetic differences
Malnourishment Gender Pregnancy
Lactation Growth
Nutrients: Increased Infections Other diseases
Extra need & metabolic rate & tissue
Poor supply Surgery Drug-Nutrient interaction
damage.
Low immunity Smoking Alcohol
Caffeine Environmental pollutants
Activity Exercise level
Diet factors e.g. intake of : Carbohydrates; Fat; Fibre; Proteins
In GI infections Need for extra
nutrient absorption nutrients and Dietary Standards : Concept of Recommended Dietary
diminished also reduced Allowance (RDA)
appetite
It is extremely important to plan the rations and food supplies
for various groups, may it be the general community or a
Let’s take fever as an example. The raised temperature escalates specialized group like the armed forces, a school or a prison.
the metabolic rate and thus increases the nutritional demand; For such a planning we must have a set of standard allowances
it also increases the tissue breakdown further putting an extra that are universally acceptable and followed. The first such
nutritional load on the system. In almost all infections the example (for cereals) can be traced back to ancient Rome (see
appetite goes down and the absorption and assimilation is also Box - 4). The concept of various macro-nutrients first evolved
hampered. The requirement of nutrients is increased and to make in the nineteenth century. At that time the dietary requirements
matters worse, the supply is diminished and the absorption is were stated in terms of nutrients rather than foods. In the early
reduced. The body can cope up with this situation for few days twentieth century vitamins came on the landscape and their
but subsequently acute severe malnutrition develops. Repeated requirements were also worked out and stated (10).

• 714 •
 keeping the RDAs in mind.
Box - 4 : The Roman Pound of Wheat
The concept of recommended allowance for the day probably
Reference Man and Woman
came from the Romans. The Romans gave their legionaries The final goal of all nutritional policies and recommendations
a ration of one ‘librum’ of wheat per day and that was at a national level is to provide adequate nutrition to its
supposed to meet their caloric requirement for the day. The population in order to attain their full genetic potential
‘librum’ became the British Pound (abbreviated to and still of growth and development. It is important that the ideal/
used as ‘lb’). One pound of cereal is now known to be good desirable weights and heights are considered to recommend
enough to provide energy needed for an adult man for resting nutrient intakes. For this purpose the ICMR expert committee
metabolism. recommended reference weights for adult men and women to
be 60 Kg and 50 Kg respectively.
Recommended Dietary Allowances or Intakes (RDA or Reference Indian Adult Man : Reference Indian adult man is
RDI) between 20-39 years of age and weighs 60 Kg. He is free from
The RDA of a nutrient is the amount (of that nutrient) sufficient disease and physically fit for work. On each working day he
for the maintenance of health in nearly all people (11). In is employed for 8 hours in occupation that usually involves
other words these are the estimates of nutrient intakes which moderate activity. While not at work he spends 8 hours in bed,
individuals in a population group need to consume to ensure 4-6 hours sitting and moving about and 2 hours in walking
that the physiological needs of all subjects in that population and in active recreation or household duties.
are met. It is an estimate that corresponds to mean intake of Reference Indian Adult Woman : Reference Indian adult
the given nutrient + 2 Standard Deviation (that is about 25% of woman is between 20-39 years of age and healthy; she weighs
the mean has been added). It covers the requirement of 97.5% of 50 Kg. She may be engaged in general household work, in light
the population. This is the safe level of intake and the chances industry or in any other moderately active work for 8 hours.
of this level being inadequate is not more than 2.5%. This ‘safe While not at work she spends 8 hours in bed, 4-6 hours sitting
level’ approach is however not used for defining the energy and moving about in light activity and 2 hours in walking or
requirement, as any excess of energy intake is as undesirable active household chores.
as its inadequate intake. Hence for defining the RDA of energy Energy requirements for sedentary, moderate and hard work
only the average requirement is considered. The recommended (12) : Energy requirements of an individual vary over a wide
dietary allowances for Indians are summarized in Table - 1 in range depending upon the sex, age, body size, BMR and degree
‘Chapter on Nutritional Tables’. of physical activity. As it has been discussed earlier, energy
Can the RDA be Applied to Individuals? requirements are given in terms of a Reference man/woman.
Energy requirements for other individuals with different
It must be appreciated that the RDA is the mean requirement
weights and age have to be calculated.
figure for a nutrient (except energy), to which an allowance
corresponding to 2 SD has been added. There are several The classification of physical activity as sedentary, moderate
individuals in a population whose requirement is actually well and heavy is essentially based on the occupational activity.
below or above the RDA. If all the students in a class of 100 Some more examples are given in the Box - 5. The energy
were to eat food exactly as per their RDA about half would loose requirements for these three categories are summarized in
and the other half would gain weight, to the extent of being Table 1.
seriously undernourished or obese after a year! It is because
the RDA for energy is a catering average; individuals however Box - 5 : Some examples : Sedentary, moderate and hard
consume as per their appetite, which follows their energy workers
expenditure. The RDA can therefore, not be used as standard Sedentary worker : Teacher, tailor, barber, priest, executive,
to determine whether or not a given individual’s requirement peon, retired personnel, shoe maker, housewife, maid, nurse,
of a nutrient has been met. It is therefore important to keep doctor, clerk, shopkeeper, manager, goldsmith etc.
the principles of probability in mind and be cautious, when
Moderate worker : Potter, basket maker, carpenter, mason,
applying RDA at an individual level (10). electrician, fitter, turner, driver, welder, fisherman, coolie,
RDAs provide a standard against which the nutrients in the food site supervisor, post man etc.
eaten by a section of the community /country can be assessed.
Heavy worker : Stone cutter, blacksmith, mine worker, wood
It is thus possible to find out a group with a low intake of a cutter, farm labourer, army soldier etc.
particular nutrient. Further nutritional investigations are then
mounted to go into the details and suitable measures can be
recommended. As discussed earlier, RDAs should not be used to Table - 1 : Energy Requirements of Reference Indian Man
assess the diet of an individual patient as they are designed to and Woman
be on the higher side than the average individual requirement. Body
Whenever diets are required to be planned for a group like the Sex Activity levels
weight (Kg)
armed forces, a school, hostel etc., the diet should meet the
Sedentary Moderate Heavy
RDA. Similarly, RDAs are the starting point for the food and
economic planning for the agricultural, economic and food Male 60 2425 2875 3800
sectors. The national level food balance sheets are prepared Female 50 1875 2225 2925

• 715 •
Prevention of Nutritional Disease and Upkeep of Government level : The responsibility of maintaining the health
Nutrition in the Community - Role of Individuals, of individuals lies with the state. The government endeavors
Family, Communities and Governments to provide all the health services possible. Various nutritional
programmes are being implemented as direct intervention to
It can be well appreciated that it is not merely the ‘nutritional’
improve the nutritional status of the community. Noteworthy
factors that are responsible for nutritional disease. These
of these are the ICDS Programme, Balwadi nutrition programme
conditions are truly multi-factorial in origin and progression.
and the Special Nutrition programme under the Ministry of
The scarcity of food, its nutritional value, distribution, balance
Social welfare. Ministry of Health and Family Welfare runs the
in diet, cultural, local and religious factors and beliefs, other
Nutritional anaemia prophylaxis programme, Iodine deficiency
social factors like ignorance, poverty, taboos, fads, peer pressure,
disorders control programme and the Vitamin A prophylaxis
education, hygiene and sanitation practices, infections,
programme. The Mid Day Meal programme (for primary
availability of health services, level of immunization services,
children) is being run by the Ministry of Education.
political will, corporate interests, national commitment,
international influences like trade laws and treaties, export- Besides these various indirect measures are being taken by
import dynamics and compulsions, inter country relations, the the government for rural development, increasing agricultural
state of global warming - each one of these have a bearing production, population stabilization and improving the public
on the nutritional status of a society. When the etiology is so distribution system. Research in the field of nutrition is being
diverse, the prevention too has to be so much broad based carried out at premier institutions like the National Institute
and multifaceted. The issue can be tackled at the levels of the of Nutrition at Hyderabad that has contributed to offering
individual, family, community and governments. solutions to nutritional problems.
Individual level : Health begins with the individual. The Summary
individual has to take care of himself. Selecting the correct kind
The science of foods and nutrients and their action, interaction
of food is vital, based on his age, physiological state, taste and
and balance in relationship to health and disease; the processes
tradition. Besides good diet, physical activity, adequate sleep,
by which the organism ingests, digests, absorbs, transports and
mental peace and appropriate meditative or religious activities
utilizes nutrients and disposes off their end products is termed
go a long way in keeping an individual healthy. Knowing the
as nutrition. Good nutrition is a fundamental requirement
nearest health centre, services available there and warning
for positive health, functional efficiency and productivity.
signs of common illnesses is also important.
There has been a close association between malnutrition and
Family level : Most of the foods are ‘handed over’ to us infections. It is a vicious cycle that perpetuates in the setting of
through traditions, and it is not easy to break out of those. poverty, ignorance and lack of health services.
Within that framework, it might be decided by the head of the
The variation in the daily requirements of nutrients depends on
family as to what food stuff is to be brought, cooked or eaten.
the genetic differences, age, environment and life style choices.
The family needs to be aware and educated on the issues of
Factors as diverse as pregnancy, lactation, sports training,
nutrition to select the correct foods in different situations
smoking and pollutants can also cause nutritional needs to
of infancy, childhood, pregnancy or lactation. This can
vary. However a set of universally acceptable standard nutrient
happen only when they have risen above the myths, taboos,
allowances have been devised that are useful to plan the rations
fads and misconceptions encompassing foods. Misleading
and food supplies for diverse groups. The RDA of a nutrient is
advertisements must be put in the right perspective. Children
the amount (of that nutrient) sufficient for the maintenance of
must be explained the hazards of junk food and food additives.
health in nearly all people. The RDA is based on the concept of
Traditional values with respect to food must be highlighted.
Reference Indian man and woman.
The family foods used during pregnancy, lactation and weaning
must be acknowledged. Locally available foods that are easily Study Exercises
available, cheap, fresh and suitable to a particular season Long Question : Discuss the role of individual, family,
are ideal and must be consumed in preference to ‘imported’ community and government in the prevention of nutrition
foods. A small kitchen garden will go a long way not only in related diseases.
appreciating good and wholesome food but also in fulfilling
Short Notes : (1) Indian reference man (2) Nutritional
the nutritional needs of the family in the most inexpensive and
requirement of sedentary man (3) Malnutrition-infection cycle
enjoyable manner. The most crucial nutritional decisions are
taken at the family level, so the family must be empowered MCQs
through correct knowledge. 1. Who coined the term ‘vitamin’ : (a) McCollum (b) Funk
Community level : There might be a number of bottlenecks that (c) Hopkins (d) James Lind
exist at a local level which prevent the national programmes 2. A teacher will be classified as a (a) Sedentary worker
reach the grassroot. It is up to the community to meet this (b) Moderate worker (c) Heavy worker (d) Average worker
challenge of making these programmes actually beneficial to 3. A ‘safety margin’ of + 2 SD is not incorporated for the
the people. For example the Gram Sabha, the local ICDS unit RDA of (a) Energy (b) Fats (c) Water soluble vitamins
(Anganwadi) etc. must be aware of their rights and duties, and (d) Fat soluble vitamins
whom to approach in case of neglect. The community must be 4. Which of the following diseases is most notorious to
organized and ‘live’ up to these needs, otherwise they will have prove fatal in combination with malnutrition : (a) Tetanus
to be satisfied with whatever is ‘served’ to them! (b) Anaemia (c) Measles (d) Diarrhoea

• 716 •
5. Choosing what type of food to eat in a household is the 5. Mc Collum EV. A history of Nutrition, Boston, Houghton Miffin Company,
1957.
function of the (a) Family (b) Government (c) Community
6. Todhunter EN. Chronology of some events in the development and application
(d) Any of the above of the science of Nutrition. Nutrition Reviews, 1976, 34 : 354- 375.
Answers : (1) b ; (2) a ; (3) a ; (4) c ; (5) a. 7. Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and
Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.
References 8. Mahan LK, Stump SL. Krause’s Food, Nutrition & diet therapy.11th edition
1. Nix Staci. Williams Basic Nutrition and Diet Therapy. 12th edition. Mosby, Saunder’s Philadelphia, USA. 2000
Elsevier. Missouri, USA. 2005 9. Gabr M. IUNS in the 21st century on the shoulders of 20th century giants of
2. Bamji MS, Rao NP, Reddy V. Textbook of Human Nutrition. 2nd ed. Oxford & nutrition. In : Modern Aspects of Nutrition, Present knowledge and Future
IBH Publishing Co Pvt Ltd, New Delhi.2003. Perspectives. Eds Elmadfa I, Anklam E, Konig JS. 2003. 56 : 13-18
3. Report of the Working Group on Integrating Nutrition with Health for the 10. Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and
XI Five Year Plan (2007-2012 Government Of India Ministry Of Women And Dietetics. Churchill Livingstone, ELBS London. 1986.
Child Development November 2006. 11. World Health Organization. Technical Report Series no. 477; 1971.
4. Hippocrates, the authentic writings of; Translated by Adams F. Wm Wood 12. National Institute of Nutrition, Nutritional requirements and recommended
and Company., New York, 1929; Vol 1, 272-277 and Vol 2 42, 193-98. dietary allowances for Indians; A report of the ICMR, 2004.

of internal organs and to maintain the body temperature.

The Proximate Principles and
128 Energy
This energy is required for maintaining the basal or resting
metabolism. Age, sex, height, weight and state of nutrition of
the individual are some of the factors that influence it. The
Rajul K Gupta Basal Metabolic Rate (BMR) is determined experimentally when
the subject is lying down at complete physical and mental rest,
wearing light clothing in a thermo-neutral environment and in
The human body requires various nutrients for survival,
the post absorptive state (at least 12 hours after the last meal).
maintenance of health and to prevent disease. Proteins, fats,
The BMR is related more closely to lean body mass (fat free
carbohydrates, vitamins, minerals and antioxidants are the
body) rather than to the surface area. The reported value of
most important of these. Proteins, fats and carbohydrates are
BMR for Indians is 1 Kcal / Kg/ hr.
the ones which form the backbone of the nutrients in terms
of quantity and these are termed as the proximate principles Units of Energy
of food. In order to appreciate the influence of food on health Calorie is the basic unit of energy. Kilo calorie is defined as the
and the factors which affect food requirements, it is necessary heat required to raise the temperature of 1 Kg of water by 1°C
to know the chemical composition of food and its metabolism from 14.5°C to 15.5°C. The Joule (J) is the SI unit of energy. It is
in man. The most primary function of food is to be broken defined as the energy expended when a mass of one kilogram
down in the body to generate energy, which is vital for the very is moved one meter by a force of one Newton (N). Since Joule is
survival of the body. too small a unit to describe the energy value of diet, kilo Joule
Energy for basal functions, work metabolism and heat for (KJ) and mega Joule (MJ) are of more practical use. One KJ is
maintenance of body temperature is produced by the oxidation equal to 1000 J and one MJ is equal to 1000 KJ. However, the
of carbohydrates, fats and proteins. The intake of food is old unit of energy, namely, kilocalorie (Kcal) has been in use
normally balanced by hunger which thus, indirectly balances in nutrition for a long time and is still being used (1, 2). For
energy expenditure. Hunger may, however, not indicate this conversion, 1 Kcal = 4.184 KJ and 1 KJ = 0.239 Kcal. Energy
in various pathological states, notably in certain forms of contents of common food items are shown in Table -1 & 2 :
malnutrition. Moreover, hunger can be modified not only by
enough intake of food but also by doing less muscular work.
Proteins
Absence of hunger is not, therefore, necessarily an index of Proteins are large molecules made up of nitrogen containing
an adequate food intake. Before going into the biochemical amino acids that are united together by peptide linkages. In
and physiological qualities of food let us dwell on the basics adults approximately 16% of body weight is attributable to
of energy. proteins. Next to water, protein is the major component of
body tissues. Proteins are indispensable constituents of living
Energy protoplasm as they participate in all vital processes. Proteins
Energy is required for maintaining the body temperature and are macromolecules consisting of amino acid chains. The
vital activity of organs, for mechanical work and for growth. human body has a limited capacity of converting one aminoacid
Even when an individual is at complete rest and no physical into another (1, 4). A total of 22 aminoacids are now known
work is being carried out, energy is required for the activity to be physiologically important for the human body. Under
proper conditions, the body is capable of synthesizing some of

• 717 •
 Table 1 : Major contributors of energy to our diet - (Some Table 2 : Energy content of selected Indian food items
raw foods and their energy content per 100g) (1) (per serving) (3)
Energy Energy Food item Kcal Food item Kcal
Food stuff Food stuff
(Kcal) (Kcal) Samosa (1 no.) 256 Dalia (1 plate) 80
Cereals & Millets Non vegetarian foods Masala dosa (1 no.) 360 Khichri (1 plate) 160
Wheat flour 341 Egg (hen) 173 Kachori (2 nos.) 500 Biscuits (4 nos.) 150
Rice polished 345 Fish (Hilsa) 273 Omlette (1 egg) 236 Poha (1 plate) 120
Bajra 361 Chicken 109 Puri (4 nos. x 320 Bread (2 slices) 125
Maize dry 342 Mutton (lean) 118 25 g each)
Ragi 328 Pork (muscle) 114 Chapati with ghee 360 Chapati ( 2 nos. 160
Pulses & Legumes Milk & milk products (4 nos.) x 35 g each)

Bengal gram 360 Milk, cow 67 Cake (1 small piece) 250 Kheer (1 katori) 120

Soya bean 432 Milk, buffalo 117 Butter chicken 400 Cornflakes (1 bowl) 190
(1 katori)
Rajmah 346 Milk, human 65
Chiken biryani 400 Veg salad 50
Redgram (Arhar) 335 Butter 729 (200 g)
Greengram Ghee Malai paneer 270 Butter milk (1 glass) 90
334 900
(Moong) (1 katori)
Lentil (Masoor) 343 Cheese 348 Paratha (2 nos. 360 Jam (1table spoon) 40
Pea dry 315 Curd 60 x 50 g each)
Fruits & Vegetables Nuts Ice cream (100 ml) 250 Dhokla (2 pcs) 100
Banana 116 Groundnut 567 Pastry (1 no.) 290 Green leafy veg 130
Apple 59 Cashew nut 596 (1 katori)

Grapes, pale green 71 Coconut, fresh 444 Milk cake (1 piece) 300 Idli (2 nos. x 155
55 g each)
Custard apple 104 Miscellaneous
Butter (2 table spoon) 180 Dosa (2 nos. x 250
Jack fruit 88 Jaggery 383 45 g each)
Raisins 308 Sugar 398 Fried Cashew (50 g) 375 Tinned cheese 105
Potato 97 Veg oils 900 (2 tbsp)

these amino acids, provided the supply of nitrogen is adequate. oilseed cakes
These amino acids are known as nonessential amino acids. The major sources of proteins are depicted in Table - 3.
Others cannot be synthesized by the body and must therefore
Role in health and disease : The important functions of
be supplied in diet. These are the eight essential amino acids
proteins are summarized in the Box- 1.
viz. leucine, isoleucine, lysine, valine, methionine, threonine,
tryptophan and phenylalanine. To these may be added histidine Quality of Proteins
which appears to be essential for the growth of infants (5, 6). The nutritive value of a protein depends upon its amino acid
Sources of proteins : There are two main dietary sources of composition. A biologically complete protein is one which
proteins : contains all the essential amino acids in adequate amounts to
(a) Animal Sources : These include eggs, milk, meat and fish meet human requirements. Proteins from foodstuffs of animal
origin, such as milk, meat and eggs are biologically superior
(b) Vegetable Sources : Pulses, nuts, cereals, beans and
to proteins of vegetable origin as animal proteins have all the

Box - 1: Functions of Proteins

(a) Proteins are important for body building, growth, repair and maintenance of body tissues
(b) Proteins are required for the synthesis of plasma proteins, haemoglobin, enzymes and hormones
(c) Proteins like collagen, actin and myosin form the structural tissues - skin and muscles
(d) Proteins act as transport carriers for many molecules like iron, haemoglobin, lipids etc.
(e) Antibodies are also proteins. Proteins are involved in the acute phase of inflammation as well
(f) Albumin, a protein, acts as a buffer in the maintenance of blood pH (7)

• 718 •
 Recommended Dietary Allowance (RDA) for Proteins :
Table 3 : Major sources including their protein content (g
The requirement of proteins is generally accepted to be 1g/
per 100g)
Kg/day for adults. So the recommended dietary allowance
Protein for a reference adult male works out to 60g/day and for a
Food Item Protein Food Item
content reference adult female it is 50g/day. An additional allowance
(Source) content (g) (Source)
(g) of 15g/day is recommended for pregnancy. During lactation
Eggs 13.3 Milk (Cow) 3.2 an extra allowance of 25g in the first 6 months and 18g in
the subsequent 6 months is recommended. Children have a
Meat (goat, lean) 21.4 Fish (Hilsa) 21.8 higher protein requirement as elaborated in Table - 4 (1). A
Pulses (red gram) 22.3 Soya bean 43.2 detailed account of the requirements of proteins for pregnant
Groundnuts 25.3 Wheat flour 12.1 and lactating women, infants and children is discussed in
the chapter on “Physiological requirements of nutrients”. An
Rice (raw, milled) 6.8 French Beans 1.7 attempt is also made to elaborate as to how this requirement
could be met in the typical Indian conditions. Some tips on
improving the consumption of proteins is given in the Box- 3.
essential amino acids present in them. Most of the vegetable
proteins lack one or more amino acid and are thus classified as Deficiency can occur when the diet does not provide enough
biologically incomplete proteins. protein in relation to the requirement which may be high as in
the case of young growing children. Secondly, if energy intake
The essential amino acid that is in shortest supply in a given is insufficient proteins will be diverted to produce energy and
food item is known as the limiting amino acid, for example thus causing a deficiency of proteins. Childhood infections
the limiting amino acid in wheat is lysine and in pulses it is (esp. measles) also play an important role in triggering and
methionine. The quality of vegetable proteins in a vegetarian sustaining a long term protein deficiency. Protein Energy
diet can be improved by providing a suitable combination of Malnutrition (PEM) is a major cause of concern for children in
vegetable proteins. A relative lack of a particular amino acid in our country. PEM is discussed in greater details in Chapter on
one protein can be compensated by simultaneous consumption ‘Nutritional Deficiency Diseases’.
of another protein, which contains that limiting amino acid.
This is known as supplementary action. Thus a diet combining Table - 4 : Recommended Dietary Allowance (RDA) for
wheat products such as bread (chapati) with pulses (dal) will Proteins
compensate for these deficiencies (of lysine and methionine)
and provide all the essential amino acids. Other similar Body Requirement
Group Activity
examples from Indian diet are Idli-Sambhar, Wada-Pav, Rice- weight g/day
Dal, Khichri etc. Sedentary work
Quantitatively the quality of a protein is worked out in terms Man Moderate work 60 60
of biological value, digestibility co-efficient, net protein
Heavy work
utilization and protein efficiency ratio. The working formulae
for each of these parameters are shown in the Box- 2. The net Sedentary work
protein utilization (NPU) is the most commonly used parameter. Moderate work 50 50
A protein with an NPU of more than 65 is considered as of
Heavy work
optimum quality. Egg protein is considered to have an NPU
of 100 and is considered as ideal or reference protein against Woman Pregnant woman 50 +15
which other proteins are compared with. Lactation
0-6 months 50 +25
Box- 2 : Quality of Proteins
6-12 months +18
The quality of a protein depends upon its amino acid
composition. A protein containing all amino acids is 0-6 months 5.4 2.05/ Kg
Infants
considered as ‘ideal’. Egg protein is taken as the reference 6-12 months 8.6 1.65/ Kg
protein.
1-3 years 12.2 22
Nitrogen retained x 100
Biological value (BV) = Children 4-6 years 19.0 30
Nitrogen absorbed
7-9 years 26.9 41
Nitrogen absorbed x 100
Digestibility co-efficient = Boys 10-12 years 35.4 54
Nitrogen intake
Girls 10-12 years 31.5 57
Retained Nitrogen x 100
Net Protein Utilization (NPU) = Boys 13·15 years 47.8 70
Intake of Nitrogen
Girls 13·15 years 46.7 65
Weight gain in g
Protein Efficiency Ratio (PER) = Boys 16-18 years 57.1 78
Protein intake in g
Girls 16-18 years 49.9 63

• 719 •
 Box - 3 : Recommendations on Diet for Proteins Table-5 : Major sources including their fat content
Eat nutritionally balanced diet to get adequate protein (g/100g)

Meat and fish are good sources Food Item (source) Fat content (g/100g)

Vegetarians must eat proper combination of plant proteins Eggs (hen) 13.3
from both cereal and pulses groups Milk, cow 4.1
Include Soyabean in your diet Meat (Goat lean) 3.6
Two to three servings of protein-rich food must be ensured Fish (Hilsa) 19.4
every day Ghee 100
One serving may be equivalent to : Butter 81.0
- One to two cups of cooked meat, poultry, fish
Groundnut 40.1
- Half cup of cooked dry beans/ lentils/ legumes
Mustard seeds 39.7
- One egg
Coconut, fresh 41.6
- Handful of fried/roasted- salted groundnuts
Sunflower seeds 52.1
- Handful of roasted Bengal grams

than 80 g / day.
Fats
Some amount of fat is present in all food stuffs. From the
Fats are organic compounds, which are insoluble in polar
nutritional standpoint, important of them are cereals, pulses,
solvents (water) but soluble in organic solvents such as ether,
oilseeds, nuts, milk, eggs and meat. Contrary to general
chloroform and benzene. These are actual or potential esters
awareness, this invisible fat contributes substantially to the
of fatty acids. Fats are only distinguished from oils by their
total fat consumption and essential fatty acid intake of our diet.
different melting points; fats are solid and oils liquid at room
Cereals and pulses which are otherwise perceived to be poor in
temperature. ‘Fats’ and ‘oils’ are the ones which the housewife
fats contribute significantly towards fat intake of a Indian diet.
buys and ‘lipid’ (Greek, lipos meaning fat) is the term used by
This is because most Indians depend on the ‘staple’ of cereals,
biochemists. However, the general term fat is commonly used
consumed in a large quantity. The invisible fats may account
to refer to the whole group and is used interchangeably with
for 20 to 50% of all fats consumed, depending on the type of
lipids.
diet. It should however contribute to not less than 6% of total
Sources of fats : Dietary fats are derived from two main energy or about 15g of invisible fats per day.
sources:
Types of Fatty Acids
(a) Animal Sources : They are milk and milk products (ghee,
butter), lard, egg and fish oils. Animal fats in general are poor Fatty acids are composed of a straight hydrocarbon chain with
sources of essential fatty acids with the exception of certain one methyl group (—CH3) and terminating with a carboxylic
marine fish oils such as cod liver oil and sardine oil, but they acid group (—COOH). Hydrogen atoms are attached to the
are good sources of retinol and cholecalciferol. carbon chain; the number of hydrogen atoms determines the
degree of saturation (with hydrogen atoms) of the fatty acid.
(b) Vegetable Sources : They include various edible oils such as
A fatty acid with hydrogen atoms on every arm is said to be
groundnut, gingely, mustard, cottonseed, safflower, rapeseed,
‘saturated’. Unsaturated fatty acids contain double carbon
palm and coconut oil. Vegetable oils with the exception of
bonds where there is no hydrogen. If there is only one double
coconut oil are all rich sources of essential fatty acids, but they
bond, the fatty acid is termed as monounsaturated and when
lack retinol and cholecalciferol except red palm oil which is rich
more than one double bond is present, the fatty acid will be
in carotenoids. Major sources including their fat content are
polyunsaturated.
given in Table - 5.
Saturated Fatty Acids (SFA) : Saturate (Latin, to fill, in this
Visible and invisible fats : The visible fats are generally
case with hydrogen). Saturated Fatty acids have a relatively high
derived from animal fats e.g. butter or ghee or from plant
melting point and tend to be solid at room temperature. These
(vegetable) oils like groundnut, mustard, coconut, sunflower or
are obtained from animal storage fats and their products e.g.
safflower seeds. Hydrogenated oils and margarine would also
meat fat, lard, milk, butter, cheese and cream. Fats from plant
be classified as visible oils. The visible fat is added to food for
origin tend to be unsaturated with the exception of coconut
cooking, flavouring or shortening. These are the major sources
oil and palm oil. A high intake of SFA is associated with an
of fats in our diet. Chemically they are triglycerides of fatty
increase in LDL and total cholesterol and thus increases the risk
acids and could be saturated or unsaturated. It is now believed
of atherogenesis and cardiovascular disease. Some examples of
that the bare minimal requirement of visible fats to meet the
SFAs are Myristic acid, Palmitic acid and Stearic acid.
essential fatty acid requirements is 15 to 25 g per day. The
upper limit is fixed at 30% of the total energy intake or less Monounsaturated Fatty Acids (MUFA) : MUFA contain
only one double bond and are usually liquid (oil) at room
temperature. Olive oil and rapeseed oil are good dietary sources

• 720 •
of MUFA. MUFA are also present in meat fat and lard. Dietary Trans Fatty Acids (t-FA)
MUFA does not raise plasma cholesterol. They lower LDL Trans fatty acids rarely occur in nature. These are produced
cholesterol without affecting the HDL. Oleic acid is an example during the partial hydrogenation of PUFA. In Indian homes this
of MUFA. process takes place commonly when oil is heated over and over
Polyunsaturated Fatty Acids (PUFA) : PUFA contain two or again as it happens during the process of frying puri, pakori or
more double bonds and they too are liquid at room temperature. samosa, esp. when the same oil is boiled repeatedly. Trans fatty
They are easily oxidized in food and in the body. PUFA have a acids have been associated with adverse effects on lipoprotein
vital role in immune response, blood clotting and inflammation. status by elevating LDL and depressing HDL.
PUFA are divided into omega-3 (ω3) or omega 6 (ω6) groups
Essential Fatty Acids (EFA)
of PUFA. Omega-3 (ω) polyunsaturated fatty acids PUFA are
found in fish and fish oils. The health benefits of these include If fats are entirely excluded from the diet, retarded growth,
reducing the cardiovascular risk factors (see Box - 4). Research dermatitis, kidney lesions and an early death might result.
also indicates their beneficial role in cognitive function of brain. Studies have shown that feeding of certain unsaturated fatty
Some common omega-3 fatty acids are α-linolenic acid (linseed, acids e.g. linoleic and linolenic acid is effective in curing the
soyabean, rapeseed, leafy vegetables), eicosepentaenoic acid condition. It is therefore evident that certain unsaturated fatty
(marine algae, fish oils) and docosahexenoic acid (fish oils). acids cannot be synthesized in the body and must be acquired
from diet. These are essential fatty acids. EFA are commonly
Box-4 : Omega-3 (ω3) Fatty Acids in Prevention and found in plant and fish oils (8). The EFA requirement is 3-6% of
Therapy the total energy intake depending on the age and physiological
status of the individual. Fatty acid content of different fats is
Coronary artery Disease (CAD) : Omega-3 (ω3) Fatty Acids given in Table - 6.
reduce the tendency of platelet aggregation, blot clot Why fats in diet? : If the contemporary literature is to be
formation and thus atherosclerosis. Chances of cardiac believed, one tends to agree that fats are well known for their
arrhythmias also go down, thus benefiting in CAD. role in causation of many chronic diseases rather than any
Hypertension : They lower the high blood pressure in worthwhile virtue! Then why should fat be consumed at all
hypertensives. and how much? The main functions of fat are elaborated in
the Box - 5.
Hyperlipidaemia : They lower the high blood lipids
(triglycerides and total cholesterol), while increasing HDL-c. Unlike proteins where the precise intake, assimilation, excretion
and thus requirement can be worked out, the quantity of fats
Bronchial asthma : ω3 Fatty Acids reduce inflammation, that should be included in a well balanced diet is a matter of
frequency and severity of asthma. conjecture. The following aspects however are important in
Diabetes : They lower the high blood triglycerides blood considering the recommendation for fat intake :
pressure and reduce leakage of proteins from small vessels, a) The quantity of fat intake should be good enough so that
thus improving the overall metabolism and the diabetic requirement of essential fatty acids (which are a component
state. of fats) is met.
b) Absorption of fat soluble vitamins should not be
Autoimmune disorders : Omega 3-Fatty Acids are known to compromised.
reduce pain, inflammation and joint stiffness in rheumatoid c) Fat intake should be sufficient enough to make diet
arthritis. Other autoimmune disorders also improve with palatable.
their supplementation. d) Some stores must be maintained in the body to tide over a
Miscellaneous : They are found to be useful in conditions like lean period.
migraine, inflammatory skin disorders and osteoarthritis. e) It should not be so much in quantity that it causes
undesirable effects on health.
Cholesterol
Cholesterol is always talked as if it is the hazardous abnormal fat. It is considered by many as a type of a saturated fat. In fact
it is only a fat related compound. Chemically it falls under the group of sterols. It is named after the body material where it was
first identified, the gallstones (Greek, chole, bile; steros, solid)
Synthesis : It is synthesized only in the animal body. All plant products are free of cholesterol. The human body synthesizes
indigenous cholesterol primarily in liver (but also in adrenal cortex, skin, intestines, testis and ovaries), for sustaining life. It
is a normal constituent of bile and a principal part of the gall stones
Sources : The important dietary sources are egg yolk, meat (liver and kidney). There are no plant sources of cholesterol
RDA : Since it is synthesized indigenously in the body, there is no dietary requirement of cholesterol. However, the upper limit
of cholesterol consumption has been put at 300mg per day
Functions : It is vital as a precursor to various steroid hormones e.g. sex hormones and adrenal corticoid hormones.
Hazards : In dysfunctional lipid metabolism, it is considered the major factor for atherosclerosis. Epidemiological studies have
linked high cholesterol intake to the increased risk of coronary heart disease

• 721 •
 Table - 6 : Approximate fatty acid composition of common Table - 7 : RDA of Fats for Indians
fats and oils (g/100g) (8)
Group Particulars Body wt (Kg) RDA Fat (g/d)
Oil/Fat Satu- MUFA Lino- α-lino- Predomi-
Sedentary work
rated leic lenic nant FA
acid acid Man Moderate work 60 20
Coconut 90 7 2 <0.5 SFA Heavy work
Palm kernel 82 15 2 <0.5 SFA Sedentary work
Ghee 65 32 2 < 1.0 SFA Moderate work 50 20
Vanaspati 24 19 3 <0.5 SFA (t-FA) Heavy work
Red palm oil SFA + Woman Pregnant woman
50 40 9 <0.5 50 30
MUFA
Lactation
Palm oil SFA +
45 44 10 <0.5 0-6 months
MUFA 50 45
Olive 13 76 10 <0.5 MUFA 6-12 months

Groundnut 24 50 25 <0.5 MUFA 0-6 months 5.4

Infants
Rape/ MUFA 6-12 months 8.6
8 70 12 10
Mustard 1-3 years 12.2
Sesame MUFA + Children 4-6 years 19.0 25
15 42 42 1.0
PUFA
7-9 years 26.9
Rice bran MUFA +
22 41 35 1.5 Boys 10-12 years 35.4
PUFA
22
Cotton seed 22 25 52 1.0 PUFA Girls 10-12 years 31.5
Corn 12 32 55 1.0 PUFA Boys 13·15 years 47.8
22
Sunflower 13 27 60 <0.5 PUFA Girls 13·15 years 46.7
Safflower 13 17 70 <0.5 PUFA Boys 16-18 years 57.1
22
Soyabean 15 27 53 5.0 PUFA Girls 16-18 years 49.9

Based on these aspects, the ICMR has recommended levels of Quantity of Fat : With an improving economy and a richer
fat intake for Indians (RDA) that are summarised in Table - 7. lifestyle we tend to consume a higher calories especially from
the fat source. Higher calories lead to obesity and many other
Recommended Dietary Allowance : The RDA for adults is 20g
lifestyle diseases. A high level of fat in diet is notorious in
of visible fat per day. For pregnant and lactating women it is 30
the causation of atherosclerosis and so is a major risk factor
and 45 g respectively. The RDAs for various groups are given in
for Cardiovascular Diseases (CVD) including coronary artery
Table - 7 (1). Fat content of diet should not exceed 20 to 30% of
disease and strokes. Any amount that contributes to more than
the total calories consumed. The dietary cholesterol should be
30% of total calorie intake is considered as high. Low physical
limited to 300 mg/day.
activity and sedentary lifestyle further augment the risk.
Hazards of Excess Fat in Diet : Excess fat is dangerous on
Quality of Fat : High levels of saturated fatty acids are more
two accounts. First, in case it is consumed in a higher quantity
dangerous. A proportionately higher content of polyunsaturated
and secondly if the wrong quality of fat is consumed.

Box - 5 : Functions of Fats

They are concentrated sources of energy providing about 37.7 KJ/g or 9 Kcal /g.
Fats serve as vehicle for fat soluble vitamins (A.D, E and K).
Fats are structural components of cell and cell membrane.
They are the sources of essential fatty acids. Linoleic acid and arachidonic acid are precursors of prostaglandins which are
required for a wide variety of metabolic functions.
Apart from their nutritional significance, fats improve the palatability of diet, delay gastric emptying & raise the caloric
density.
Some fats can be converted to biologically active compounds such as steroid hormones, interleukins, thromboxanes and
prostaglandins and bile acids (from cholesterol).

• 722 •
fatty acids is found to be protective for CVD. Unfavourable Table - 8 : Major sources of carbohydrates (per 100 g) (1)
levels of certain lipoproteins have adverse effects on health.
High levels of LDL are associated with higher atherosclerotic Carbo- Carbo-
risk so LDL is colloquially known as ‘bad cholesterol’. A high Food stuff hydrates Food stuff hydrates
level of HDL has favourable effect on the cardiovascular system (g) (g)
and is termed as ‘good cholesterol’. Cereals & Millets Pulses & Legumes
Wheat flour 69.4 Bengal gram 60.9
Tips on fat intake
Rice polished 78.2 Soya bean 20.9
Use minimal oil for preparation
Bajra 67.5 Rajmah 60.6
Food preparation Rotate the types of oil used
Maize dry 66.2 Redgram (Arhar) 57.6
Use only lean cuts of meat
Prefer fish to poultry Ragi 72.0 Pea dry 56.5

Meat Prefer poultry to mutton/beef/pork Fruits & Vegetables Miscellaneous

Limit added oils in meat preparations Banana 27.2 Milk, cow 4.4
Avoid more than one egg a day Apple 13.4 Groundnut 26.1
Eggs Avoid adding oil to egg preparations Mango 16.9 Cashew nut 22.3
Use egg whites freely Raisins 74.6 Coconut, fresh 13
Milk Prefer low fat milk Tapioca 38.1 Jaggery 95
Sweet potato 28.2 Sugar 99.4
Carbohydrates Potato 22.6 Honey 79.5
Carbohydrates are the basic source of fuel to run life on earth.
It is these carbohydrates into which the energy from sun is fructose. Lactose is found in milk. It is hydrolysed to glucose
converted through the process of photosynthesis by plants. and galactose. Maltose is present in malted wheat and barley.
In fact this is the energy that is used by all living organisms. Other sources are nuts and seeds.
Thus carbohydrates can be considered as the very ‘basis’ of Functions of Carbohydrates : Carbohydrates are the most
life. Chemically carbohydrates are polyhydroxy aldehydes or significant and cheapest source of energy in the diet. One
ketones, or substances that produce such compounds when gram of carbohydrates provides 4 Kcal energy. Carbohydrates
hydrolyzed. They contain carbon, oxygen and hydrogen in provide 60 to 85% of energy in our Indian diet. Various kinds
proportion approximating that of a ‘hydrate of carbon’ (CH2O), of sugars (glucose, fructose, sucrose etc.), most literally,
hence the term carbohydrate. impart the sweet taste to life! Carbohydrates play an important
Classification : From the nutritional or functional point of role wherein glycogen resources in the muscles and liver are
view, carbohydrates can be divided into two categories. in a state of dynamic exchange with the energy balance (of
(a) Available carbohydrates : These are the carbohydrates intake and expenditure) through the liver. A constant supply
which can be digested in the upper gastrointestinal tract, of carbohydrates has a protein sparing action and proteins
absorbed and utilized. These are further sub-classified as are not required to be broken down for energy. Similarly fats
polysaccharides, disaccharides, monosaccharides. are also spared to be used up if enough carbohydrate supply
(i) Polysaccharides such as starch, dextrin and glycogen is maintained. The brain exclusively uses glucose and is
(ii) Disaccharides such as lactose, sucrose and maltose dependent on its constant supply for its functioning.
(iii) Monosaccharides such as glucose, fructose and galactose. Fibre, which is a type of carbohydrate, has the important
(b) Dietary Fibre : The second category comprises of function of increasing faecal bulk, stimulating peristalsis and
unavailable carbohydrates or dietary fibre, which are difficult blocking cholesterol synthesis in the liver.
to digest. These are cellulose, hemicellulose, gums, pectins etc. Requirement of Carbohydrates : In a prudent diet
A detailed account of these is given later in this chapter. carbohydrates should contribute to 60 to 70% of total energy
Sources of Carbohydrates : The major source of dietary (1). This translates to about 360 to 400g carbohydrates for a
carbohydrates in an Indian set up is starch from cereal grains, 2400 Kcal diet. Details about role and requirements of dietary
millets, legumes, roots and tubers (Table - 8). fibre are discussed in forthcoming paragraphs.
With increasing prosperity as in industrial societies, sugar Problems Due to Deficiency and Excess : Whenever there
has replaced complex carbohydrates as the main source. is a deficiency of carbohydrates in diet not compensated by
The presence of monosaccharides (free glucose or fructose) other nutrients, a situation of energy deficiency sets in. This is
is limited to fruits and vegetables, otherwise they are not typically seen in infants and children wherein protein calorie
abundant in natural foods. Fructose is found in honey, fruits malnutrition is not uncommon. A similar situation of energy
and vegetables. Sucrose and Lactose are the commonest deficiency may result in food deprived people in cases of
disaccharides. Sucrose is extracted from sugar cane. Table starvation as encountered in famines and droughts. Anorexia
sugar is 99% sucrose. Sucrose gets hydrolysed into glucose and nervosa is a condition with a major psychological component,

• 723 •
wherein the patient doesn’t eat food and ends up being cachexic. On the other hand the natural gel forming fibres like pectins,
A very low carbohydrate diet results in utilization of other gums and mucilages are soluble.
macronutrients (lipids and proteins) for energy and result in Sources and Losses : Cereals, fruits and vegetables are the
production of ketone bodies (ketosis). Eventually bone mineral chief sources of fibres. The important sources of soluble and
loss, hypercholesterolaemia and increased risk of urolithiasis insoluble fibre are summarised in Table - 9.
may result.
Consumption of an excess of carbohydrates seems to be a bigger Table - 9 : Major food sources of fibre
problem in the present day scenario of progressive economies.
Insoluble fibres
If the intake is large enough to provide excessive calories such
an individual ends up being obese and might fall prey to a Vegetables : Peas, beans, amaranth leaves
host of lifestyle diseases (discussed in another chapter). It is Cereals : Rye, bran flakes, brown rice, Corn, whole wheat
interesting to note that excess of even few calories per day
(100-200 Kcal) over a couple of months accumulates enough Whole meal cereals : Dalia, whole meal flour, Ragi
calories to cause obesity. porridge
Dietary Fibre Breads : Granary bread, brown bread
Denis Burkitt (a surgeon) and Hugh Trowell (a physician), Legumes : Bengal gram (whole), Lentils pulses and dals
served for 30 years, after the World War II, in Makareree Sprouts : Sprouted grains, legumes
University, Kampala, Uganda, before returning to Britain. They
were struck by the great difference in the pattern and nature Fruits : Fruits with edible seeds
of disease affecting the affluent West as opposed to more Soluble fibre
primitive communities. They concluded that the large amount Citrus fruits : Orange, lime
of dietary fibre was not only responsible for the faecal bulk but
was also directly or indirectly related to the difference in the Berries : Straw berry, rasp berry
pattern of disease. A ‘fibre hypothesis’ was thus formulated Other Fruits : Pomegranate, Figs, grapes, guava, Sapota,
which suggested that unrefined complex carbohydrates Custard apple
protected against the ‘western ailments’ : colonic cancer,
diverticular disease, appendicitis, constipation, hemorrhoids, Functions : Dietary fibre stimulates chewing, improves flow
hiatus hernia, varicose veins, diabetes, heart disease, gall of gastric juice and provides a sense of satiety. Insoluble fibre
stones, obesity etc. binds to water in the colon and swells. Hence, it forms substrate
Dietary fibres are the remnants of the plant cell resistant for colonic bacterial fermentation. This stimulates peristalsis
to hydrolysis by alimentary enzymes and do not provide which increases transit time in the colon thereby reducing the
significant nourishment. They remain in the ileum but are risk of constipation and possibly that of colon cancer. Some
partially hydrolyzed by the colonic bacteria. The term ‘dietary fibres like lignin helps in prevention of absorption of bile acids
fibre’ is a broad term which includes Non Starch Polysaccharide by binding to them. On the other hand soluble fibres prevent
(NSP) and related material such as resistant starch, resistant the micelle formation by binding with bile acids &and other
oligosaccharides, lignin and complex assemblies of plant tissue lipids (11).
where polysaccharides occur in close association with other Recommended Dietary Allowance : The diet should contain
molecules (9).
35-40 grams of dietary fibre per day (15g per 100Kcal) (1).
Classification : Fibres can be Carbohydrate fibres and non- Fibre content of selected food stuffs are given in Table - 10.
carbohydrate fibres. The carbohydrate fibres include Non
Starch Polysaccharides (NSP) which are
normally present in cell wall, cement, plant Table - 10 : Dietary fibre content of common foods (g/100g)
gums, mucilages and algal polysaccharides; Fibre content Fibre content
Foodstuff Foodstuff
and the Resistant Oligosaccharides (ROS) (g per 100g) (g per 100g)
which are found in leguminous seeds e.g. Cereals & Legumes Fruits
Rajma, soy beans and gram (10). The Non
Carbohydrate fibres include Lignin which is Rice, raw, milled 0.2 Guava 5.2
a large compound forming the woody part Wheat flour, whole 1.9 Mango, papaya 0.7
of some plants. It strengthens the plant cell
Bengal gram, whole 3.9 Pomegranate 5.1
walls.
Fibre can also be classified according to Red gram (Dal arhar) 1.5 Peach, pears, apple 1.0-1.2
solubility in water, as soluble or insoluble. Peas dry, Rajmah 4.5 Figs, Sapota 2.2-2.6
Insoluble fibre consists mainly of cellulose, Green vegetables Nuts
hemicellulose and lignin. Since they remain
undigested in the gut they form bulk and help Cabbage, cauliflower, Areca nut
1.0 -1.2 11.2
in movement of the food and peristalsis. Thus Fenugreek (maithi)
they help in elimination of waste products as Amaranth 1 to 6.1 Coconut fresh 3.6
well. After absorption of water the fibre swells
up and facilitates the gut movement further. Spinach, radish leaves 0.6 Groundnut 3.1

• 724 •
Dietary Fibre in Health and Disease : Fibre helps in achieving 3. The limiting amino acid in wheat is____ and in pulses it
prevention of cardiovascular disease through various is_____ (a) Lysine, methionine (b) Methionine, lysine
mechanisms (c) Cysteine, lysine (d) Lysine, cysteine
(a) Soluble fibre binds with bile acids and alters the quantity 4. Which lipoprotein is termed as ‘good’ cholesterol : (a) LDL
of cholesterol or fatty acids absorbed. (b) HDL (c) VLDL (d) Chilomicrons
(b) The re-absorption of bile acids is slowed by soluble fibre to 5. Which of these will provide energy the quickest : (a) Milk
increase cholesterol losses in faeces. (b) Chapati (c) Butter chicken (d) Fruit juice
(c) Intestinal bacteria reduce soluble fibre to short chain fatty Answers : (1) b; (2) b; (3) a; (4) b; (5) d.
acids which block cholesterol synthesis in the liver.
Fibres also help in the maintenance of weight and prevention
References
1. Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian
of obesity. Soluble fibre blunts the response of blood glucose foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.
through prevention of direct glucose absorption in the gut. This 2. World Health Organization. Energy and protein requirements. Technical
helps in the control of hyperglycaemia. Soluble and viscous Report Series No. 724. Geneva, 1985.
3. Pasricha S, Count what you eat. National Institute of Nutrition (ICMR),
fibres (pectin and gums) have the greatest hypoglycemic effect Hyderabad. 1989.
(12). 4. Kleiner SM. Nutrition Guidelines for diet and health, In : Matzen RN and
Lang RS (Eds) : Clinical Preventive Medicine. Mosby Publishers USA. 1st Ed
Fibre is also considered to be an important contributory factor 1993 : 385 - 410.
to the prevention of colonic cancer (13). 5. Garrow JS, James WPT, Ralph A, Human Nutrition and Dietetics. Churchill
Livingstone, UK. 10th Ed 2000.
In addition, fibre increases faecal bulk and relieves constipation.
6. Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed.
This reduces the incidence of colonic cancers, diverticulitis Wadsworth Thomson Learning, California. 2000.
and appendicitis. The alteration in cholesterol production and 7. Chaney MS, Ross ML. Nutrition. Houghton Mifflin Company, USA. 1996.
further metabolism reduces the formation of gallstones as most 8. Ghafoorunissa, Krishnaswamy K. Diet and Heart Disease. 2000 National
of them are of cholesterol origin. Institute of Nutrition, Hyderabad - 500007.
9. Gandy JW, Madden A, Holdsworth M. Oxford handbook of Nutrition and
Study Exercises 10.
Dietetics. Oxford University Press, New Delhi. 2007.
Geissler C, Powers H. Human Nutrition.11th ed. Elsevier Churchill Livingstone
Short Notes : (1) Dietary fibre in prevention of lifestyle diseases London. 2005.
(2) Hazards of excess fats in diet (3) Invisible fats (4) Dietary 11. Antia FP, Abraham P. Clinical Dietetics and Nutrition. 4th ed Oxford University
Press, New Delhi 1998.
importance of egg (5) Supplementary action of proteins 12. Steyn NP, Mann J,Bennett PH, et al. Diet, nutrition and the prevention of type
MCQs 2 diabetes. Public health nutrition. 2004 Feb, 7 (1A). 147-165.
13. Key TJ, Schatzkin A, Willett WC, Allen NE, Spencer EA, Travis RC. Diet,
1. Which is true for cholesterol (a) It is a type of saturated nutrition and the prevention of cancer. Public health nutrition. 2004 Feb,
fatty acid (b) It is present in egg yolk, ghee and coconut 7 (1A). 187-200.
oil (c) The dietary requirement of cholesterol is zero 14. Key TJ, Schatzkin A, Willett WC, Allen NE, Spencer EA, Travis RC. Diet,
nutrition and the prevention of cancer. Public health nutrition. 2004 Feb,
(d) Everyone with high cholesterol gets IHD 7 (1A). 187-200.
2. Which of the following is not a source of dietary fibres
(a) Vegetable fibres (b) Muscle fibres (c) Bran (d) Fruits

as ‘limeys’.
129 Micronutrients : The Vitamins Many subsequent observations and experiments in 1896 by C
Eijkman on rice polishings and beriberi, Frederich Hopkins of
Rajul K Gupta Cambridge University on milk in 1906, Verner McCollum (USA)
on the fat soluble factor (Vitamin A) in 1916 just to name a
few, established them to be vital for life that paved the way for
“Milk and leaves occupy a unique position, as they correct
the vitamins to be named so (from the words vital amine) by
the defects of cereals, tuber, roots and meats. Thus…they be
Casimer Funk, a Polish scientist in 1912.
distinguished by the term ‘Protective foods’.”
Definition : Vitamins are organic compounds required in
~ EV McCollum (1)
very small but definite quantities for normal growth and
By and large vitamins were discovered during the search for maintenance of a healthy life. They are not synthesised in the
cures of classic deficiency diseases. In 1753 when James Lind, body and have to be supplied in the diet. They do not furnish
a British naval surgeon, observed that fresh lemons, limes and energy and play no part in the constitution of the structure
oranges, prevented/cured scurvy, the British sailors always of tissues, but are essential for the transformation of energy
carried lemons with them on long voyages and were nicknamed

• 725 •
and regulation of tissue metabolism. They are necessary for active form of thiamine in the body.
the efficient functioning of the organism as a whole, each in Sources : The important stores are seeds of plants. The germ of
a specific manner. Deficiency of vitamins causes profound cereals, nuts, pea, beans and other pulses and in addition yeast
changes in structural and functional wellbeing, the picture of is a rich source. In cereal grains, thiamine is found in highest
each deficiency being specific. concentration in the germ or embryo, less in bran and least in
Dietary sources : Vitamins are widely distributed in diet. Fresh endosperm. All green vegetables, roots, fruits, nuts, flesh foods
milk, meat, eggs, fresh vegetables and fruits are rich sources. and dairy produce contain significant amounts of the vitamin.
Cereals (esp. whole unrefined cereals) which form the bulk of Pork has a higher content of thiamine than beef or mutton.
our diet are also important sources. Storage, processing and Highly processed foodstuffs like white bread, polished rice and
cooking of food may cause considerable vitamin loss, so that refined sugar are deficient in thiamine (See Table-1).
the maintenance of an adequate intake is more difficult when
fresh food is scarce. The pharmaceutical use of vitamins should Table 1: Thiamine content of selected food items (per
be restricted to rectify or supplement the envisaged or existing 100g) (4)
deficiency in the diet or to meet the increased physiological
Thiamine Thiamine
demands (e.g. in pregnancy). No physiological benefit, however, Food stuff Food stuff
(mg) (mg)
can be expected from a large dose of vitamins under normal
circumstances. Cereals Vegetables
Classes of vitamins : Vitamins have long been classified into Wheat flour 0.49 Beans 0.10
two groups; water soluble and fat soluble. The water soluble Rice polished 0.06 Spinach 0.03
group comprises of vitamins B and C; the fat soluble vitamins
Bajra 0.33 Carrot 0.04
are A, D, E and K. This division is still useful, since it helps
to understand the distribution of vitamins in foods and their Maize dry/ Capsicum
0.42 0.55
absorption and metabolism in the body. Ragi
Storage and excretion : There is an important distinction in Pulses & Legumes Fruits
the handling of the two classes of vitamins by the body. An Bengal gram 0.30 Pineapple 0.2
excess intake of water soluble vitamins is excreted in the urine.
Thus, there is virtually no danger in giving an excess of these Soya bean 0.73 Guava 0.03
vitamins. On the other hand, the fat soluble vitamins cannot Green gram 0.47 Amla 0.03
be excreted in this way. Any excess of these vitamins, beyond Red Gram 0.45 Tomato 0.12
the immediate requirement is stored in the liver. The storage
capacity of the human liver is large and it normally holds a Peas dry 0.47 Mango 0.08
reserve of vitamins sufficient for many months; this is a useful Non vegetarian foods Nuts
provision for times when the dietary supply may temporarily
Egg 0.10 Groundnut 0.90
be cut off. However the amount that can be stored is not
unlimited (2). Liver sheep 0.36 Cashew nuts 0.63
Functions : As mentioned earlier they do not furnish energy Milk cow 0.05 Almond 0.24
and play no part in the constitution of the structure of tissues Fish, Rohu 0.05 Coconut, fresh 0.05
directly, but are essential for control of cell metabolism,
Mutton 0.18 Coconut, dry 0.08
transformation of energy, and prevention of specific nutritional
deficiencies.
Losses : Milling of cereals below an extraction rate of 75
Many vitamins are now known to have antioxidant properties. percent reduces the content of thiamine to a great extent. As
This has rejuvenated the interest of scientist in exploring thiamine is readily soluble in water, considerable amounts
further the hidden potential of these vitamins in maintaining may be lost when foodstuffs are cooked in an excess of water
health and also curing disease. The scope of vitamins has now which is afterwards discarded. It is relatively stable to heat up
widened from their earlier role of curing specific deficiencies to boiling point, provided that medium is slightly acidic, as in
to preventing cancers and even aging! A summary of the baking with yeast. But if baking powder is used, or if soda is
traditional functions of major vitamins are given in tables at added in the cooking of foodstuffs, almost all the vitamin may
the end of this chapter. be destroyed.
Water Soluble Vitamins Functions : Thiamine is one of the most important water soluble
vitamins and acts as a coenzyme in many metabolic reactions.
Thiamine (Vitamin B1)
The important ones being the oxidative decarboxylation of
Thiamine hydrochloride is a crystalline substance which is pyruvic acid and transketolase reaction in HMP shunt. The
readily soluble in water. It is rapidly destroyed by heat in neutral vitamin is essential for the health of the nerve tissue and for
or alkaline solutions. In acid solutions however, it is resistant normal cardiac and gastro-intestinal functions (5,6).
to heat up to 120°C. It is mainly excreted in urine. Thiamine is
Requirements : Since thiamine plays an important role in
present in the body mostly as thiamine pyrophosphate (TPP)
carbohydrate metabolism, its dietary allowance is related to
but about 10 percent as thiamine triphosphate. TPP is the
energy intake. It is 0.5mg per 1000 Kcal (4).

• 726 •
Deficiency : Thiamine deficiency causes beriberi and Wernicke- Table 2 : Riboflavin content of selected food items (per
Korsakoff psychosis. Three forms of Beriberi are known: Wet 100g) (4)
Beriberi (cardiac), Dry Beriberi (neurological) and Infantile
Beriberi. The early symptoms and signs are common in both Riboflavin Riboflavin
Food stuff Food stuff
dry and wet Beriberi. The onset is usually insidious, though (mg) (mg)
sometimes precipitated by unwanted exertion or a minor febrile Cereals Vegetables
illness (5).
Wheat flour 0.17 Beans 0.06
Beriberi Rice polished 0.06 Spinach 0.26
(Singhalese, meaning “I can’t, I can’t”). The disease caused Bajra 0.25 Carrot 0.02
by the deficiency of thiamine, characterized by oedema Maize dry 0.1 Amaranth 0.30
resulting from cardiac failure (Wet beriberi) or peripheral
Pulses & Legumes Fruits
neuritis, pain in limbs and paralysis (Dry beriberi).
Bengal gram 0.15 Pineapple 0.12
(a) Wet beriberi is the acute form. It is characterized by high Soya bean 0.39 Guava 0.03
output cardiac failure, bounding pulse, warm extremities,
Green gram 0.47 Raisins 0.19
peripheral oedema and cardiac dilatation.
(b) Dry beriberi is the chronic form of disease and is characterized Red Gram 0.45 Tomato 0.06
by progressive peripheral neuropathy. The tendon jerks are Peas dry 0.47 Mango 0.09
sluggish and anaesthesia of the skin (especially over tibia) is Non vegetarian foods Nuts
common. The muscles become progressively wasted and weak
and walking becomes increasingly difficult. The thin, even Egg 0.40 Groundnut 0.13
emaciated individual needs at first one stick, then two and may Liver sheep 1.7 Cashew nuts 0.19
finally become bedridden. Milk cow 0.19 Almond 0.57
(c) Infantile beriberi occurs in the first few months of life (of an
Fish, Rohu 0.07 Coconut, fresh 0.10
infant), if the diet of mother is deficient in thiamine. The infant
remains constipated and appears plump due to water retention. Mutton 0.14 Coconut, dry 0.01
The heart is enlarged and the heart sounds are muffled. The
infant may die of a heart failure if untreated (7) Requirements : The requirement of this vitamin is also related
to energy intake. It is about 0.6 mg per 1000 Kcal. The daily
(d) Wernicke-Korsakoff psychosis is seen in chronic alcoholics
safe requirement ranges from 0.7 to 2.2 mg/day (4).
with poor diet. It is characterised by confusion, low levels
of consciousness and poor coordination (encephalopathy). Deficiency
Memory loss often follows the encephalopathy. Certain conditions are known to be at high risk of Riboflavin
deficiency (Box - 1).
Riboflavin
Riboflavin, the word comes from a Latin word flavous, yellow, Box - 1 : Increased Risk of Riboflavin Deficiency
containing a sugar named ribose). As is clear from the name it
is a yellow green fluorescent compound, soluble in water but Growth : childhood, adolescents
not in fats. Though stable in acid solution, in alkaline solution Pregnancy, lactation
it is readily destroyed by heat. It is also destroyed by short
Malabsorbtion : Tropical sprue; Celiac disease; Chronic
visible and ultraviolet rays.
diarrhoea; Irritable bowel syndrome
Sources & Losses : The best sources of riboflavin are liver,
Drugs impairing absorbtion : Thyroid hormones; Oral
milk, eggs and green vegetables (See Table-2). Cereals and yeast
contraceptives; Phenothiazines; Barbiturates
extracts also contain the vitamin. Cooking does not destroy
the vitamin apart from losses that occur when the water in Alcoholism
which green vegetables have been boiled is discarded. If food,
especially milk, is left exposed to sunshine, large losses may (1) The clinical signs suggestive of riboflavin deficiency are
occur. cheilosis, angular stomatitis, glossitis, magenta tongue,
nasolabial seborrhoea and genital (scrotal or vulval) dermatosis.
Functions : Riboflavin is involved in oxidation-reduction
Corneal vascularisation is also seen but is not a specific sign of
reactions within the cells in many metabolic pathways. The
riboflavin deficiency.
important functions of riboflavin include:
(a) Promotion of normal growth (2) Severe deficiency is rarely seen, however the elderly, people
(b) Assisting synthesis of steroids, RBC and glycogen suffering from anorexia nervosa and chronic dieters are at a
(c) Maintenance of mucous membranes, eyes and the nervous higher risk.
system (3) Secondary nutrient deficiencies may be seen in riboflavin
(d) Aiding iron absorption (5) deficient people like: Hypochromic anaemia, Vitamin B6
deficiency and Pellagra (6).

• 727 •
Niacin (Nicotinic Acid & Nicotinamide) Deficiency : Pellagra (Latin pelle, skin; Greek agra, seizure)
Niacin is the generic term for a group of compounds that results from the deficiency of niacin. This is characterized by
prevent pellagra. It is a white crystalline substance readily the three ‘D’s (5).
soluble in water and is resistant to heat, in solution or in a (a) Dermatitis: (Pellagrous dermatosis) Skin exposed to sunlight
dry state. Although related chemically to nicotine it possesses gets inflamed, that progresses to pigmentation, cracking and
very different physiological properties. It occurs naturally in peeling. The neck is frequently involved and the distinctive
the body in the form of an amide - nicotinamide. distribution of skin lesions is known as Casal’s Collar.
Sources : Nicotinic acid is widely distributed in plant and animal (b) Diarrhoea: This is often accompanied by inflamed scarlet
foods. Meat (especially the organs), fish, chicken, eggs, milk, tongue.
whole meal cereals, groundnuts and pulses are good sources (c) Dementia : It may present as mild confusion and
(See Table-3). In some cereals, especially maize, the greater disorientation to mania and psychosis.
part of the vitamin may be in a bound unabsorbable form. The
Folic Acid (Folate or Pteroyl Glutamic Acid)
human body is not entirely dependent on dietary sources of
nicotinic acid as it may also be synthesized from tryptophan. It is a yellow crystalline substance, sparingly soluble in water
On an average about 60 mg of tryptophan is needed to form and a stable molecule. When heated in neutral or alkaline media
1mg niacin (4). it undergoes rapid destruction. Free folate is actively absorbed
from the upper small intestine. It is stored mainly in the liver.
Table - 3 : Niacin content of selected food items (per 100g) Small amount is excreted in urine and faeces. Free folic acid
(4) is converted in the liver into tetrahydrofolic acid (folinic acid)
which is the functionally active form in the body.
Food stuff Niacin (mg) Food stuff Niacin (mg)
Sources and Losses : It occurs in green leaves, pulse, cereals,
Cereals Vegetables liver, kidney, mushroom and yeast. Canning, prolonged heating,
Wheat flour 4.3 Cauliflower 1.0 reheating and discarding ‘cooking’ water causes serious losses
Rice polished 1.9 Spinach 0.5 of folic acid. Reducing agents in food tend to protect folic acid.
Folic Acid content of selected food items is depicted in Table-4.
Bajra 2.3 Carrot 0.6
Maize dry 1.8 Amaranth 1.2 Table - 4 : Folic Acid content of selected food items (per
Jowar 3.1 Potato 1.2 100g) (4)

Barley 5.4 Radish 1.4 Folic Folic

Food stuff Food stuff
Acid (µg) Acid (µg)
Pulses & Legumes Fruits
Cereals Vegetables
Bengal gram 2.9 Raspberry 0.8
Wheat flour 35.8 Cabbage 23
Soya bean 3.2 Guava 0.4
Rice raw, milled 8.0 Spinach 45.5
Green gram 2.4 Raisins 0.7
Bajra 45.5 Carrot 123
Red Gram 2.9 Tomato 0.4
Maize dry 20.0 Amaranth 149
Peas dry 3.4 Mango 0.9
Jowar 20.0 Ladies finger 105
Lentil 2.6 Custard apple 1.3
Ragi 18.3 Spinach 123
Non vegetarian foods Nuts
Fruits & Nuts Pulses & Legumes
Egg 0.1 Groundnut 19.9
Tomato 30 Bengal gram 186
Liver sheep 17.6 Cashew nuts 1.2
Guava 20 Soya bean 100
Milk cow 0.1 Almond 4.4
Groundnut 20 Green gram 140
Fish, Rohu 2.8 Coconut, fresh 0.8
Coconut, fresh 12.5 Red Gram 103
Mutton Coconut, dry 3.0
Coconut, dry 16.5 Peas dry 7.5
Functions : Nicotinamide is incorporated into the pyridine Lentil 36
nucleotide coenzyme, and various other coenzymes, which Non vegetarian foods
are involved in numerous oxidoreductase reactions including
glycolysis, fatty acid metabolism, tissue respiration and Egg 78.3 Milk cow 8.5
detoxification. Liver sheep 188 Mutton 5.8
Requirement and Intake : Since this vitamin takes part in
many reactions of energy metabolism, its requirement is also Functions
related to energy requirement. Its safe level is estimated to be (a) Folinic acid plays important role in the synthesis of purines,
6.6mg niacin equivalents per 1000 Kcal. The daily requirement pyramidines, glycine and methionine. It is essential for the
varies from 8 to 26 mg (4). synthesis of DNA.

• 728 •
(b) It is a potent anti anaemia factor in the treatment of Functions
megaloblastic anaemia of malnutrition, pregnancy and (a) It recycles the folate coenzyme.
malabsorption. It is also effective in treatment of pernicious (b) Vitamin B12 plays important role in the synthesis of DNA.
anaemia. (c) It helps in maintenance of myelin in the nervous system.
(d) It has an important role in the treatment of pernicious
Folic Acid and Plasma Homocysteine anaemia.
A high plasma homocysteine level is a risk factor for (e) It also helps in conversion of homocysteine to
heart disease and stroke. A strong inverse correlation methionine.
between folate intake and plasma homocysteine has been Measurement : Serum B12 is assessed by radioligand binding
found. A significant dose response relationship has also or microbiological assay. Absorption is assessed by Schilling
been established. Folate supplementation is known to test (5).
proportionately reduce the plasma homocysteine levels and Requirement and intake : The daily losses of this vitamin
thus the risk of heart disease. range from 0.25 μg to nearly 1 μg. An intake of 2 μg per day
has been recommended by FAO/WHO. The ICMR has, however,
Requirement and Intake: The requirement of folic acid ranges suggested a daily intake of 1 μg of the vitamin for Indian adults
from 50 μg to 100 μg. In pregnancy it increases to 150-300 μg (4).
(4).
Deficiency : Since the vitamin doesn’t occur in vegetable foods,
Measurement : Recent intake can be assessed by serum folate. vegans and strict vegetarians are at a high risk of its deficiency.
Cellular status is assessed by red cell folate levels. Malabsorption, gastric atrophy, and reduced production of
‘intrinsic factor’ are some other causes of deficiency. Pernicious
Uses of Folates in Prevention and Therapy anaemia, which is a megaloblastic anaemia, results due to
Birth Defects: Use of supplementary folates (400μg/day) deficiency of this vitamin. Neurological symptoms characterized
during the early weeks of conception & pregnancy can reduce by loss of sensation and motor power in the lower limbs (due
birth defects like neural tube defects, cleft lip and palate. to degeneration of myelin) may also be seen. Since it is also
synthesized in the gut, many cases of vitamin B12 deficiency
Atherosclerosis : Folates are known to reduce high
are not seen very frequently.
homocysteine levels and thus help prevent atherosclerosis.
Vitamin C (Ascorbic Acid)
Nervous Disorders : Folate supplementation is beneficial in
depression, irritability and impaired concentration. It is also It is a water soluble, crystalline, white substance. Ascorbic
useful as an adjunct therapy in MDP and senile dementia. acid is very sensitive to oxidation, which is accelerated by
heat, alkaline solutions, light and traces of metals, especially
Infections : Folates augment the immune function of the copper. It is present in all body tissues but is found in a high
body, thereby reducing infections. concentration in the adrenal glands, pituitary gland, and
Cancers : Folate also reduces the chances of cervical, colonic intestinal wall.
and lung dysplasia. Sources and Losses : Its rich sources are citrus fruits (oranges,
lemons), guavas, papayas, pineapple, mangoes, gooseberry
Deficiency : Dietary folate deficiency is not uncommon. (amla), kiwi fruit and green leafy vegetables. Root vegetables
Deficiency results in megaloblastic anaemia. Deficiency may also contain vitamin C, esp. sweet potato. It is also synthesized
be accompanied by depression, insomnia, forgetfulness, in germinating seeds, pulses and grains (See Table-5).
irritability and dementia. Low folate levels are also associated
with neural tube defects. Lack of folic acid is known to cause Table - 5 : Vitamin C content of selected food items (per
accumulation of homocysteine (hyperhomocysteinaemia), 100g) (4)
which is a potential risk factor for coronary artery disease.
High folate levels overcome the hyper-homocysteinaemia. Low Vitamin Vitamin
Food stuff Food stuff
folate levels can also cause an altered methylation of DNA, C (mg) C (mg)
increasing the risk of cancer (5, 6). Fruits Vegetables
Vitamin B12 (Cyanocobalamin) Tomato 31 Cabbage 124
Cobalamin is a complex molecule containing 4-percent cobalt, Guava 212 Spinach 28
besides phosphorous and nitrogen. Cyanocobalamin is the
commercially available form. Vitamin B12 is the ‘extrinsic factor’ Straw berry 52 Drum stick 120
originally postulated by Castle. It requires the ‘intrinsic factor’, Amla 600 Amaranth 179
secreted by the parietal cells of the stomach, to be absorbed.
Lime 63 Chillies, green 111
It is freely soluble in water and resistant to boiling in neutral
solution though unstable in the presence of alkalis. Mousambi 50 Potato 17
Sources : It is unique among vitamins in that it is not present Orange 30 Bitter gourd 96
in any vegetable foods. It is present in animal products - milk, Papaya 57 Capsicum 137
milk products, meat and fish. It is also synthesized by the micro
organisms in the gut and assimilated in the food chain.

• 729 •
The vitamin C content of fruits and vegetables is reduced by Sources and losses : Retinol is found in foods of animal
storage and damage to plant cells by rough handling, bruising origin. The important sources of Retinol are meat, liver, kidney,
or cutting, which results in release of enzyme ascorbic acid milk, fish and eggs (See Table- 6). Retinol can also be formed in
oxidase which oxidizes ascorbic acid. Also cooking of vegetables the intestinal mucosa from the pigments known as carotenoids
destroys vitamin C through the enzyme action and heat and by which are widely distributed in plants. Carotenoids are found
its extraction into cooking water. High pressure steaming as in coloured fruits and vegetables. The green outer leaves of
well as rapid frying of green vegetables destroys the oxidase vegetables (e.g. cabbage) are good sources of carotene. One of
enzyme thereby causing a greater retention of vitamin C than these, β-carotene is by far the most important source of retinol
boiling. (provitamin A) and is found in abundance in yellow-orange
Functions : Ascorbic acid is a powerful reducing agent vegetables and fruits (e.g. pumpkin, papaya, mango, apricots,
(antioxidant) and is essential for many oxidation-reduction yellow peaches and green leafy vegetables). β-Carotene, another
reactions. carotenoid, is found in carrots, lutein in dark green leafy
(a) It is required for the formation of collagen and is therefore vegetables and β-Cryptoxanthin in citrus fruits. The pigments
necessary for the formation and maintenance of the normal with no vitamin A activity include lycopene in tomatoes and
structure of the intercellular ground substance (connective zeaxanthin in sweet corn (4)
tissue), bone, tendons, skin, teeth and capillaries. Vitamin E protects it from oxidation. It is destroyed by exposure
(b) It is important for hydroxylation of dopamine to nor- to sunlight. Foods which are heated for long period of time lose
adrenaline. an appreciable amount of vitamin A. Boiling, canning or freezing
(c) It enhances the absorption of iron, through the conversion of foods does not cause loss but drying and dehydration causes
of ferric (Fe3+) to ferrous ions (Fe2+). considerable loss.
(d) It has anti-oxidant property like vitamins A and E, which
has an important role in free radical scavenging, as an Table - 6 : β-Carotene content of selected food items ((µg)
anti-aging and anti-cancer factor. per 100g) (4)
(e) It influences the maturation of the red blood cells, synthesis β-Carotene β-Carotene
of bile and metabolism of drugs and carcinogens by the Food stuff Food stuff
(µg) (µg)
liver (5)
Cereals Vegetables
Requirement : The requirement of vitamin C is 40 mg/day for
adults. For lactating women 80 mg/day is recommended (4) Wheat flour 25 Pumpkin 1160
Deficiency : Vitamin C deficiency is not common now. It causes Rice raw, 2 Fenugreek 9100
defective formation of intercellular ground substance whose hand pound leaves
characteristic gross lesions occur in gums, bones and capillaries. Bajra 132 Carrot 6460
Reparative process especially involving connective tissues, as
in wound healing, are interfered in vitamin C deficiency due Maize dry 90 Amaranth 8340
to the lack of the formation of collagen. Deficiency leads to a Spinach 9440
condition called as scurvy. The signs and symptoms include Pulses & Legumes Fruits
spongy and bleeding gums, perifollicular haemorrhages in the
skin, sub periosteal haematomas and poor wound healing. Bengal gram 189 Apricot 2160
Fatigue and muscle weakness is also reported. Soya bean 426 Raspberry 1248
Fat Soluble Vitamins Green gram 94 Papaya 880
Vitamin A (Retinol) Red Gram 132 Tomato 590
Hopkins conducted an experiment in young rats (1906-1912). Peas dry 39 Mango 1990
These were fed on casien, starch, sugar, lard and inorganic Non veg foods Nuts
salts. These rats failed to grow and died. An addition of only
Egg 420 Groundnut 37
3 ml milk enabled them to thrive! An ‘Accessory food factor’
was thus demonstrated. Mc Callum isolated it in 1913 and Liver sheep 6690 Cashew nuts 60
was named as Vitamin A. Wald was awarded Nobel Prize for Milk cow 53 Almond 0
description of ‘dark vision’ and its association with Vitamin
Mutton 9 Coconut, fresh 0
A (2,8)
Vitamin A is a term for the biologically active compound retinol Retinol Equivalents : Vitamin A activity of a diet is usually
and its provitamin (precursor) carotenoids. Retinol is a fat expressed in Retinol Equivalents. As mentioned, the term
soluble pale yellow compound. It is stable to heat at ordinary vitamin A is applied to both retinol (preformed vitamin A)
cooking temperatures but liable to oxidation and destruction and pro-vitamin A (beta-carotene). One microgram retinol is
on rancidity of fat. However, carotenoids cannot wholly be considered as 1 Retinol Equivalent (1RE). It is also known that
converted into retinol in the body and man absorbs and utilizes the biological activity of 6 µg beta carotene has an activity
these pigments less efficiently. 6 microgram of β-carotene of 1 µg retinol. International Unit or IU is an old unit and is
has the biological activity of 1microgram retinol (RE). Other sometimes used.1 IU is equal to 0.3 µg of Retinol (Box - 2).
Carotenoids have even lesser vitamin A activity (4)

• 730 •
 Box - 2 : Vitamin A Activity Toxicity - Hypervitaminosis A :There are exotic stories of arctic
explorers and fishermen who reported reddening and exfoliation
1 Retinol Equivalent (RE) equals of skin after feasting on polar bear liver or halibut liver.
●● 1μg of retinol Hypervitaminosis A can be induced by a single dose of retinol
●● 1 µg retinol activity greater than 200mg (200,000 RE). Chronic hypervitaminosis
●● 6 µg β-carotene may result from chronic misuse of supplements which is,
●● 3.33 IU (International Units) greater than 4000 RE (infants) to 7000 RE (adults) consumed
OR daily. Persistent large doses of vitamin A (more than 100 times
●● 1 µg β-carotene = 0.167 µg retinol the required amount), overwhelm the liver storage capacity
●● 1 IU Vitamin A = 0.3 µg of Retinol and produce intoxication and liver disease.
Hypervitaminosis A is characterized by skin/mucous membrane
Functions changes. Dry lips (cheilitis), dryness of nasal mucosa and eyes,
(a) It is vital for the formation of retinal pigment rhodopsin in erythema, scaling, peeling of skin, hair loss and nail fragility
rods of the retina. Exposure to light results in a series of are other signs. Headache, nausea and vomiting follow. Bone
changes in its configuration, which leads to the adaptation abnormalities in the form of hip fractures are also reported.
of vision in dark. Retinol deficiency leads to impairment of Retinoids can be toxic to the fetus, causing craniofacial, CNS,
dark adaptation or night blindness. cardiovascular and thymic malformations. Pregnant women
(b) Retinol is essential for integrity of cellular structure are therefore advised against exceeding daily intakes of 3000
esp. epithelial tissue - respiratory, gastrointestinal, RE of vitamin A.
genitourinary and skin.
Vitamin D (Calciferols)
(c) It has a role in the immune defence mechanism of the
body. The term Vitamin D refers to two molecules - ergocalciferol
(d) Vitamin A has an antioxidant property of free radical (Vitamin D2) and cholecalciferol (Vitamin D3). Cholecalciferol is
scavenging (For details refer to chapter on antioxidants). the natural form of vitamin and is produced by the ultraviolet
Requirements & Recommended Dietary Allowance : The irradiation (through sunshine) of 7-dehydrocholesterol
recommended intake is 600 mg of retinol equivalent per day widely distributed in animal fats such as the oily secretions
for adults (including children above 6 years and pregnant in mammalian skin. Dietary ergocalciferol and cholecalciferol
women). Lactating mothers require 950 mg. In converting the are biologically inactive and are activated to 25-hydroxy-
carotene figures to retinol, a conversion factor of 0.25 has been cholecalciferol in liver. Further conversion in the kidney results
suggested by ICMR (6). For vitamin A the RDA is given in terms in the production of the more active form 1,25-dihydroxy
of retinol (vitamin A alcohol). If the diet contains vitamin A cholecalciferol (Calcitrol) (8).
and carotene, its content can be expressed as retinol using the
following formula: How much sunshine is good enough?
Retinol content = µg retinol + µg of β-carotene X 0.25 Even a brief and casual sunlight exposure of the exposed
parts of body (face and arms) is good enough to provide about
Deficiency : Deficiency of Vitamin A leads to ocular and extra
5 μg equivalent of vitamin D. The ultraviolet penetration
ocular manifestations. The ocular manifestations are more
depends on melanin content of the skin and is higher in
common. The ocular manifestations resulting from vitamin A
light skinned people. Window panes and use of sunglasses
deficiency are termed as Xerophthalmia. Deficiency is often seen
and sun screen creams block ultraviolet penetration, thus
to be associated with weaning, protein energy malnutrition and
limiting the vitamin D intake. Dark clothing, face masks and
a diet poor in vegetables, fruits, milk and butter. The deficiency
burqa will also block UV rays and Vitamin D availability.
signs / symptoms are given in the Box - 3.
Therefore a person getting even a casual exposure to sun gets
enough Vitamin D through the skin conversion. Conversely,
Box - 3 : Signs and symptoms of Vitamin A Deficiency
those permanently indoors (as in cold countries) or keeping
Dryness, itching, redness of conjunctiva themselves covered from head to toe (practice of compulsory
Night blindness (inability to see in dim light) burqa cover) are those who might be at a risk of vitamin D
deficiency.
Other signs of xerophthalmia : Bitot spots; Corneal xerosis;
Keratomalacia Food sources : Cod liver oil, other oily fish, milk, margarine,
Dry, rough, itchy skin; rash eggs, liver.
Dry, brittle hair and nails Functions : Vitamin D regulates the absorption and excretion
of calcium from the small intestine and also plays an essential
Loss of acuity of senses: smell and taste
part in the mechanism for mineralizing bone. It is considered
Loss of appetite as a hormone rather than a vitamin.
Anaemia, fatigue Measurement : Vitamin D status can be assessed by the
Poor growth measurement of plasma 25-hydroxy- cholecalciferol. In severe
deficiency plasma calcium and phosphate fall and alkaline
Low immunity: Increased vulnerability to infections phosphatase is elevated.
Increased risk of certain cancers

• 731 •
Requirement and Intake : The vitamin D requirement severe fat malabsorption (5).
for a child is placed at 100 to 400 IU/day (2.5-10 μg). This Vitamin K
requirement can be obtained from exposure of the body to
sunlight. ICMR expert group therefore has not recommended It exists in nature in two forms. Vitamin K1 (phylloquinone),
any dietary intake. Whenever this requirement is not met, a originally isolated from lucerine, is the only form that occurs
therapeutic supplementation may be needed (4). The food and in plants. It is a yellow oil, soluble in fat solvents, but only
nutrition board, USA recommends a daily dietary intake of 5 μg slightly soluble in water. Vitamin K2 (menaquinone) is produced
for adult males, females, pregnant and lactating women. by bacteria in the lumen of large intestine.

Deficiency : People who stay indoors and are fully covered Food sources : Green leafy vegetables, vegetable oils esp. soya
(purdah system amongst women in some religious/ethnic bean oil, eggs, meat and dairy products are good food sources
groups) are at a higher risk of deficiency due to lack of of vitamin K.
exposure to UV radiation due to sunlight. Malabsorption also Functions
increases the risk of deficiency. Severe deficiency results in (a) Vitamin K promotes the synthesis of γ-carboxy glutamic
rickets in children, characterized by reduced calcification of acid (Gla) in the liver which is essential for formation
bone epiphysis. It leads to skeletal deformities, bone pain and of prothrombin (or factor II) and also factors VII, IX and
muscle weakness. In adults deficiency results in osteomalacia. X. It is well known that these factors participate, in the
coagulation of blood.
Vitamin E (Tocopherol)
(b) Some other proteins also contain Gla and require vitamin
Eight naturally occurring forms of vitamin E are synthesized K for their synthesis e.g. osteocalcin, a bone protein made
in plants; four tocopherols (α,β, γ and δ tocopherols) and four by osteoblasts (5).
tocotrienols (α,β, γ and δ tocotrienols). Alpha tocopherol which
Requirement & Intake : No recommendations are given by the
is synthesized commercially has the highest biological activity,
ICMR. The US authorities recommend an intake of 120µg for
and is used as the standard against which activity of other
males and 90µg for females.
forms is measured. Being fat soluble, vitamin E is found in all
cell membranes (5). Deficiency : This is characterized by poor blood clotting and
results in low prothrombin activity. Neonates are born with
Sources : Vitamin E is widely distributed in foods and the
very low stores of vitamin K due to sterility of intestines
richest sources are vegetable oils like groundnut, sunflower,
(and absence of bacteria producing vitamin K). So neonates
safflower, cotton seed, corn, wheat germ, rape seed, palm and
are given an injection of this vitamin at birth. Adults rarely
other oils. Nuts (like almonds and peanuts) are also good
manifest the deficiency, but can be seen in cases of obstructive
sources. Eggs, butter, whole meal cereals are moderately good
jaundice as lack of bile leads to poor absorption of vitamin
sources. Meat, fruits, vegetables contain small amounts. Foods
K. The anticoagulants Warfarin and Dicoumarol can cause a
rich in PUFA are also rich in Vitamin E.
deficiency.

Tocopherol Summary
(Greek, tokos, childbirth; pherin, to carry) Vitamins which were historically considered as the vital amines
have not lost their vitality, and are as important today as they
This vitamin was so named in Greek, as the work of early
were at the time of their discovery. They help in many metabolic
investigators indicated a strong relationship to reproductive
reactions and are essential for control of cell metabolism,
function in rats, which was not found to be true in humans.
transformation of energy, and prevention of specific nutritional
Functions deficiencies. Their role as antioxidant agents has enabled
(a) Like vitamin A and C, it has a strong antioxidant property scientists to refocus their attention on vitamins. A summary
and protects cell membranes and lipoproteins against of the most important vitamins is tabulated at the end of
damage from free radicals. It also prevents the non- chapter.
enzymatic destruction of polyunsaturated fatty acids by Study Exercises
molecular oxygen.
Long Questions : (1) Enumerate the water soluble vitamins.
(b) It maintains the cell membrane integrity.
What is the role of vitamin C in the human body? (2) Name the
(c) It has a role in the DNA and prostaglandin synthesis.
fat soluble vitamins. Discuss the dietary sources, functions and
Requirement & Intake : The human requirement of vitamin deficiency symptoms of Vitamin A.
E is not known with certainty (4). The US authorities have
recommended a daily intake of 12mg/day. Short Notes : (1) Hypervitaminosis A (2) Beriberi (3) Vitamins
as antioxidants
Deficiency : Deficiency of vitamin E in animals interferes with
normal reproduction and causes a form of muscular dystrophy, MCQs
but the effects if any, on human beings are being studied. 1. Which of the following will help you increase the iron
However, a genetically inherited disease Familial Isolated absorption from diet : (a) Nicotinic acid (b) Ascorbic acid
Vitamin E (FIVE) deficiency is known. Patients develop reduced (c) Pantothenic acid (d) Folic acid
tendon reflexes by age 3-4, loss of touch and pain sensation, 2. Which of the following is not a source of beta carotene
unsteady gait, loss of coordination and impaired eye movement (a) Green vegetable (b) Potatoe (c) Liver (d) Papaya
in adolescence. Deficiencies have also been seen in people with 3. Which of the following is not known to have an

• 732 •
 antioxidant effect (a) Vitamin A (b) L-Ascorbic acid 2. Garrow JS, James WPT, Ralph A, Human Nutrition and Dietetics. Churchill
Livingstone, UK. 10th Ed 2000.
(c) Alpha-Tocopherol (d) Phylloquinone
3. Mahan LK, Stump SL. Krause’s Food, Nutrition & diet therapy.11th edition
4. Which of the following does not fall under ‘xerophthalmia’ Saunder’s Philadelphia, USA. 2000.
(a) Conjunctival xerosis (b) Corneal xerosis (c) Retinal 4. Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian
xerosis (d) Lachrymal xerosis foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.
5. Gandy JW, Madden A, Holdsworth M. Oxford handbook of Nutrition and
5. Which of these is available only from animal sources Dietetics. Oxford University Press, New Delhi. 2007.
(a) Vitamin B12 (b) Vitamin B1 (c) Vitamin B6 (d) Vitamin 6. Geissler C, Powers H. Human Nutrition.11th ed. Elsevier Churchill Livingstone
B2 London. 2005.
7. Antia FP, Abraham P. Clinical Dietetics and Nutrition. 4th ed Oxford University
Answers : (1) b; (2) c; (3) d; (4) d; (5) a. Press, New Delhi 1998.

References 8. Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and
Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.
1. Mc Collum EV. A history of Nutrition, Boston, Houghton Miffin Company, 9. Zimmermann M. Burgerstein’s Handbook of Nutrition: Micronutrients in the
1957. Prevention and Therapy of Disease. 9th Ed. Heidelberg, Germany. 2007

Fat Soluble Vitamins

Vitamin Function RDA Deficiency Sources
Vitamin A (Retinol, Vision, Integrity of 600 µg/ day Xerophthalmia, Retinol (animal foods):
Retinal, Carotenes, epithelium, Gene Dry skin, impaired liver, egg, meat, milk
Cryptoxanthines) regulation, Antioxidant immunity, growth Provitamin A (plant foods)
and reproduction yellow, green vegetables
Vitamin D (Cholecalciferol, Calcium homeostasis, 100 - 400 Rickets in children Synthesised in skin with
D3 ; Ergocalciferol, D2) Bone metabolism IU /day - Osteomalacia in adults exposure to sunlight;
(Child) Fish oils, milk
Vitamin E (Tocopherols) Cellular membrane 12mg / day RBC breakdown, Vegetable oils, green
antioxidant anaemia, nerve vegetables, cereal
damage, retinopathy germ, nuts, seeds
Vitamin K (Phylloquinones, Clotting of blood, 120 µg / Bleeding tendencies Synthesis by intestinal
Menaquinones, Menadione) Calcium metabolism day (Males) bacteria, green vegetables
90 µg / day soya oil, liver, milk
(Females)

Water Soluble Vitamins

Vitamin Function RDA Deficiency Sources
Scurvy: Spongy, Citrus fruits,
Reductant in hydroxylations
Vitamin C bleeding guava, amla, green
in collagen and carnitine 40mg /day
(Ascorbic acid) gums, fatigue, vegetables , tomatoes,
synthesis Metabolism of drugs
haemearthrosis strawberries
Normal growth Coenzyme for Beriberi - Cardiac
Vitamin B1 Meat, liver, legumes,
decarboxylation of 2-keto acids 0.5mg / 1000Kcal (wet), Neuritic (dry)
(Thiamine) wheat germ
and transketolation reactions and Infantile
Ariboflavinosis:
Normal growth Coenzyme Magenta tongue,
Vitamin B2 Milk, meat, green
in redox reactions of fatty 0.6mg / 1000Kcal Cheilosis, angular
(Riboflavin) vegetables
acids and TCA cycle stomatitis,
corneal ulcer
Niacin Coenzyme for dehydrogenases 6.6mg / 1000Kcal Pellagra, characterized Meat, groundnus,
(Nicotinic acid, br 3 Ds- dermatitis, legumes, grains
Nicotinamide) diarrhea, dementia
Vitamin B6 Coenzymes in amino 2mg / day Anaemia, neuritis, Grains, seeds,
(Pyridoxamine) acid metabolism convulsions poultry, meat
Folic Acid Coenzymes in single 100µg / day Megaloblastic anaemia Liver, green vegetables
carbon metabolism yeast, fruits
Vitamin B12 Coenzymes in amino acid, 1µg / day Pernicious anaemia Liver, lean meat
(Cobalamin) propionate and single carbon fish, seafood, milk
fragment metabolism

• 733 •
 ascertained by early analytic methods (4). Classically, iron
130 The Micronutrients : Minerals appears to be the mineral that divides the macrominerals from
microminerals. Thus a trace element (or micromineral) can be
defined as one that is required by the body in the concentration
Rajul K Gupta
equal to or less than that of iron (5). Microminerals include
iron, zinc, iodine, copper, manganese, molybdenum, selenium
Minerals are required in small quantities and constitute only a chromium and flourine. Cobalt, nickel, tin, silicon, vanadium,
small portion of the body weight but enter into the metabolism arsenic and boron can be classified as ultra-trace elements (2).
to a much greater degree than their mere weight indicates. A An element is termed ‘essential’ if a dietary deficiency of that
large portion of the ash of the body is composed of calcium, element consistently results in a suboptimal biological function
magnesium, sodium, potassium, phosphorous, sulphur and that is preventable or reversible by physiological amounts of
chlorine. The main functions of the minerals include: providing the element (6).
rigidity and relative permanence to the bones and teeth;
providing essential elements for the formation and activities Calcium (Ca)
of the muscular, glandular; neural, and epithelial tissues; Calcium is essential for the building of bones and teeth. It is the
forming components of enzyme systems; and providing most abundant mineral in the human body. Most is deposited
dynamic characteristics to the intra and extra cellular fluids as hydroxyapatite, in bones and teeth. Constant levels of
for regulation of pH, osmotic pressure and electro-neutrality calcium in the body/plasma is maintained under the influence
and those of secretion and excretions (1). of parathyroid hormone and calcitonin. Factors promoting
Minerals like zinc, molybdenum, copper, manganese and absorption of calcium are vitamin D, proteins and lactose.
magnesium are either structural parts or functionally activate Sources, Absorption and Losses : Rich sources of calcium are
many enzyme systems. Iodine is a part of hormone, thyroxine. milk and milk products, ragi, fish (if eaten whole), dried fruits
Sodium and potassium are important in fluid dynamics and such as raisins, apricots and dates, and betel leaves with lime,
energy transfer. They along with chloride, carbonates and pulses and tofu (See Table- 1).
bicarbonates maintain the acid base balance. Some amount
of minerals is excreted daily through urine, sweat, skin and Table 1: Calcium content of common foods (mg/100g)
intestinal exfoliations and thus has to be replaced. Growing
infants, children, pregnant and lactating women require a higher Calcium Calcium
quantity of some of these minerals to meet the physiological Foodstuff (mg per Foodstuff (mg per
needs. Deficiency, leads to a deranged function of systems and 100g) 100g)
various pathological states in extreme conditions. Cereals & Legumes Fruits
Classification Rice, raw 10 Figs 187
Minerals can be classified into macrominerals and microminerals Wheat flour, 48 Raisins 87
(See Box- 1). Macrominerals also referred to as major minerals whole
are distinguished from the microminerals by their occurrence
Ragi 344 Dates, dried 120
in the body. Taking this as criterion, various definitions of
macrominerals have evolved, such as “those which constitute Red gram 73 Lemon 70
at least 0.01% of body weight (5g in a 60 Kg man)” ; or a (Dal arhar)
more quantifiable and unambiguous definition like “mineral Bengal gram, 202 Apricots, dry 110
whose requirement is more than 100mg per day”. Calcium, whole
phosphorous, magnesium, sodium, potassium, chloride and
Vegetables Miscellaneous
sulphur are the macrominerals (2).
Turnip greens 710 Fish, Rohu 650
Box - 1 : Classification of Minerals Amaranth species 200-800 Coconut dry 400
The Macrominerals Cauliflower 626 Gingelly seeds 1450
Calcium, phosphorous, magnesium, sodium, potassium, greens
chloride, sulphur Onion 46.9 Almond 230
The Microminerals Spinach 73 Milk, cow 120
Iron, zinc, iodine, Copper, manganese, molybdenum, Cluster beans 130 Mutton 150
selenium, chromium and fluorine, cobalt, nickel, tin, silicon,
vanadium, arsenic, cadmium, boron, aluminium Calcium in food is not uniformly available to the body e.g.
calcium in vegetables and fruits is poorly absorbed due to the
As a corollary microminerals or trace elements can be defined presence of oxalic acid in these foods which forms insoluble
as those comprising less than 0.01% of total body weight or calcium oxalate. Spinach is one of the foods which is very rich
more appropriately those which are needed in a concentration in oxalic acid. Phytic acid in the pericarp of cereal grains unites
of less than 1ppm (3). These were initially known as trace with calcium to form phytin, which is not absorbed. However,
because their concentration in tissues could not be easily many cereals such as rye and wheat contain an enzyme

• 734 •
phytase, which splits phytic acid so that it can no longer bind cereals, meat, fish, nuts, fruits and vegetables are good sources.
with calcium and thus makes calcium available for absorption. A large part of phosphorus present in vegetable foods occurs in
Excess of fatty acids, particularly saturated fatty acids in the combination with phytin (fibre) and is available to the body
small intestine may form insoluble soaps with calcium and only to the extent of 40-60 percent.
may carry significant amount of calcium into faeces. Calcium Functions
in milk and dairy foods is more readily absorbed (7, 8).
Bone formation : It is essential for the formation of bones and
teeth along with calcium as hydroxyapatite.
Foods interfering with absorption of Calcium
Energy metabolism: It also plays an important role in all
Protein intake >20% of calories metabolism for derivation of energy from the phosphate bonds
Phosphorus (milk, meat, colas) in adenosine triphosphate (ATP).
Oxalates (Spinach, tomato) Acid base balance: Phosphorus acts as an important buffer
that prevents changes in the pH of body fluids.
Sodium (salt)
Miscellaneous: It is an important constituent of nucleic acids,
Tannins (black coffee, tea) phospholipids and membranes (11).
Alcohol Requirements : It is suggested that phosphorus intake should
be about 1 g per day that is about twice as large as that of
Functions
calcium (10).
Bone formation : More than 99% of body calcium is found
Deficiency : Phosphorus deficiency is unlikely to occur as it
in the bones. Calcium is essential for providing the structural
is widely available in foodstuff. However hypophosphataemia
rigidity to bones and teeth.
may occur in pathological conditions (sepsis, liver disease,
Nerve conduction: Calcium is responsible for the maintenance alcoholism, diabetic ketoacidosis) patients on prolonged
of optimum excitability of the nervous and muscular tissues. parenteral nutrition, hypophosphataemic rickets and excessive
Blood Coagulation: Calcium has an important role in the use of aluminium-containing antacids (9).
coagulation of blood as factor IV.
Sodium
As a cofactor : Calcium acts as a co-factor for a number of
enzymes e.g. lipase (9). Sodium is one of the most abundant minerals present in the
human body. An adult male has total body sodium of about 92-
Requirement and Intake : The suggested levels for calcium 110 g, almost equally divided into the Extracellular Fluid (ECF)
intake for adult men and growing children are 400 to 600mg/ and bone. In the blood and interstitial fluid it is found to be
day. In case of pregnant and lactating women it is 1000mg/ largely combined with chloride and bicarbonate. Intracellular
day (10). fluid contains about a third of the sodium content of the
Deficiency : Plasma calcium levels are tightly controlled and are extracellular fluid (9).
not usually affected by dietary insufficiency in healthy adults. Sources : Common salt (sodium chloride) is the cheapest, best
Reduction in the level of circulating ionised calcium produces and most widely available source of sodium; 3 g salt is roughly
a clinical condition known as tetany. This is characterized by equivalent to 1.2 g of sodium. Indian diet is particularly rich
twitching of muscles of face, hand and feet. Cardiac arrhythmias in sodium (pickles, chutneys, etc.). It is also present in food
may also result. A long term calcium deficiency during the bone additives like monosodium glutamate, mainly used in Chinese
formative age can cause stunted skeletal growth and a low cuisine. Natural foods like meat, milk, eggs, vegetables and
bone density. Vitamin D deficiency leads to rickets in children fruits all contain sodium. Salt is added to almost all processed
due to poor calcium absorption (9). foods, thereby increasing their sodium content.
Osteoporosis is an abnormal thinning of bones. It is not due to a Functions : Sodium is the main cation in the ECF of human body.
primary calcium deficiency but results from conditions leading It takes an important part in osmotic processes. It is important
to chronic calcium deficiency. These factors are inadequate in the blood pressure regulation along with potassium. Acid-
calcium intake, poor absorption, abnormal hormone levels, base regulation is a function of sodium. It also maintains the
upsetting the calcium homeostasis and subnormal physical osmotic pressure. Sodium is also a vital component of the
activity. Osteoporotic bones are more likely to get fractured with electrophysiological control of muscles and nerves.
trivial injuries (falls), as commonly seen in post-menopausal
women and the elderly. Requirement : The daily intake varies from 2 to 20 gm/day.
The recommended daily intake of sodium chloride is about 5
Phosphorus g (10).
The role of phosphorus in bone formation is almost as important Deficiency : Excessive sweating as in hot and humid climates
as calcium and so it is a macromineral of extreme value. It and extreme exertion, diarrhoea and dehydration can lead to
gets deposited in bones and teeth as calcium phosphate. An sodium deficiency. This may be manifested as muscle cramps
adult human body contains about 400-700 g of phosphorus as and severe dehydration and hypovolemia.
phosphate mostly in bones and teeth (10).
Potassium
Sources : Phosphorus is widely distributed in food stuffs and
therefore, its deficiency rarely occurs. Milk, milk products, The adult human body contains about 250 g of potassium

• 735 •
which is twice the amount of sodium. Potassium occurs widely body contains about 25 g of the metal and greater part of this
in foodstuffs, so there is little likelihood of its deficiency. It is amount is present in bones in combination with phosphate
the principal intracellular cation. and bicarbonate. About one fifth of the total magnesium in the
Sources : Most foods contain useful amounts of potassium, body is present in the soft tissues, where it is mainly bound to
particularly those of vegetable origin. Fruits like melons, protein. Inside the cells, the metal is concentrated within the
apricots, fruit juices, vegetables including potatoes, pulses, mitochondria.
meat and whole grain cereals are good sources (See Table- 2). Sources : Most foods contain useful amounts of magnesium,
particularly those of vegetable origin. Green vegetables,
Table - 2: Potassium content of common foods (mg/100g) pulses, meat, nuts and whole grain cereals are good sources.
Hard drinking water may make a significant contribution to
Potassium Potassium
magnesium intake.
Foodstuff (mg per Foodstuff (mg per
100g) 100g) Functions : Magnesium is an integral part of bones and teeth.
Within the mitochondria it is a co-factor for co-carboxylase
Cereals & Legumes Fruits
and co-enzyme A and is concerned with intracellular energy
Rice, flakes 154 Apricots 430 metabolism. It is important in the replication of DNA, synthesis
Wheat flour, 315 Peaches 453 of proteins and RNA. It is essential for muscle and nerve cell
whole function.
Ragi 408 Musk melon 341 Requirements : Estimated to be about 350 mg/day for adults
(10).
Red gram 1104 Mosambi 490
(Dal arhar) Deficiency : It is unlikely that magnesium deficiency would
arise in man from simple lack of food. Vitamin D appears to
Bengal gram, 808 Cherries 320 increase magnesium absorption from the intestine. Excessive
whole losses of magnesium in the faeces or urine occur in many
Vegetables Miscellaneous diseases e.g. renal or adrenal disease, malabsorption, use
of some drugs (e.g. diuretics) and in re-feeding syndrome.
Spinach 206 Rohu 288
Magnesium deficiency leads to apathy and muscular weakness
Amaranth 341 Coconut meal, 2003 and sometimes to tetany, convulsions, cardiac arrhythmias and
deoiled cardiac arrest (9).
Brussels 477 Mutton 270
sprouts
Iron
Iron is probably one of the most studied minerals in context of
Sweet potato 393 Milk cow 140
human health. It is one of the most important micronutrients
Brinjal 200 Drumstick 259 and is of fundamental importance to life. The body of an adult
human contains iron equal in weight to a large ‘nail’ (about
Functions : Potassium is the principal ion in the intracellular 4 g), of which more than two thirds (about 2.4g) is present in
compartment, thus plays an important role in the water balance haemoglobin. The rest of the iron in the body is present as a
of the body with sodium being in the extracellular compartment. reserve store in liver and to a lesser extent in other organs.
Along with sodium, potassium too is involved in acid-base
Sources : The sources of iron can be divided into two main
regulation. Potassium along with sodium is essential for the
groups:
cellular uptake of molecules through the sodium-potassium
pump. Potassium is necessary for the release of insulin from (a) Haem Iron Sources: These are essentially the non-
the pancreatic cells in response to high blood glucose. There vegetarian sources of iron e.g. meat, fish and eggs. Milk is
is an important role of the sodium to potassium ratio in the considered a poor source of iron but breast milk is an efficient
regulation of blood pressure, rather than sodium alone. This source for the infant.
ratio should ideally be 1:1 to have a healthy blood pressure. (b) Non-haem Iron Sources : These are the vegetarian sources,
Requirements : The daily requirement of potassium has not namely cereals, dark green leafy vegetables, pulses, nuts and
been determined accurately (10). The acceptable intake appears dry fruits. Absorption of iron from these foods is only 1 to 20
to be about 4.7 g per day, almost the same as of sodium. percent (See Table- 3).
Deficiency : Dietary deficiency is not common. However Non-haem iron is poorly absorbed (1-20%) and is influenced
deficiency could be caused by diarrhoea, vomiting, dehydration, by dietary constituents. Certain compounds like Phytic acid
purgatives, chronic acidosis or alkalosis, diuretics, etc. (in cereals, fibre), polyphenols (in plants), tannins (in tea),
Potassium deficiency affects the electrophysiology of cell. It phosphates (in milk and eggs) present in foods of vegetable
may cause cardiac arrhyth­mias and muscle weakness (9). origin inhibit the absorption of iron. There are also factors
in the diet that increase non-haem iron absorption, such as
Magnesium red meat, fish, chicken and liver. Ascorbic acid and low pH
Magnesium has wide ranging body functions. All human also enhance the absorption of non-haem iron. Haem-iron is
tissues contain small amounts of magnesium. The adult absorbed directly into the mucosal cells where iron is released
by haem oxidase and then bound to transferrin.

• 736 •
 Table - 3: Iron content of common foods (mg/100g) Group Requirement RDA
Iron Iron Male 0.9 mg 28 mg
Foodstuff (mg per Foodstuff (mg per Female 2.8 mg 30 mg
100g) 100g)
Pregnancy 3.5 mg 38 mg
Cereals & Legumes Fruits
Lactation 2.4 mg 30 mg
Rice, raw milled 0.7 Apricots 2.2
Wheat flour, 4.9 Pineapple 2.42 Deficiency : Iron deficiency anaemia is the most common
whole nutritional deficiency in the world. It is estimated that up to
half of all women and two-thirds of all pregnant women have
Jowar 4.1 Water melon 7.9
anaemia esp. in developing countries (9). Contrary to common
Lentil 7.6 Custard apple 4.31 belief, the prevalence of anaemia in males is also of a very high
Bengal gram, 5.3 Mango 1.3 magnitude of about 40%.
whole
Increased risk of Iron Deficiency
Soyabean 10.4 Pomegranate 1.79
Women
Vegetables Miscellaneous
Growing children and adolescents
Spinach 1.14 Fish, Hilsa 2.1
Pregnancy
Amaranth 1.8-38.5 Milk cow 0.2
Heavy menstruation
Cauliflower greens 40 Mutton, muscle 2.5
Chronic bleeds
Radish leaves 18.0 Jaggery 2.64
●● Haemorrhoids
Maximum absorption of iron takes place in duodenum and ●● Peptic ulcers
upper part of small intestine. The amount of iron absorbed ●● Irritation from drugs/alcohol
from a given meal depends to a large extent on the iron status ●● Acute gastritis
of the individual. Iron absorption increases during growth and Iron poor diets
pregnancy.
Strict vegetarians
When the body needs iron it passes directly through the
Heavy tea/coffee drinkers
mucosal cells and is transported by transferrin to the bone
marrow. If iron is not required it is stored in the mucosal cells Reduced gastric acid secretion
as transferrin. It will be lost in faeces when the mucosal cells Atrophic gastritis
are exfoliated. Excess iron is stored as ferritin or haemosiderin
in the liver, spleen, or bone marrow. It can be mobilized from Stomach surgery
these stores when demand is increased. Chronic antacid use
It is lost mainly during menstruation and from the Reduced transport due to deficiency of
gastrointestinal tract. Physiological losses from all other routes ●● Vitamin A
(exfoliation from alimentary, urinary and respiratory tract and ●● Vitamin B6
by dermal and hair losses and losses in the sweat) also occur. ●● Copper
Excretion of iron is very low (about 1mg/day in men).
Functions : Iron is a component of haemoglobin and myoglobin. The details of the condition are extensively elaborated in a
Iron is an essential component of heme. It is also a constituent separate chapter on nutritional deficiencies.
of important enzymes like cytochromes, catalase, peroxidase, Toxicity : The major cause of iron overload is hereditary
etc. As a part of these haemocomplexes and metallo-enzymes, haemochromatosis, another cause could be transfusion
it serves important functions in oxygen transport and cellular overload. The latter may be seen in cases receiving frequent
respiration. It is also involved in cellular immune response for transfusions as in Sickle cell anaemia and Thalassemia.
appropriate functioning of phagocytic cells (9, 11). Haemosiderosis is a condition seen in individuals consuming
Requirements : The requirement of iron is quite small, in the an abnormally large amount of iron.
vicinity of 1 to 3 mg/day. It changes constantly depending on Recent studies suggest that iron plays an active role as a pro-
the age, sex and the physiological status of the individual like oxidant (opposite to the ‘favourable’ antioxidant activity of
pregnancy, lactation and growth. But since the absorption of certain vitamins and minerals) (See Box- 2).
iron is rather poor, the dietary intake of iron should be 10 to 25
times the requirement. Hence the RDA of iron is about 28 mg Iodine
for males and 30 mg for females (38mg for pregnant females) Iodine has also been studied for a very long time. As early
(10). as 2800 BC Shan Nuang in China suggested sea weeds as a
remedy for goiter. It was discovered as an element in 1811 by
Courtois (France). It is an essential trace element because it is

• 737 •
 Box - 2 : Pro-oxidant activity of Iron
There is no doubt in the fact that iron is an important mineral involved in various vital metabolic functions. But lately, a pro-
oxidant role of iron is being studied. Excess iron promotes lipid peroxidation and tissue damage in vitro. There is a possibility
that, via these pro-oxidant effects, disturbances in iron metabolism play a pathogenic role in many diseases. Therefore iron
may be potentially harmful in some situations, esp. during preexisting inflammation and disease (12). For more details section
on ‘Antioxidants’ can be referred to.

an integral component of the thyroid hormones: thyroxine and encountered in many districts in India. The deficiency of iodine
triiodothyroxine, both of which have important metabolic roles. leads to various deficiency disorders, commonly termed as
Iodine deficiency is endemic in the mountainous areas with Iodine Deficiency Disorders (IDD) that shows a wide spectrum
poor soil content such as the sub-Himalayan regions. This is of picture ranging from still births to goiters in adults (See Box
due to iodine being washed from the soil. Its deficiency causes - 4). Fortification of salt with iodine is carried out to reduce
the widely prevalent preventable iodine deficiency disorders IDD. The PFA act has specified an iodine concentration of 30
that affect all ages: abortions, still births, cretinism, mental and 15 ppm in salt at source and consumer ends respectively
retardation, deaf-mutism, dwarfism and goiter. thereby providing 150 mg of iodine in 10 gm of salt.
Sources and losses : The presence of iodine in the food is a
function of the iodine content of local soil. Wherever the soil Box - 4 : Iodine Deficiency Disorders
contains adequate amount of iodine, all crops growing there Adults : Iodine deficiency disorder (IDD) in adults results
are rich in iodine. Among the natural foods the best sources of in hypothyroidism and raised levels of TSH, which
iodine are seafoods and vegetables grown on iodine-rich soils. cause hyperplasia of thyroid tissues resulting in goitre.
Dairy products, eggs, cereal grains, legumes and green leaves Hypothyroidism is characterized by lethargy, poor cold
(spinach) are also reasonable sources of iodine. Water contains tolerance, bradycardia, and myxoedema. Infertility is known
traces of iodine which contributes to as much as 10% of our to occur in IDD.
total iodine intake.
Fetus & infants: In the fetus, IDD results in cretinism. The
Goitrogens : Certain vegetables of Brassica group such as same is manifested as mental retardation, hearing, speech
cabbage, cauliflower and radish contain goitrogens such defects, squint, disorders of gait, and growth retardation in
as thiocyanates and cynoglycosides. Consumption of large infant life.
quantities of these foods may lead to the development of goiter
by making the iodine present in food unavailable to the body. At birth : IDD is also linked to an increase in the rates of still
Goitrogens are inactivated by heating. birth, miscarriage. Neonatal hypothyroidism is a sensitive
indicator of the incidence of IDD in a community.
Absorption : Dietary iodine absorbed from the small intestine
follows two main pathways within the body. Approximately 30
percent is used up by the thyroid gland for the synthesis of Recent Advances : Detection of iodine in salt
thyroxine hormone; the remainder is excreted in the urine (9). It must be appreciated that mere iodination of salt does not
Functions : Iodine is an integral component of the thyroid ensure availability of iodine to the consumer. Iodine has a
hormones thyroxine (T4) and tri-iodothyronine (T3). In addition, property to ‘sublimate’ and is thus constantly lost from its
the fetus and neonate normal protein metabolism in the brain ‘iodized vehicle (salt)’ on keeping. It is therefore recommended
and CNS requires iodine. to consume the iodized salt within a period of 6 months of
Requirement : The daily requirement of iodine is 150µg for iodization. There is a simple inexpensive rapid test (UNICEF)
an adult (10). However the requirements differ with age and available to detect the level of iodine in salt. Test kits can be
physiological states. See box-3. obtained by directing requests to MBI, 85 GN Chetty Road, III
Floor, T Nagar, Madras 600 017 (13)
Box - 3 : RDA of Iodine
Infants 50 μg
Fluorine
It is normally present in the bones and teeth and is essential
Children 100 μg
for the normal mineralisation of bones and formation of dental
Adults 150 μg enamel.
Pregnancy 200 μg Sources : Fluorine is widely but unevenly distributed in
nature. It is found in many foods, but seafoods, cheese and
Deficiency : Endemic goiter of varying degrees is found in a tea are rich sources. However, the main source of fluorine to
large proportion of the population in India, where the soil and man is drinking water. The fluoride content of drinking water
thus food materials are deficient in iodine. This is particularly in India is about 0.5 mg/l but in fluorosis endemic areas, the
true for the sub-Himalayan regions of India. By virtue of the natural waters have been found to contain as much as 3 to 12
slopes, iodine from the top soil constantly gets washed off mg of fluoride/l. A concentration of 0.5 to 0.8 mg/l in water is
by rains. Other regions located close to the hills e.g. Western considered a safe limit in India. In temperate climate where
and Eastern Ghats, Jharkhand, Chhatisgarh etc also face the intake of water, is low, the optimum level of fluorine in
this problem. Hence, iodine deficiency of varying degree is drinking water is accepted as 1 mg/l (14).

• 738 •
Deficiency : Deficiency of fluoride in water below 0.5 mg/1 is Functions : Many metalloenzymes contain Copper. These
usually associated with dental caries. enzymes have various functions which are summarized in the
Excess : Ingestion of large amounts of fluorine (>2-3ppm Box- 5 (9).
in water) is associated with dental and skeletal fluorosis.
Skeletal fluorosis has been reported to be health problem in Box - 5 : Functions of some copper containing
rural districts of Andhra Pradesh, Haryana, Karnataka, Kerala, metalloenzymes
Punjab, Rajasthan and Tamil Nadu. Scientists working at the Enzyme Function
National Institute of Nutrition Hyderabad found new form
Caeruloplasmin - Iron oxidation and transport
of fluorosis characterized by genu valgum and osteoporosis
(Ferrioxidase 1)
of the lower limbs in some districts of Andhra Pradesh and
Tamilnadu. Superoxide dismutase - Antioxidant
Cytochrome-c oxidase - Electron transport
Zinc
Zinc is present in small amounts in all tissues of the body. Dopamine hydroxylase - Hydroxylation of Dopa in brain
Total content of the body is over 2.0 g. Tyrosinase - Formation of melanin
Sources : Zinc is widely distributed in food stuffs of both animal Clotting factors V and VIII - Thrombogenesis
and vegetable origin. Good sources of zinc are meat, whole
grains and legumes. Its bioavailability in vegetable foods is Requirement : Suggested daily intake is 1-2 mg (10).
poor due to presence of phytates which impair its absorption. Deficiency : Copper deficiency is rare. Hypocupraemia occurs
Requirement : The daily requirement of zinc is about 15 mg in in patients with nephrosis, Wilson’s disease and sometimes in
men and 12 mg in women (15). protein energy malnutrition. Neutropaenia is the commonest
Functions : Zinc is part of over 100 enzymes and is thus of documented abnormality of copper deficiency. Infants, especially
importance in protein and carbohydrate metabolism, bone those who are premature, may develop copper deficiency
metabolism, and oxygen transport. Zinc is also important in which usually presents as chronic diarrhoea. Neutropaenia
the immune response and gene expression. It is an important and later anaemia develop and they do not respond to iron.
structural constituent of leucocytes and has a vital role to Menke’s disease, a rare hereditary defect of copper absorption
play in the synthesis of nucleic acids (9). Lymphoid tissue is invariably fatal. Copper deficiency may be a risk factor for
too contains substantial amounts of zinc. Zinc interacts with coronary heart disease as it has been associated with raised
insulin in the pancreas and serves in the efficient storage of the plasma cholesterol levels and heart-related abnormalities.(9)
hormone. Zinc is a also powerful antioxidant. Selenium
Deficiency : A clinical syndrome characterized by small stature, There is a resurgence of interest in the mineral selenium due
hypogonadism, mild anaemia and low plasma zinc occurs in to its antioxidant properties. It is an essential component of
older children and adolescents in poor peasant communities glutathione peroxidase, an important enzyme. It is present in
in Iran and elsewhere in Middle East, where the staple diet is all body tissues except fat.
unleavened bread. The zinc intake is low and its absorption
is impaired by phytate in the unleavened bread. However, the Sources : Meat, fish, nuts and eggs are good sources. Lacto-
common deficiency symptoms are: ova vegetarians and vegans may be at risk of deficiency.
●● Severe deficiency results in growth retardation, failure to Functions : Selenium is an integral part of over 30
thrive, delayed sexual maturation esp. in children. selenoproteins; the most important of which are glutathione
●● Deficiency of zinc impairs cellular immune mechanism peroxidases and iodothyronine deiodinases. Glutathione
while excess of it may depress neutrophils. peroxidase has an important role in the detoxification of
●● Zinc deficiency may present as a tetrad of symptoms peroxides and free radicals. Its antioxidant action might be
comprising of neuro-psychiatric changes, dermal lesions, protective against certain cancers especially prostate, lung,
diarrhoea and alopecia (Acro-dermatitis Enteropathica). colon and non-melanoma skin cancers. It may also be helpful in
Zinc supplementation has been found useful in these delaying the aging process. It is also involved in the production
conditions (9,15). of tri-iodothyronine from thyroxine. It also contributes to
antibody responses, the production of eicosanoids as well as
Copper cytotoxicity of natural killer cells (9).
It is an essential trace element as it is a component of many Requirements : Recommended daily intake is 70 µg (11).
metallo-enzyme systems and iron metabolism is closely
Deficiency : Its deficiency has a wide range of symptoms,
dependent on it. The amount of copper in the adult body is
not all attributable to glutathione peroxidase. Its deficiency
estimated to be 80 -100mg. Copper is widely distributed in
is associated with increased coronary artery disease. Keshan
nature and therefore primary copper deficiency in adults has
disease (endemic cardiomyopathy) in China and Kashin Beck
never been reported in adult man. Even poor diets provide
syndrome, an osteo-arthropathy in children of 05-13 years age
enough copper for human needs.
is seen in selenium deficient areas (9,10).
Sources : Meat, nuts, cereals and fruits are good sources.

• 739 •
 Who is likely to get Selenium Deficiency?
Poor Soil Content : Poor soil content of Selenium compromises its dietary availability through poor contents of crops and
animals. It is seen in large parts of Scandinavia, China, Central Europe, Africa and New Zealand.
Increased Oxidative Stress : Strenuous exercise, physical activity, smoking, exposure to environmental chemicals, radiation
and chronic illness increase oxidative stress. This escalates the turnover of glutathione peroxidase which in turn increases the
requirement of Selenium and likelihood of its deficiency.
Malabsorption : As caused in pancreatic disorders, cystic fibrosis, inflammatory bowel disease also put one to the risk of
Selenium deficiency.

Summary
contraction. They could be macrominerals or microminerals
Minerals are single inorganic elements, used by the body to
depending on their requirements (more than 100 mg and less
activate, regulate and control metabolic activities, in structural
than 100 mg/day respectively). Salient features are tabulated
building of cell/tissue and in neural transmission and muscle
in Summary Box 1 and 2.

Summary Box - 1 : The Macrominerals

Mineral Function RDA Deficiency Sources
Calcium Bone & teeth formation, Blood Adults: 400 mg Tetany, Rickets, Osteoporosis Dairy products,
clotting, Muscle contraction, Pregnancy & Meat products,
Nerve transmission Lactation 1 g Leafy vegetables
Phosphorus Bone & teeth formation, Energy 1g Not seen often Can cause Dairy products,
metabolism, Nucleic acid bone loss, anorexia Meat products,
synthesis, Acid base balance Leafy vegetables
Sodium Extracellular fluid component, 5g Cramps, Acid-base Table salt
Water balance Acid base balance imbalance, Water imbalance
Nerve transmission, Muscle action
Potassium Major Intracellular fluid 5g Muscle weakness, Fresh fruits, meats,
component, Acid-base balance; Arrhythmias whole grains,
Nerve transmission, Muscle action vegetables
Magnesium Coenzyme in metabolic 350 mg Tremors, spasm Meat, cheese, eggs,
reactions, Nerve conduction nuts, legumes

Summary Box - 2 : The Microminerals

Mineral Function RDA Deficiency Sources
Iron Haemoglobin & Myoglobin Male:28mg Anaemia, Meat products, Liver,
formation, Cellular oxidation Female:30mg fatiguability. Impaired Green leafy vegetables
reactions, Antibody formation Pregnancy:38mg immune function
Lactation:30mg
Iodine Thyroxine synthesis Adults 150μg Goitre, cretinism, Iodized salt, Plant products
Pregnancy 200μg hypothyroidism, grown in iodine rich soil
Infertilty, still births
Zinc Essential enzyme constituent, 15mg Retarded sexual Dairy products, Meat products,
Protein metabolism, Immune and physical Eggs, whole grains
function, Insulin storage, activity; Impaired
Sexual maturation wound healing
Selenium Antioxidant function Forms 70 μg Impaired immune Liver, meats, whole
glutathione peroxidase, function, Keshan grains, sea food
spares Vitamin E disease
Fluoride Bone and teeth constituent < 1mg Dental caries Flouridated water, toothpaste

• 740 •
Study Exercises References
1. Chaney MS, Ross ML. Nutrition. Houghton Mifflin Company, USA. 1996.
Long Question : Which are the minerals of importance to
2. 2.Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed.
public health in India? Discuss the sources, requirement and Wadsworth Thomson Learning, California. 2000
functions of Iodine. 3. Taylor A. Detection and monitoring of disorders of essential trace elements.
Ann Clin Biochem. 1996;33:486-510
Short Notes : (1) Importance of selenium as an antioxidant 4. Mertz W. The essential trace elements. Science. 1981; 213:1332-8.
(2) Osteoporosis (3) Trace elements. 5. Tracing the facts about trace elements. Tufts University Diet and Nutrition.
MCQs Letter March 1987; 5:3-6.
6. Nielsen FH. Ultratrace elements in nutrition. Ann Rev Nutr. 1984;4:21-41
1. Which of the following iron sources falls under the category 7. Garrow JS, James WPT, Ralph A, Human Nutrition and Dietetics. Churchill
of non heme iron (a) Jaggery (b) Meat (c) Eggs (d) Milk Livingstone, UK. 10th Ed 2000.
2. Calcium homeostasis is maintained by (a) T3 and T4 8. Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and
Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.
(b) Vitamin D and parathyroid hormone (c) Phosphorus
9. Gandy JW, Madden A, Holdsworth M. Oxford handbook of Nutrition and
and magnesium (d) Calcitonin and bone matrix Dietetics. Oxford University Press, New Delhi. 2007.
3. Ideal sodium potassium ratio should be (a) Not specified 10. Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian
(b) 1:1 (c) 1:2 (d) 2:1 foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.
11. Geissler C, Powers H. Human Nutrition.11th ed. Elsevier Churchill Livingstone
4. Which of the following does not fall under ‘IDD’ : London. 2005.
(a) Cretinism (b) Mongolism (c) Deaf-mutism 12. Thurnham JA. Iron as a pro-oxidant. In Wharton BA, Ashwell M (eds). Iron,
(d) Infertility nutritional and physiological significance. Chapman & Hall, London. 1995.
5. Which of these is not a constituent of metallo-enzymes 13. World Health Organization. Assessment of Iodine Deficiency Disorders and
Monitoring their Elimination. A guide for programme managers.2nd ed,
(a) Copper (b) Zinc (c) Iron (d) Nickel 2001
Answers : (1) a; (2) b; (3) b; (4) b; (5) d. 14. Ravindranathan I. Essential trace elements in food. Nutrition 2001. 35(3):9-
32.
15. Antia FP, Abraham P. Clinical Dietetics and Nutrition. 4th ed Oxford University
Press, New Delhi 1998.
16. Rayman MP. The importance of selenium to human health. Lancet. 2000;
356: 233-241.

health, disease and its prevention. This chapter endeavors to

Major Foods and their Nutritive
131 Value
elaborate in brief the commonly used food items.

Box - 1 : Ten major food groups

Rajul K Gupta Cereals and millets
Pulses and legumes
The Major Food Groups Vegetables, roots and tubers
There are innumerable food items that constitute human diet.
Fruits and nuts
The major foodstuffs can be broadly classified into ten major
groups. These are shown in the Box-1. Animal foods
Foods have different nutritional profiles. Moreover, availability ●● Meat/Poultry
of foods varies at different places and in different seasons. ●● Milk and milk products
People from diverse cultures, religions and states tend to ●● Eggs
consume different types of food stuff. But one thing that is Oilseeds
common for the good health of all humans is the absolute
Sugar, jaggery, salt
necessity of a well balanced diet. To formulate a well balanced
diet for optimum health, it is extremely important to appreciate Non - Alcoholic beverages
the details of these food items and their nutritive value. Alcoholic beverages
Therefore these facts are required to be learnt before we could
proceed further in unveiling the complex relationship of food, Spices and condiments

• 741 •
Cereals and Millets content of whole meal flour is relatively higher (3). Milling
is undoubtedly a necessary evil. Cereals should not be ‘hard’
Cereals and millets form the staple food for human diet as they
milled. Highly milled cereals should be avoided. It is advisable
are cheap and have a high energy value, approximately 350
to consume whole wheat atta of 85 percent extraction. Not more
Kcal/100g. In an agricultural country like ours, rice, maize,
than 5 percent bran should be permitted to be removed during
wheat and millets (jowar, bajra and ragi) form the bulk of the
milling. Parboiling of rice is also an effective solution. Parboiled
diet which makes up for as much as three fourth of the total
rice is the only cereal which does not suffer appreciably when
energy requirement of a rural Indian. Thus knowing about the
machine milled.
nutritive quality of these staple cereals is of great importance.
Cereals and millets provide almost all major nutrients, as
elaborated below. Effects of Refining on Nutrient Content of Wheat Flour
(per 100 g) (2).
Carbohydrates : Cereals are most important sources of
carbohydrates and energy in our diet. They provide 60 to 75 % Content before Content after
Nutrient
of the total energy in our diet. refining (per 100 g) refining (per 100 g)
Proteins : Cereals are moderate sources of proteins (about 6 to Thiamin 580 μg 140 μg
12g/100g). Cereal protein is of poor quality as it is deficient in Vitamin B6 750 μg 130 μg
essential amino acids. Wheat proteins are deficient in Lysine
Niacin 2520 μg 340 μg
and maize in Tryptophan. Pulse proteins on the other hand,
are rich in these deficient amino acids (lysine and tryptophan). Folate 57 μg 6 μg
A predominantly cereal diet should therefore invariably be Vitamin E 1.4 mg 0.3 mg
supplemented with other sources of proteins like the pulses,
Calcium 44 mg 23 mg
especially for the vegetarians. This helps to improve the quality
of protein in our diet. This is called as the supplementary action Zinc 29 ppm 8 ppm
of proteins. Copper 4 ppm 1.3 ppm
Cereal proteins are quantitatively an ample amount of protein Iron 35 ppm 10 ppm
in an otherwise protein deficient Indian diet. As much as 50%
of the total proteins in Indian diet is contributed to by cereal Rice
proteins. Hence cereals constitute a vital source of proteins in
Rice is staple to more than half of the world population.
our diet.
Nutritive value : Rice is high in energy (about 350 Kcal/100g).
Micronutrients : Cereals contain minerals like iron and
The protein content is moderate, 6-9 g%. It is richer in lysine
calcium, little carotene but no vitamin C. Ragi is particularly
than other cereals. Rice is also fairly rich in thiamine, riboflavin
rich in calcium. The millets are also rich in phytates and
and niacin. It is a poor source of vitamins A, C and D. It is poor
tannins which interfere with the absorption of minerals. Whole
in calcium and iron as well.
(unrefined) cereals are relatively good sources of the B complex
vitamins. Most of the vitamins lie in the outer layers so milling Nutritive losses : Milling and polishing cause the greatest
and polishing removes these vitamins to a great extent. nutritional loss. Polishing is a process where milled rice is
passed through rubber rollers to make it smooth, shiny and
Fibre : The outer layers of cereals and millets contain the all
whiter. During processing the B -complex vitamins, fibre and
important fibre in plenty (1-8g/100g). The fibre is lost depending
proteins are lost to a great extent, depending on the level of
on the level and extent of milling.
milling and polishing. Rice also loses substantial amount of
Milling : Now a days machine milling of cereals has become water soluble vitamins and minerals during washing it in
an integral part of the processing of grains. Milling not only plenty of water and discarding it. Similarly draining the water
does the basic processing but also makes the grain more shiny, in which the rice was cooked also causes loss of water soluble
whiter and sparkling (‘refined white flour and polished white nutrients.
rice’). This appeals to the sense of sight and thus improves
Preventing nutritive losses : The nutritive losses because of
the palatability. But we have to pay the cost for it in terms
milling, polishing, other processing and cooking practices can
of losing its nutritive value. Milling separates germ and outer
be prevented by taking suitable and timely measures. One such
layers (pericarp and testa) that are discarded as bran. Such
widely used method is parboiling.
highly milled wheat and rice is thus devoid of fibre. Since the
vitamins are also concentrated in the outer layer of the whole Parboiling : It is an old technique practiced in India for a long
grains, which are removed by machine milling, these refined time at the household level. This involves steaming the rice
cereals lose not only much of their fibre but also the vitamin, that renders it partially cooked. The technique is now being
mineral and protein content during processing (1). used at a commercial level as well. The ‘Hot Soaking Process’
of parboiling has been recommended by the Central Food
Machine milling and refining cause considerable deterioration
Technological Research Institute, Mysore.
of nutritive value of cereals that eventually affects public
health. For example, beriberi is endemic in countries where The process : The paddy is soaked in hot water at 70°C for 3 to
polished rice is habitually eaten. Even though whole meal flour 4 hours. With this soaking the outer husk splits and becomes
has marginally lower energy value than white flour, the protein easier to remove. The excess water is drained. This paddy is
then steamed for about 10 minutes. The paddy is dried. At a

• 742 •
domestic level it is home pounded and commercially, it is milled make custards.
for final use. Advantages of parboiling are given in Box - 2. Nutritive value : The calorie content of maize is about 342
Kcal/100g. The protein content is higher than that of rice i.e.
Box - 2 : Advantages of parboiling 9 to 16g %. The quality of protein is poorer as it is deficient in
Parboiling causes the B group vitamins in the outer layers lysine and tryptophan. It also contains excess leucine which
(aleurone) to diffuse in to the interior of the grain (endosperm) interferes with conversion of tryptophan to niacin (60mg of
thus saving them from being lost during milling. trytophan is required to produce 1mg niacin). Thus maize
eaters may face the deficiency of niacin and a higher risk of
Drying the rice causes the germ to attach firmly to grain, so
pellagra. Maize is also rich in carotenoids. Nutritive values of
that the germ is not lost during milling and polishing.
common Cereals and Millets are given in Table - 1.
The heat hardens the grain as the starch gets gelatinized.
Millets
This increases the keeping quality and storage capacity of
rice. Millets are consumed without milling. The commonly used
millets are jowar (sorghum), bajra (pearl millet) and ragi. These
The parboiled grain also becomes more resistant to insects. are traditional foods in many parts of India. Jowar and Bajra
are widely used in Maharashtra and Rajasthan respectively.
Disadvantage of parboiling : There are no disadvantages
of the parboiled rice except for the fact that it imparts an off Nutritive value : The calorie content of millets is about 350
flavour to rice. The rice also attains a pale hue. The off flavour Kcal/100g. The protein content is about 8 to 14g %. They are
is not liked by people who are used to eating the non-parboiled also rich in minerals. Ragi contains a high amount of calcium
rice. - 344 mg / 100 g.
Wheat Jowar is important millet in the western and central India (esp.
Maharashtra, MP and Andhra Pradesh) and is the staple for
Wheat is the most widely consumed cereal in North India. It many Indians. It is nutritious millet with a high iron content
is used to make flour (atta for chapattis and puri), maida for of 4.1 mg/100g. The protein content is in the range of 9 to
bread, dalia and also suji, to make various savouries. 14%. Like other millets the protein is limited in the amino acids
Nutritive value : The calorie content of wheat is almost the lysine and threonine. In some species the leucine content might
same as that of rice ie about 350 Kcal/100g. The protein content be higher that interferes with the conversion of tryptophan to
is higher than that of rice i.e. 9 to 16g %. The quality of protein niacin thus sole consumption of Jowar could be pellagrogenic.
is however poor as it is deficient in the essential amino acids Bajra (Pearl millet) is grown in the arid regions of our
lysine and threonine. country. It is relished in Rajasthan, Gujarat and some parts
Nutritive losses and their prevention : Hard milling, extraction of Maharashtra as porridge. It is also used to make flour for
and discarding the bran causes loss of fibre, vitamins and preparing chapatis. The protein content is in the range of 10 to
proteins. As discussed earlier it is advisable to consume whole 14%. The iron content of Bajra is the highest among all cereals
wheat atta and dalia. Products made up of refined flour like and millets at 8mg/100g. It is also relatively rich in calcium,
white bread, biscuits, cakes, noodles and burgers should be carotene, riboflavin, niacin and folic acid.
discouraged.
Pulses and Legumes
Maize
Pulses and legumes comprise of dried peas, beans, dals and
Maize is the staple diet in many parts of Africa and Central
grams and are an integral part of the Indian diet. Commonly
Asia. However, in most parts of India and many other parts
used dals are red gram (arhar), green gram (moong), lentil
of the world it is commonly eaten only as corn. It is also used
(masoor), bengal gram (channa) etc. They are, therefore a
to make cornflakes. Cornflour is used in confectionery and to

Table - 1 : Nutritive value of common cereals and millets (per 100g) (1)
Vitamin C (mg)
Thiamine (mg)
Carbohydrates

Folic acid (µg)

Energy (Kcal)

Carotene (µg)

Niacin (mg)
Proteins (g)

Riboflavin
Food stuff

Iron (mg)
Fibre (g)
Fat(g)

(mg)
(g)

Rice parboiled 6.4 0.4 0.2 79 346 1 9 0.21 0.05 3.8 8.9 0
Rice polished 6.8 0.5 0.2 78.2 345 0.7 0 0.06 0.06 1.9 8 0
Wheat 11.8 1.5 1.2 71.2 346 5.3 64 0.45 0.17 5.5 142 0
Wheat flour 12.1 1.7 1.9 69.4 341 4.9 25 0.49 0.17 4.3 35.8 0
Maize dry 11.1 3.6 2.7 66.2 342 2.3 90 0.42 0.1 1.8 20.0 0
Bajra 11.6 5 1.2 67.5 361 8 132 0.33 0.25 2.3 45.5 0

• 743 •
 Soya bean - The ‘Queen’ of pulses and legumes
Soya bean is a pulse which has very high protein (43.2g/100g) and fat content (19.5g/100g). It possesses high contents of iron
as well. It is also rich in carotene, niacin and folic acid. The nutritive value of soya bean proteins is equivalent to milk proteins
even though the protein quality is inferior. The rather bland taste of unprocessed soya bean can be made up by suitably cooking
or processing it. It can be simply cooked as dal or can be prepared with other legumes as mixed dal. Soya bean can be processed
into many foods which are enjoyed by the community. It is commonly eaten as nuggets (baris). Its flour can be mixed in wheat
flour to make it more nutritious. Soya milk and curd is also popular. It can be processed to fried nuggets (kurkure), which are
relished by the children. In the South East Asian countries its preparations like tofu, miso and soya sauce are relished. By virtue
of its high fat contents its oil is extracted and used as cooking oil. This oil is one of the very few oils rich in alpha-linolenic acid
(>5%) besides its high contents of linoleic acid (53%). Soya bean is truly the ‘Queen’ of pulses and legumes.
Nutritional profile of Soya bean (per 100g)
Nutrient Contents Nutrient Contents
Protein 43.2 g Thiamin 0.73 mg
Fat 19.5 g Riboflavin 0.39 mg
Iron 10.4 mg Niacin 3.2 mg
Carotene 426 µg Folate (total) 100µg

valuable constituent of the vegetarian diet. Pulses are cheap these are 10 to 20 mm long the process is complete. The vitamin
and easily available. C content is maximal after about 30 hours of germination.
Nutritive Value : Pulses and legumes are colloquially referred Germination causes an increase in vitamin B also (4).
to as the poor man’s meat as they have high protein content Fermentation too improves the nutritional value of pulses. The
of about 20-25g%. Although they are poor in methionine and vitamin content of B group of vitamins esp. thiamin, riboflavin
cysteine and the biological values of their protein is inferior to and niacin goes up. The digestibility of pulses also improves
foods of animal origin (meat, fish eggs and milk), they are a with germination. The nutritive value of common pulses and
substantial source of proteins for those not consuming meat. legumes is summarized in Table - 2.
Pulse protein is rich in lysine which compensates for the low
lysine content of cereal proteins. They are an important source Animal Foods
of vitamins and minerals like calcium, iron and vitamin B. Meat and fish
Bengal gram (channa dal) and to a lesser extent green gram Meat is a word commonly used for the flesh of cattle (beef),
(moong) contain a small amount of ascorbic acid in the dry goat and sheep (mutton), pig (pork) or chicken. It is a good
state. The energy content is approximately the same as that of source of high quality protein (15 to 20g per 100g). Moreover
cereals i.e. about 350 Kcal/100g (1). this protein is qualitatively as good as that of fish, egg, milk,
Germination of Pulses : The ascorbic acid content of all cheese and other dairy produce, since it contains all essential
unsplit pulses can be increased by germinating or sprouting. amino acids. It is also a good source of most B vitamins like
Whole unsplit dal or gram is first soaked in water for 12 to 24 nicotinic acid. Meat is rich in phosphorous but poor in calcium.
hours and then spread on a damp blanket in a thin layer to Liver, a component of meat, too has not only high quality
allow access of air and covered with another blanket kept damp proteins but also vitamin A and vitamin B complex. Meat is
by sprinkling water. In few hours small sprouts appear; when also rich in minerals especially iron and zinc. The iron content

Table - 2 : Nutritive value of common pulses and legumes (per 100g)

Riboflavin (mg)

Vitamin C (mg)
Thiamine (mg)
Carbohydrates

Folic acid (µg)

Energy (Kcal)

Carotene (µg)

Niacin (mg)
Proteins(g)
Pulses and

Iron(mg)
Fibre (g)
legumes

Fat (g)

(g)

Peas dry 19.7 1.1 4.5 56.5 315 7.05 39 0.47 0.47 3.4 7.5 0
Green gram 24.5 1.2 0.8 59.9 348 3.9 94 0.47 0.47 2.4 140 0
Bengal gram 17.1 3 3.9 60.9 360 4.6 189 0.30 0.15 2.9 186 3
Soya bean 43.2 19.5 3.7 20.9 432 10.4 426 0.73 0.39 3.2 100 -
Rajmah 22.9 1.3 4.8 60.6 346 5.1 - - - - - 0
Redgram 22.3 1.7 1.5 57.6 335 2.7 132 0.45 0.45 2.9 103 0

• 744 •
of meat is of the heme variety which has high bioavailability. of cow’s milk) and phosphorus. One litre of cow’s milk provides
Meat has a high content of fat including the saturated fatty about 670 Kcal (2.8 Mj) of energy (1).
acids, which may be a risk for good health. Curd : Curd is traditionally relished in the Indian diet. It is
Fish is generally considered good for health as it is rich in produced by the action of lactobacilli on lactose (in milk), which
unsaturated fatty acids including the omega 3 fatty acids and is broken down to lactic acid. The proteins are coagulated by
vitamins A and D. Fish has high quantity of proteins (15 - the acid and curd is formed. Curd and whole butter milk are
25g/100g), which are of high biological value and are easily easily digestible. They have the same nutritive value as that
digestible. Sea fish is also rich in minerals like Iodine. With of the original milk from which they were prepared, being very
the current emphasis on higher intake of polyunsaturated fatty good sources of protein, calcium, vitamin A and riboflavin.
acids, including the omega-3 fatty acids fish is of immense Cream, Butter and Ghee : Cream, butter and ghee are the
value in diet. various types of fats extracted from milk. Cream can be extracted
Milk and Milk Products by centrifugation of unboiled milk. Butter is the fat extracted
Milk is the complete food on which the young one may subsist from buttermilk. Ghee is the clear fat extracted after boiling
for up to six months. It is the sole food for all growing young butter. Cream has nutritive value in between whole milk and
mammals. The human milk might be poorer than cow’s or butter. Good butter should not contain more than 16 percent of
buffalo’s milk, but is adequate for the infant. Milk is used to water and not less than 80 percent of fat. 100gm butter yields
prepare curd, yogurt, butter, ghee and buttermilk. These are about 729 Kcal (3.05 Mj). On the other hand, ghee is almost
used extensively for the preparation of many traditional Indian 100% fat, 100 g of ghee yielding 900 Kcal (3.76 Mj). Nutritive
sweets. value of milk and milk products is summarized in Table - 3.
Nutritive Value of Milk : All the important nutrients are well Skimmed and Toned Milk : The milk available in market may
represented in milk except for iron and nicotinic acid. Newly be pure milk from cow or buffalo. Sometimes a mixture of
drawn milk contains 2 mg of vitamin C per 100 ml but this buffalo’s and cow’s milk might also be available. Some people
readily disappears on storage, heating or processing in any prefer low fat or fat free milk. This is the skimmed milk from
other way. On the average, one liter of cow’s and buffalo’s which fat has been removed. This is useful for those who have
milk contains 32 and 43 g of protein respectively. Human milk been recommended low fat in diet, due to a medical condition.
contains about 1.1g % proteins. Milk proteins are caseinogen Toned milk can be manufactured by adding 1 part water and
(85%), lactalbumin (12%) and lactglobulin (3%). These proteins 1/8 part skimmed milk to 1 part milk. This blend is then stirred,
are of high biological value and are rich in tryptophan and pasteurized and bottled. It becomes quite similar to cow’s
cystein. Calcium caseinogenate is a complex formed with milk.
calcium in milk. Tinned Milk : Powdered or tinned milk could be an alternative
The fat content in milk varies from 3.4 (human) to 6.5 % to whole milk when fresh milk cannot be made available.
(buffalo), depending on the source. Milk fat is an emulsion of Condensed, evaporated or homogenized milk can be tinned. It
extremely fine particles of the glycerides of butyric, palmitic could be sweetened or unsweetened. Condensed milk contains
and oleic acid rendering it easily digestible and this is especially 50 percent cane sugar, which is a good preservative. Dried
so in cow’s milk. Milk is also rich in linoleic acid and oleic or powered milk is reconstituted by adding 7 volumes of
acid. Milk is a good source of vitamin A and D as well. Milk boiled water just before consumption. Tinned milk should be
contains more than 30 types of sugars, Lactose being the most reconstituted as per instructions.
predominant of them. A litre of milk contains as much as 50 g Eggs
of lactose. Milk is also very rich in calcium (1200 mg per litre Eggs contain all the nutrients required for the embryo. They

Table - 3 : Nutritive value of milk and milk products (per 100ml) (1) Vitamin C (mg)
Thiamine (mg)

Folic acid (µg)

Energy (Kcal)

Carotene (µg)

Niacin (mg)
Proteins (g)

Riboflavin
Food stuff

Iron (mg)
Fat (g)

(mg)

Milk, buffalo 4.3 6.5 117 0.2 48 0.04 0.10 0.1 3.3 1
Milk, cow 3.2 4.1 67 0.2 53 0.05 0.19 0.1 5.6 2
Milk, human 1.1 3.4 65 - 41 0.02 0.02 - 1.3 3
Ghee - 100 900 - 600 - - - - -
Butter - 81 729 - 960 - - - - -
Cheese 24.1 25.1 348 2.1 82 - - - - -
Curd 3.1 4 60 0.2 31 0.05 0.16 0.1 3.3 1

• 745 •
have a high nutritive value. An egg provides about 70 Kcal. preventing hyperglycemia and hyperlipidaemia.
An egg contains about 6 g protein. The proteins are of a high
biological value. The NPU of egg protein is 100 and is taken as The Rainbow of Phytochemicals
the standard protein, to compare other proteins with. An egg
Colour Fruit or vegetable Phytochemicals
contains about 6 g of fat. It also has a high cholesterol content
of 250mg. The fat is present in the yolk. It is finely emulsified Red Tomato Lycopene
and hence easily assimilated. The minerals and vitamins Yellow-green Pumpkin, papaya Zeaxanthin
exist in the yolk, which is also a valuable source of calcium,
Red-purple Beet root, Anthocyanins
phosphorus, iron and vitamins A and D. The white of the egg is
one of the best sources of riboflavin. It is however deficient in Orange Pumpkin, papaya, Beta carotene
Vitamin C. Nutritive value of egg is given in Table - 4. mango
Vegetables Orange-yellow Apricots, apple, cherry, Flavonoids
tomato, orange
Vegetables and fruits add colour and variety to our food. It is
the vegetables and fruits that impart a seasonal touch to the Green Leafy vegetables, Glucosinolates
diet, as they change with the seasons. We have green leafy cabbage
vegetables, coloured vegetables, roots and tubers. White-green Garlic, onion Allyl sulphides
Nutritive Value : Vegetables esp. green leafy and coloured
vegetables are a store-house of vitamins, minerals, various d) Calories : There are not many foods in our diet that could be
phytochemicals and antioxidants, hence they along with fruits claimed to be low in calorie and yet nutritious! Vegetables have
are termed as the protective foods. this unique distinction. By virtue of their high moisture and
a) Vitamins and Antioxidants : They contain ample amounts fibre content the calorie content of most of the green vegetables
of carotene, ascorbic acid, folic acid, calcium, iron and is in the range of 20 to 60 Kcal/100g. This is a boon for those
riboflavin. The carotenoids, vitamin C and numerous other who have been advised to restrict calories.
phytochemicals possess antioxidant properties (See Box - 1). A Root and tuber vegetables are of variable nutritive value.
yellow vegetable like pumpkin is rich in carotene. However, the The carrot is outstandingly rich in carotene. Most roots and
carotene of green vegetables like drumstick, cabbage, amaranth tubers contain starch and moderate amounts of ascorbic acid.
and methi is better utilized than of yellow vegetables. Gourds Potatoes and sweet potatoes having high carbohydrate content
are generally of poor nutritive value; but the bitter gourd is have a good energy value and contain moderate quantities of
relatively rich in ascorbic acid. The tomato has good ascorbic ascorbic acid. Nutritive values of common vegetables are given
acid, riboflavin and antioxidant lycopene contents. Onion may in Table - 5.
not have outstanding nutritive properties, but is virtually Fruits
irreplaceable because of its value as a flavouring agent and
Fruits hold a special place in the nutrition of man. They can be
appetizer.
eaten any time and as much. Everyone loves them. Different
b) Minerals : Vegetables are good source of minerals like fruits are available in different seasons. They are extremely
calcium, phosphorus, iron, zinc and many trace elements. The nutritious. Being eaten raw and fresh, the minerals, vitamins
absorption and bioavailability of some of the minerals may and phytochemicals present in them, do not have to suffer the
not be very good due to various reasons. Iron from green leafy humiliation of ‘mutilation’ through heat and fire. Fruits can be
vegetables is not very well absorbed as it is present in the classified into citrus, non-citrus and dry fruits.
ferric state which is not conducive for absorption. In addition
Nutritive Value
calcium, oxalates, phosphates and phytates present alongside
(in the vegetables) inhibit the absorption of minerals further. a) Vitamins and Antioxidants : It is known since James Lind
that citrus fruits like oranges, lime, lemon, mosambi, malta, etc
c) Fibre : Vegetables are rich in fibre, especially the soluble
are rich sources of vitamin C. Guava and amla too are very rich
fibre. Fibre is considered extremely important for normal bowel
sources of vitamin C. Papaya and mango are rich in carotene
motility, getting rid of toxins from the intestine and guarding
and moderately rich in vitamin C. Pineapples, strawberries
it against the rapid absorption of glucose and lipids, thus

Table - 4 : Nutritive value of egg (per 100g*) (1)

Thiamine (mg)
Energy (Kcal)

Carotene (µg)

Calcium (mg)
Phosphorus
Niacin (mg)
Proteins (g)

Riboflavin
Food stuff

Iron (mg)
Fat (g)

(mg)

(mg)

Egg, hen 13.3 13.3 173 2.1 420 0.1 0.4 0.1 220 60
Egg, duck 13.5 13.7 181 2.5 405 0.12 0.26 0.2 260 70
* One egg weighs about 60 to 70 g

• 746 •
 Table - 5 : Nutritive value of common vegetables (per 100g) (1)

Riboflavin (mg)

Vitamin C (mg)
Thiamine (mg)
Carbohydrates

Folic acid (µg)

Energy (Kcal)

Carotene (µg)

Niacin (mg)
Vegetable

Iron (mg)
Fibre (g)

(g)
Beans 1.8 4.5 26 0.61 187 0.10 0.06 0.7 45.5 24
Spinach 0.6 2.9 26 1.14 5580 0.03 0.26 0.5 123 28
Tomato 0.8 3.6 20 0.64 351 0.12 0.06 0.4 30 27
Carrot 1.2 10.6 48 1.03 1890 0.04 0.02 0.6 15 3
Onion 0.6 11.1 50 0.6 15 0.08 0.02 0.5 - 2
Potato 0.4 22.6 97 0.48 24 0.1 0.01 1.2 7 17
Cauliflower 1.2 4 30 1.23 30 0.04 0.1 1 - 56
Cabbage 1 4.6 27 0.8 120 0.06 0.09 0.4 23 124
Pumpkin 0.7 5.8 39 - 50 0.06 0.04 0.5 13 2

and papaya are moderately rich sources of vitamin C. Yellow A daily recommendation of about 400g of fruits and vegetables
peaches are a good source of carotene. Banana, orange and has been made by the American Dietetic Association. It is wise
strawberries are moderate sources of folates. Dried fruits like to consume fresh, seasonal and locally available fruits that
dry figs provide thiamin, niacin and riboflavin. Dried apricots are less costly and more affordable than the imported fruits.
and prunes are rich in vitamin A (See Table- 6). Nutritive values of common fruits are given in Table - 6.
b) Minerals : Watermelon is rich in iron. Custard apple is rich Nuts
in phosphorus and iron. Apricots, lime, guava and figs are rich The common nuts in use are almond, cashew nut, groundnut,
in calcium. Apricots are rich in zinc too. Banana and apples coconut, pistachio, walnut, etc. Nuts are relished by the young
are moderately rich in potassium. Dried fruits : Raisins, figs, and all primarily for their taste. Nuts have a very high nutritive
dates and dry apricots are rich in iron. Dried figs are also rich value (See Table - 7).
in phosphorus, calcium, potassium and zinc (1).
Nuts have a high fat and protein content and hence a high energy
c) Energy : Banana and plantain have high energy value. value. They are a good source of fats, vitamins and proteins as
d) Fibre : Fruits are rich in fibres. Their soluble fibre is well. They contain minerals too in good quantities. Groundnuts
particularly useful in inhibiting the rapid absorption of glucose are a good source of proteins, fats & vitamin B complex esp.
and lipids from the intestine. This is helpful in prevention of niacin. Even though the proteins are of low biological value, it
hyperglycemia and hyperlipidaemias is a cheap and ample source of proteins (See Box - 3). Pistachio

Table - 6 : Nutritive value of common fruits (per 100g) (1)

Carbohydrates (g)

Riboflavin (mg)

Vitamin C (mg)
Thiamine (mg)
Energy (Kcal)

Carotene (µg)

Niacin (mg)
Iron (mg)
Fibre (g)
Fruit

Guava 5.2 11.2 51 0.27 0 0.03 0.03 0.4 212

Amla 3.4 13.7 58 1.2 09 0.03 0.01 0.2 600
Mango 0.7 16.9 74 1.3 2743 0.08 0.09 0.9 16
Orange 0.3 10.9 48 0.32 1104 - - - 30
Banana 0.4 27.2 116 0.36 78 0.05 0.08 0.5 7
Lime 1.3 10.9 59 0.3 15 0.02 0.03 0.1 63
Grape blue 2.8 13.1 58 0.5 3 0.04 0.03 0.2 1
Papaya 0.8 7.2 32 0.5 666 0.04 0.25 0.2 57

• 747 •
 Table - 7 : Nutritive value of common nuts (per 100g) (1)

Vitamin C (mg)
Thiamine (mg)
Carbohydrates

Energy (Kcal)

Carotene (µg)

Niacin (mg)
Proteins (g)

Riboflavin
Iron (mg)
Fat (g)
Nuts

(mg)
(g)
Almond 20.8 58.9 10.5 655 5.09 0 0.24 0.57 4.4 0
Cashew nut 21.2 46.9 22.3 596 5.81 60 0.63 0.19 1.2 0
Coconut dry 6.8 62.3 18.4 662 7.8 0 0.08 0.01 3 7
Groundnut 25.3 40.1 26.1 567 2.5 37 0.90 0.13 19.9 0
Pistachio 19.8 53.5 16.2 626 7.7 144 0.67 0.28 2.3 -
Walnut 15.6 64.5 11 687 2.64 6 0.45 0.40 1 0

Box - 3 : Groundnuts - The King of Nuts

Groundnuts are the cheapest and arguably the most nutritious of all nuts. It contains almost as much oils and fats as an
oilseed does (40%). Its MUFA content is one of the highest amongst all Indian oilseeds, at 50% (exceeded only by mustard
and rape seed). Its protein content is very high (25.3%). Its niacin content is unmatched (about 20mg/100g), that is 5 to 20
times higher than other nuts. It is a household item in many Indian states like Maharashtra, Gujarat and Andhra Pradesh. It
is relished boiled, roasted, fried or simply salted. It can be made into powder or flour. Groundnut chikki (with jaggery) is not
only favourite with children, but is extremely nutritious even for the pregnant and lactating. Powdered or ground groundnuts
are also used in vegetable preparations and curries. Owing to its low cost and high nutrition value, it finds favour in various
national nutritional programme menus like in ‘multipurpose food and balahar’ as well.
Multipurpose food used in national nutritional programme is made using a mixture of 75 percent groundnut flour (from which
fats have been extracted) and 25 percent roasted red gram. It is further fortified with vitamins and minerals. It is a rich source
of proteins.
Its low cost, high nutritive value, immense variety of preparations and delicious taste crowns the groundnuts as the ‘King of
nuts’.
is rich in iron, containing 7.7 mg/100g. Almond and cashew provides only ‘blank calories’ at the expense of complex
nuts are also moderate sources of iron and proteins. carbohydrates lowers the relative vitamin, mineral and protein
Fats and Oils intake. Jaggery is a sweet food popular in rural India. Besides
being tasty, it contains an appreciable amount of carotene &
Fats and oils hold a vital place in our daily diet. They are an iron.
integral part of cooking as they not only impart good taste, but
also contribute to the texture, crispness and energy to our food. Salt
They also serve as a medium for cooking as their boiling point Salt contains the essential mineral sodium. Even though the
is very high. daily sodium requirement is very low, the average daily diet
Fats that are liquid at room temperature are termed as oils. Fats contains salt much in excess. The recommended daily salt
and oils could be of either plant or animal origin. Vegetable oils intake is 5 g. Excess of salt and a skewed sodium potassium
such as mustard, ground nut, gingelly, coconut and safflower ratio (>1) is known to be a causative factor of hypertension.
oils are widely used for cooking purposes. Vegetable oils (except It is the added salt that is harmful to the body rather than the
red palm oil) are free of any vitamin A activity and contain moderate amounts put in food preparations.
predominantly unsaturated fatty acids. However, coconut and
palm oils are the only commonly used plant oils that are rich in Where does ‘High’ Salt Come From ?
saturated fatty acids.
Excessively
Butter and ghee are fats of animal origin. These are also used High salt Very High Salt
High Salt
as a cooking medium. They are rich in vitamin A and D. All fats
and oils provide 9 Kcal per gram. Excess consumption of these Bread Cheese Pickles
is in disrepute as they are considered to be atherogenic. Excess Potato chips Processed meat Chutneys
consumption also contributes to dyslipidaemia, a risk factor for
cardiovascular diseases. Cornflakes Soups Salted Nuts
Sugar and Jaggery Canned vegetables Ketchups Salted fish
It is pure sucrose & is used for its sweetening effect & energy Canned fruits Processed butter Chaat
value. Excessive consumption of such refined sugar that

• 748 •
 Sugar substitutes
There are occasions when sugar substitutes have to be used instead of sugar. They are preferred for their very high sweetening
power and negligible calorific value. These are commonly used for preparing ice creams, candies, toffees, jellies, sweets, etc.
They are also used as sweetening agents in cold drinks, flavoured milk and even in tooth pastes. They are also popular amongst
diabetics and people desirous of loosing weight. Sugar substitutes can be classified into two groups :
(a) Nutritive sweeteners : Sugar alcohols (sorbitol, mannitol, xylitol) used as sugar substitutes in candies, chewing gum and
beverages. These provide 4 Kcal/gm of energy.
Advantages :
●● These are not absorbed as rapidly as sucrose, so can be used in those who cannot tolerate a high blood sugar level.
●● The risk of dental caries is lower, as these alcohols can not be used by oral bacteria.
(b) Non-nutritive sweeteners : These do not supply any calories. Common examples are aspartame, sucralose, alitame and
saccharin. They are several hundred times sweeter than sugar, so a small quantity is sufficient to sweeten the food.

Spices and Condiments in methionine. Groundnuts and soya beans are of exceptionally
Spices are used to flavour food and improve its palatability. high nutritive quality with high content of proteins, fat and
They stimulate the appetite and thus improve health. They vitamins. Fats are the storehouse of energy, present in animal
are essential to the Indian culinary art. They are used in very oils (ghee/butter) or in vegetable oils (mustard, groundnut,
small quantities as flavouring agents and for their carminative etc).
properties. Green or dry chillies have a high carotene and Fruits and vegetables are rich sources of vitamins, minerals
vitamin C content. As per the new research turmeric (haldi) and antioxidants. Roots and tubers also contain starch that
has very high antioxidant content and has medicinal value. is high in calories. Milk which is a complete food is essential
Tamarind (Imli) is widely used for its preservative effect and for infants and children. Egg protein is one of the best quality
high vitamin C content. Cloves, Black pepper, ginger, garlic and proteins available to us and its use must be encouraged. Meat
red chillies have been shown to have antioxidant properties. contains high quality iron and proteins. But owing to its high
Spices and condiments are used to prepare pickles and chutney saturated fat content, excessive consumption of meat should
which are used as appetizers. be guarded against. Spices and condiments not only provide
flavour to the diet but also contribute to the antioxidant
Non Alcoholic Beverages
content of food.
Earlier it was thought that by themselves tea, coffee, cocoa or
other non-alcoholic beverages do not provide energy or vitamins Study Exercises
except that from the sugar and milk added to them. Tea contains Long Question : Enumerate major food groups. Describe the
alkaloids like caffeine, theophylline and theobromine which are importance of legumes in diet.
cortical stimulants and help relieve fatigue. If used in excess
Short Notes : (1) Importance of fruits in diet (2) Parboiling of
they may cause insomnia, tachycardia and gastritis in some
rice (3) Nutritional importance of eggs.
individuals. Recent studies show that they contain substantial
amounts of antioxidants which have distinct health benefits. MCQs
Alcoholic beverages have been discussed in another chapter. 1. The highest content of niacin is present in : (a) Jaggery
(b) Groundnuts (c) Pistachio (d) Milk
Summary 2. Yellow-orange fruits and vegetables are rich in
The ten major food groups are cereals/millets, pulses/legumes, (a) Carotenes (b) Vitamin D (c) B Complex vitamins
vegetables (including roots and tubers), fruits/nuts, animal (d) Zinc
foods (meat/poultry, milk and milk products, eggs), oilseeds, 3. Food item with highest protein content is (a) Groundnuts
sugar, jaggery, salt, beverages and lastly spices/condiments. (b) Meat (c) Soyabean (d) Fish
Each of these has their own vital value in our diet and for good 4. Egg is a poor source of vitamin (a) A (b) B (c) C (d) D
health. 5. Jaggery is a rich source of (a) Carotene and thiamine (b)
Cereals and millets contribute to up to 75% of total energy Zinc and iron (c) Iron and carotene (d) Sugar and proteins
intake. They also contain substantial amount of proteins and Answers : (1) b; (2) a; (3) a; (4) c; (5) c.
invisible fats which contribute handsomely to an Indian diet
that is otherwise considered to be poor in these nutrients.
References
1. Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian
Excessive milling denudes cereals of their outer cover and foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.
with that the major portion of vitamins, minerals and proteins 2. Pederson B. World Rev Nutr Diet, 1989;60 : 1
are lost. Coarse ground flour (atta) and parboiled rice help in 3. Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and
Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.
reducing the nutritive losses due to milling. 4. Chaney MS, Ross ML. Nutrition. Houghton Mifflin Company, USA. 1996.
Pulses are the major contributors of proteins esp. in a vegetarian
diet. Cereal proteins are poor in lysine which are compensated
by the pulse proteins that are rich in these amino acids but poor

• 749 •
 energy required is based on the volume of milk secreted, its
Nutritional Requirements of energy content and the efficiency of conversion of food energy
132 Special Groups : Mothers, into milk energy. Women secrete up to 850 ml milk per day at
Children and the Elderly 80% efficiency of conversion of food energy into milk energy.
All these changes demand a change in the woman’s lifestyle
Rajul K Gupta including her dietary habits, to cope up with the increased
requirement of nutrients. The nutrient requirements
during pregnancy and lactation are discussed here. A Table
It is amazing as to how the same human body changes and
summarizing the same is also appended (Table - 1).
behaves differently in different ‘periods’ of its lifecycle. At
different stages of the organism with reference to changing Nutrient Requirements During Pregnancy and
age and continuously changing physiological status, the Lactation
requirement of nutrients is based on activity, BMR, growth Energy requirements : The energy equivalent of the raised
rate, etc. These factors change constantly as the organism resting oxygen consumption is of the order of about 27,000
grows over a lifetime. With these variations change the Kcal, over the entire duration of pregnancy. The diet also has
nutritional requirements. This chapter discusses the nutritional to provide energy for the fat and proteins laid out in the foetus
requirements over a lifecycle and how to meet that changed and maternal tissues. The maternal fat deposited is about 4
requirement through a typical Indian diet. kg. The total energy cost of pregnancy could be put at about
73,000 Kcal. Most of this extra energy is needed in the latter
Pregnancy & Lactation two trimesters. An additional requirement of 300Kcal per day
Physiological Changes During Pregnancy and is to be met, throughout the pregnancy. The additional energy
Lactation requirement during lactation has been worked out to 550 Kcal
Immense physiological changes take place in the human body in the first 6 months and 400 Kcal thereafter.
during pregnancy. The uterus undergoes hypertrophy and Protein requirements : The rapid growth of foetus, development
hyperplasia, there is an increased vascularity within the uterus of placenta and other maternal tissues, the expanding fluids
(and placenta). The heart rate, stroke volume and cardiac output (blood volume, amniotic fluid) and other storage reserves
increase so do the tidal volume and oxygen consumption. The demand extra proteins. It has been recommended that an
renal plasma flow and GFR also increase. Appetite changes; additional 15 g of proteins per day must be catered for during
cravings and aversions set in for certain foods. This is pregnancy. During lactation, extra protein demand is incurred
augmented by certain endocrine changes. Changed peristalsis for the production of milk. Therefore an additional intake of 25
state leads to constipation. Besides these the requirement for g proteins/day in the first six months and 18 g in the next 6
energy and various other nutrients go up steeply to cater for months (6 - 12 months) is recommended.
the developing fetus (1). The physiological changes continue Fats & Essential Fatty Acids (EFA) : The linoleic acid
during lactation. There are hormonal changes followed by requirement during pregnancy is put at 4.5% of total energy.
physiological changes in the mammary system, involution of This can be met by the normal intake of invisible fats along
uterus continues. Psychological and emotional changes too play with an intake of 12.5% of total energy equivalent of visible
a part. The process of lactation requires energy. The additional fats. The EFA requirement goes up further during lactation
Table - 1: Nutrient requirements for a sedentary woman during Pregnancy and Lactation (2,4)
RDA (Sedentary
Nutrient Pregnancy Lactation (1st 6 months) Lactation (6-12 months)
woman)
Add Total Add Total Add Total
Energy (Kcal) 1875 300 2175 550 2425 400 2275
Proteins (g) 50 15 65 25 75 18 68
Fat (g) 20 10 30 25 45 25 45
Iron (mg) 30 8 38 0 30 0 30
Vitamin A (RE) 600 0 600 350 950 350 950
Thiamin (mg) 0.9 0.2 1.1 0.3 1.2 0.2 1.1
Riboflavin (mg) 1.1 0.2 1.3 0.3 1.4 0.2 1.3
Niacin (mg) 12 2 14 4 16 3 15
Pyridoxine (mg) 2 0.5 2.5 0.5 2.5 0.5 2.5
Folic Acid (μg) 100 300 400 50 150 50 150
Vitamin B12(μg) 1 0 1 0.5 1.5 0.5 1.5
Vitamin C (mg) 40 0 40 40 80 40 80

• 750 •
to 6% of total energy. This can be met by the normal intake Folic Acid : The additional requirement of folic acid during
of invisible fats along with an intake of 17.5% of total energy pregnancy is known to increase by 200 to 400 µg/day. The
equivalent of visible fats. This would correspond to a total of additional RDA is put at 300 µg/day for the duration of
about 45g of visible fats. pregnancy. It is however difficult to provide this amount
Iron : Additional iron is required to meet the augmented through diet alone, so supplementation through medicinal
demand for foetal growth, expansion of maternal tissue folates have to be made. An amount of about 25 µg/day is
including RBC mass, iron content in placenta and blood loss lost through lactation. An additional amount of 50 µg/day is
during parturition. These additional requirements should be therefore recommended during lactation.
added to the basal ones. Owing to these additional needs the Vitamin B12 : About 0.25 to 0.30 µg of this vitamin is lost per
iron requirements go up in the second and third trimester to day during lactation. An additional intake of 0.5 µg per day is
3.3 mg and 5 mg respectively (taken as RDA of 38mg during recommended.
pregnancy). However due to amenorrhoea during pregnancy, Vitamin C : There is no data to indicate that vitamin C
the menstrual loss of iron is prevented saving some iron loss. requirement is increased during pregnancy. The foetal
Breast milk contains iron, so this iron need is to be catered requirement is too small to justify any additional requirement.
for during lactation. But since there is lactational amenorrhea, Therefore no additional allowances are considered necessary.
there is no menstrual loss and the total daily iron requirement The additional requirement during lactation is about 20 mg per
remains the same as that of a normal woman i.e. 1mg/day (or day. Taking into consideration the cooking losses of 50%, an
the RDA of 30mg). additional allowance of 40 mg per day is recommended.
Taking the poor absorption of iron (only 3 - 5%) from habitual Effect of Micronutrient Deficiency During Pregnancy
Indian diets into consideration, the RDA of iron for pregnant
women has been slated at 37.5mg, rounded off to 38mg per The micronutrient demands of the rapidly growing fetus are
day and for lactating women at 30mg per day. mandatory and inevitable. It is extremely sensitive to the
deficiency of micronutrients during the organogenesis and
Vitamins
growth. Whenever there is micronutrient deficiency in the
Vitamin A : The vitamin A requirements during pregnancy mother’s diet, the high demand of the foetus is initially met
were calculated on the basis of vitamin A content of livers of by the maternal resources. But when these resources are
the newborn. The additional intake required for this purpose is exhausted, the maternal reserves are tapped and besides foetus,
about 25 µg/day throughout pregnancy. Since this constitutes a the mother’s health is also compromised. The likely adverse
very small fraction of the RDA no additional dietary allowance effects of micronutrient deficiency on foetus and mother are
was recommended for pregnancy. On the other hand, a shown in Box - 1.
substantial amount of vitamin A is secreted in human milk,
Diet During Pregnancy
hence an additional intake of 350 µg/day is recommended for
the lactational period. Various studies indicate that diet of pregnant ladies in India are
generally deficient, esp. so in the rural areas and in the urban
Thiamine : The intake of thiamine is based on the energy intake
lower class (5). These two groups form a major proportion of
and is normally recommended at 0.5 mg/1000Kcal. The calorie
our society. The diet is mainly a cereal based diet supplemented
intake does go up during pregnancy and markedly so during
with little pulses and vegetables. Many a times only a chilly
lactation so would the thiamine intake. Hence when computed
- salt mixture or onion is eaten with rice or chapati, with no
on the basis of energy allowance, it works out to an additional
pulses, vegetables, fat or fruits. Milk is used only to prepare tea.
0.2 mg for pregnancy and 0.3 mg and 0.2 mg for the first six
Usually only two main meals are taken. The nutrient value of
months and latter six months of lactation respectively.
such a diet is grossly limited even for a non pregnant woman.
Riboflavin : The RDA of riboflavin is based on the total calorie
This inadequate diet is not only limited in calories, but is poor in
requirement and is taken as 0.6 mg/1000 Kcal. The higher
proteins, fats and micronutrients as well. The pregnant woman
energy intake during pregnancy and lactation calls for this
becomes malnourished. She is more prone to post-partum
additional demand which corresponds to an additional 0.2 mg
haemorrhage and death. This anaemic and malnourished
for pregnancy and 0.3 mg and 0.2 mg in the first six months
woman delivers a physically and/or mentally retarded neonate.
and latter six months of lactation respectively. This increment
There may be bone deformities, mental deficiencies and due
is the same as that for thiamine.
to low immunity and nutritional reserves such a child would
Niacin : The niacin RDA is fixed at 6.6 mg per 1000 Kcal as is be more prone to infections and malnutrition. In case it was
done for adult subjects. This corresponds to an additional 2 mg a girl child, she grows into a nutritionally deficient teenaged
for pregnancy and 4 mg and 3 mg in the first six months and girl and mother. The cycle continues and so perpetuates the
latter six months of lactation respectively. malnutrition cycle. It is therefore important to offer and
Pyridoxine : The Pyridoxine requirement also goes up during consume a balanced diet. The diet should be so modified that
pregnancy and lactation. It is recommended that an additional more of the protective foods (vitamins and minerals) and body
0.5 mg/day of pyridoxine be catered for pregnancy as well as building foods (proteins) are included rather than only excess
lactation. of energy. A typical balanced diet (raw) is given in Table - 2.
The general advise to be given is laid out in Box - 2.

• 751 •
Box - 1 : Adverse effects of micronutrient deficiency on foetus and mother

Nutrient Adverse effect on mother Adverse effect on foetus/infant

Thiamin - Infantile Beriberi

Folic Acid Anaemia Iugr, Neural Tube Defects, Low Birth Weight, Abortion

Vitamin A Anaemia Low Birth Weight, Premature Birth

Vitamin D Increased risk of osteomalacia Impaired Bone Development, Hypocalcemia, Rickets

Vitamin E - Birth Defect, Spontaneous Abortion

Higher risk of hypertension,

Calcium Impaired Bone Development, Hypocalcemia, Rickets
eclampsia, osteoporosis

Higher risk of hypertension,

Magnesium Premature Birth
eclampsia

Iron Anaemia Low Birth Weight, Premature Birth, Higher Infant Mortality

Iodine Hypothyroidism Still Birth, Cretinism, Neonatal Hypothyroidism, Deaf Mutism

Zinc - Birth Defect, Premature Birth, Low Birth Weight, Hypogonadism

Table - 2 : Balanced diet for a pregnant woman* (3) The Meals : In the first trimester the
woman suffers from gastritis and morning
Food Group Food stuff Amount per day sickness. In the third trimester the abdomen
Cereals Rice, wheat, millets 300 g feels too full and she may not be able to eat
much food. Therefore it is advisable to eat
Fats Oil, ghee, butter 30 g small quantities of food more frequently,
Sugars Sugar, Jaggery 20 g rather than large quantities in, say only two
meals. This means that long inter - meal
Milk Milk, curds, etc 500 ml spans must be interrupted with snacks like
Pulses & Nuts Pulses, legumes, dry beans, nuts 60 g the mid - morning snacks after breakfast
and the evening snacks with tea.
Fruits 200 g
Diet During Lactation
Vegetable 350 g Just like the diet of a pregnant woman the
Fruits & vegetables Green Leafy Vegetables 150 g diet consumed by a lactating woman is also
poor in quality and quantity, particularly
Other vegetables 120 g in the poor rural and urban slum areas, if
Roots and tubers 100 g particular attention is not paid to it. First,
the woman might have been undernourished
*The diet shown in the table is a vegetarian diet for a pregnant sedentary woman, for non vegetarians
additional 30 g of flesh foods (meat, fish, chicken) or one egg is suggested in lieu of 30 g pulses.. during pregnancy and such a person, when
starts breastfeeding her child puts herself to
great nutritional strain. Secondly her own
Box - 2 : Public Health Manager’s Advise to Pregnant ladies demand of nutrients is very high as she has
●● Eat one extra meal a day, to ensure adequacy of all nutrients to breastfeed the child. Thirdly, women esp.
●● Try and eat with the whole family and not alone in the rural, hilly and tribal areas breastfeed
●● Prefer high fibre cereals and legumes - include sprouts the child for a prolonged period. Lactational
●● Include ample amounts of vegetables and fruits amenorrhoea serves as a contraceptive
●● Take meat, milk and eggs regularly incentive for them, and the breast feeding
●● If vegetarian, insist on at least ½ lit of milk, and extra pulses continues till they become pregnant again.
●● Prefer nutritious foods like groundnuts and soya beans This cycle of pregnancy, lactation and
●● No fad diets repeated pregnancies continue, rendering
●● Take iron and folate supplements regularly the mother malnourished. The principles
●● No un-prescribed medicines, alcohol and tobacco of diet during lactation are basically the
●● Attend ANC clinic regularly and follow your doctor’s advise same as during pregnancy (please refer

• 752 •
to the earlier paragraphs for nutritional requirements during Table - 5 : Daily Energy Requirements for Children
lactation). A lactating mother must increase her diet by about
10% than what she was eating during pregnancy. A typical diet Age (years) Boys (Kcal/kg) Girls (Kcal/kg)
is outlined in Table - 3. 1-3 1287 1193
4-6 1752 1630
Table - 3 : Balanced diet for a lactating woman* (3)
7-9 2075 1833
Food
Food stuff Amount per day 10-12 2194 1965
Group
Cereals Rice, wheat, millets 330 g 13 - 15 2447 2056
Fats Oil, ghee, butter 30 g 16 - 18 2642 2064
Sugars Sugar, jaggery 20 g
Table - 6 : Daily Protein* Requirement for Infants
Milk Milk, curds, etc 500 ml
Age (months) Proteins (g/kg body weight)
Pulses & Pulses, legumes, dry 90 g
Nuts beans, nuts 0-3 2.3
Fruits and Fruits 200 g 3-6 1.85
vegetables Vegetable 350 g 6-9 1.65
Green Leafy Vegetables 150 g 9-12 1.5
Other vegetables 130 g *In terms of milk proteins

Roots and tubers 120 g

*The diet shown in the table is a vegetarian diet for a lactating sedentary
Table - 7 : Daily Protein* Requirements of Children
woman, for non vegetarians additional 30 g of flesh foods (meat, fish, chicken) Boys (g/kg Girls (g/kg
or one egg is suggested in lieu of 30 g pulses. Age (years)
body weight) body weight)
Nutrient Requirements for Infants and Children 1-2 1.81 1.81
Weight for weight, the infants and children require more food 2-3 1.67 1.67
as compared to adults. This is because the children not only 3-4 1.61 1.61
need food for maintaining the BMR, thermogenesis, repairing
wear and tear, but also for the important function of continuous 4-6 1.52 1.52
growth. Child therefore needs all kinds of extra nutrients, 7-9 1.48 1.48
namely, proteins, fats carbohydrates, minerals and vitamins. 10-12 1.46 1.45
Energy Requirements of Infants and Children
13 - 15 1.4 1.33
Infants : The energy requirement for Indian infants are adapted
from the FAO/WHO expert group and the same is summarized 16 - 18 1.31 1.21
in the Table - 4. *In terms of proteins present in routine Indian diets (cereals and pulses)

Table - 4 : Daily Energy Requirements of Infants Fat Requirements

Children and Adolescents : The minimum visible fat intake
Average during
Age Kcal/kg would also be 5% of total energy. For their energy intake of
1st year
2400 Kcal, minimum visible fat intake works out to 12 g/day,
0 - 3 months 116 but the desirable intake levels should be 20 g/day, which helps
3 - 6 months 99 to reduce the bulk of diet.
103 Kcal/kg Young Children ( 1 to 5 years) : For young children the linoleic
6 - 9 months 95
acid requirement of 3% of the total energy can be satisfied by
9 - 12 months 101 the minimum visible fat intake of 10 g/day (which would also
be 5% of total energy intake). Hence visible fat intake of up to
Children : Based on the FAO/WHO recommendations the
25 g/day is desirable.
energy requirements are worked out for Indian children. These
are given in Table - 5. Infants : Breast milk meets the EFA needs of infants which is
about 6% of total energy intake. It provides about 30g fat per
Protein Requirements
day, of which about 10% is linoleic acid and 1% linolenic acid.
Infants : The protein requirements for infants are derived from Infants who are not taking breast milk for some reason should
the breast milk intake of normally growing infants (FAO/WHO be given enough vegetable oils with high linoleic acid content
expert consultation group, 1985) and the same is summarized (e.g. safflower, sunflower, corn, soyabean, cottonseed oils) to
in the Table - 6. provide 6% energy equivalent.
Children : The RDAs are given in Table - 7.

• 753 •
Minerals Requirements Diet for the infants up to 6 months of age : The documented
Calcium, Phosphorus and Magnesium : These minerals are virtue of breast milk goes back to 2000 years to the Charak
extremely important for the infants and growing children. They Samhita. There is no variation in the opinion of the scientists
help in bone formation, teeth development, neuro - muscular that breast milk is the best for the baby. It contains all the
activities, impulse conduction and structural and metabolic nutrients required by the baby in the correct proportion for at
integrity of cells. Suggested intakes of calcium and phosphorus least the first 4 - 6 months. It is well balanced nutritionally and
are summarized in Table - 8. immunologically and is easily digestible.
Iron Requirements Composition of Breast Milk : Breast milk is an astonishing
emulsion that contains more than 200 known substances,
Infancy and childhood : The demand of iron is not great
including more than 30 types of sugars, 10 types of fats and
during infancy as the infant is born with storage iron and a
many proteins and minerals. Its primary constituents are :
high haemoglobin count, which disintegrates to provide iron.
Therefore as little as 0.3 mg iron per day is sufficient to meet Nutrients : Milk contains almost all known nutrients : fats,
his excretory losses. The demand of iron picks up in the second proteins, sugars, minerals, vitamins, etc.
year of life when 0.4 mg iron is required every day. From second Enzymes : These are present to digest and absorb the
to the twelfth year in males and 10th in females, the mean nutrients.
increase in body weight is 2.5 - 2.7 kg/year, which corresponds Immune factors : Many antibodies, lysozymes, etc are present
to an iron demand of 0.3 mg/day. The daily requirement is to protect the baby from infections.
further increased by a rise in the haemoglobin concentration
by about 1 g/100ml during this period. The amount of iron Growth factors and hormones : These are present for adequate
required to replace the losses, also increases from 0.2 mg /day growth of child.
in infancy to 0.5 mg/day in the 12th year (a total requirement Breast feeding : The mother must begin breast feeding at
of 0.5 mg and 0.8 mg respectively). the earliest. The milk that is secreted by the woman in the
Adolescence : During adolescence, there is an increase in first week after birth is a thick yellowish mixture, called as
iron demand owing to increase in body mass, growth, further colostrum. It is highly recommended that the colostrum must
increase in haemoglobin. The obligatory losses also increase be fed to the child as it is not only rich in fats, proteins,
with age. In young girls from 13 years onwards, the menstrual minerals and vitamins but also has anti - infective properties
losses also become significant (about 0.45 mg daily). (antibodies, immunoglobulins, etc). The carotene content of
colostrum is 10 times higher than milk. Vitamin A and E along
Considering all these issues the iron requirement for Indians with other antioxidants play an important role in the growth
have been worked out which are summarized in Table - 9. and immunological defence of the neonate. The practice of pre
Vitamin Requirements - lacteal feeding with honey, glucose water or formula feeds
Vitamin A : The RDA of vitamin A for infants are recommended must be discouraged. It is advisable to exclusively breast feed
on the basis of its intake through breast milk and extrapolated the child till about 4 to 6 months. Following this some liquid
for children. A summary of the recommendations is given in feeds/supplements may be started (e.g. orange / tomato juice).
Table - 10. Non availability of breast milk : Use of milk other than
Water Soluble Vitamins : The RDA of various B complex mother’s must be avoided as far as possible. In case breast milk
vitamins for infants & children are summarized in Table - 11.

Table - 8 : Suggested intakes of Calcium and Phosphorus Table - 9 : Daily Iron Requirements
(mg/day)
Daily
Group (years) Calcium (mg) Phosphorus (mg) Group Age requirement RDA (mg)
Infants 500 750 (mg)
Children 1 - 9 yrs 400 400 Infants 0 - 6 months 0.32 -
Children 10 - 15yrs 600 600 1 - 3 yrs 0.35 11.5
Children 16 - 18yrs 500 500 Children 4 - 6 yrs 0.55 18.4
7 - 9 yrs 0.78 26
Table - 10 : Recommended Daily Intake of Vitamin A for Adolescents
infants and Children
Boys 10 - 12 yrs 1.03 34.2
Group Age Retinol (μg)
Girls 10 - 12 yrs 0.95 18.9
Infants 0 - 6 months 350
Infants 6 - 12 months 350 Boys 13 - 15 yrs 1.24 41.4

Preschool children 1 - 5 years 400 Girls 13 - 15 yrs 1.4 28

School children 7 - 12 years 600 Boys 16 - 18 yrs 1.49 49.5
Adolescents 13 - 18 years 600 Girls 16 - 18 yrs 1.5 29.9

• 754 •
 Table - 11: Recommended Daily Intake of B Complex Vitamins for Infants and Children
Group Age Pyridoxine (mg) Folate (μg) Vitamin B12 (μg) Vitamin C (mg)
0-6months 0.3 25 0.2
Infants 25
6-12 months 0.4 25 0.2
1-3 years 0.9 40
Preschool children
4-6 years 0.9 50
7-9 years 1.6 60
School children 0.2 to 1.0 40
10-12 years 1.6 70
13-15years 2 100
Adolescents
16-18 years 2 100

is not available the best alternative is cow’s or buffalo’s milk. Table - 12.
Whenever this milk is to be given in the first month one part Supplementary Feeding for infants aged 6 months to 1 year
of boiled clean water must be added to 2 parts of milk. With : Depending on the age of the baby the supplements could be :
passing time the proportion of water must be reduced to 1 part
a) Liquid supplements : Breast milk must be continued in this
water and 3 parts milk. By 8 weeks of age the infant gets whole
period of the 1st year of life. However supplementation and
milk without any dilution. Since this milk is poor in iron, iron
substitution with certain liquids is recommended. Foods that
supplementation is recommended from 2 to at least 8 months.
can be used could be fruit juices like orange, mousambi and
Diet for the infants from 6 months to 1 year : Breast milk grapes. These would cater for mineral and vitamin requirement
is good enough to meet the nutritional requirements of infant of the growing infant. Green leafy vegetable soups can be used
till about 4 to 6 months of age, thereafter the requirements of as alternatives. Cow/buffalo milk is also introduced in a graded
the infant goes up and the milk yield also starts declining. As manner as described in an earlier paragraph.
a result it is advisable to supplement feeding at six months of
b) Mashed solid supplements :
age to maintain good growth rate. Introduction of a dilute and
nutritionally inadequate cereal gruel as a supplement to breast (i) Mashed solids like boiled and mashed potatoes with salt
feeding is unpardonable. This is the time when the mother and ghee, cereal gruels like sweet dalia, porridge, etc. must
might become pregnant again and breast feeding is ceased be introduced in the 7th month. These foods contribute to the
abruptly. A child in such a situation is quite likely to end up energy required for the rapidly growing baby. Well boiled and if
as a malnourished child. The weaning has to be understood required mashed dals can also be added. These will add to the
and practiced scientifically, if good growth of the child is to be variety and protein content of diet.
maintained. (ii) Vegetables : Green leafy vegetables can be used as semisolid
Weaning is the introduction of supplementary foods to augment soups suitably garnished with salt and ghee.
the energy and nutrient intake of the infant. During this (iii) Other vegetables can also be used. The skin and seeds
phase breast feeding is continued and maintained till about of these boiled vegetables can be removed and only the pulp
1 year of age. Supplementary foods are gradually introduced used for the baby. The mother should start feeding with small
and increased in quantity whilst breast feeding is slowly quantity and increase gradually.
withdrawn. The process starts with omitting one breast feed (iv) Boiled egg : It is a very useful, nutritious and easy to
and supplementing it with a chosen food in suitable quantity. cook foodstuff. One may start with egg yolk. Egg white can be
Gradually the baby is given higher quantities of top - feeds introduced later. Initially a partially boiled egg can be given
and more frequently. This allows the mother to withdraw and later on a boiled or poached egg is fed.
eventually cease breast feeding smoothly. It is ideal to wean the
(v) Meat : Well cooked, finely minced or ground meat or mashed
child completely by 18 months of age. Some basic guidelines
fish can also be introduced at this time.
to weaning an infant through 4 to 12 months are given in

Table - 12: Guidelines to weaning

Age Supplementary foods Frequency
Mashed banana, Wheat flour, porridge, Ground rice Start with 1 feed/day. Gradually increase to 3 feeds/
4-6 months
and/or ragi mixed with oil or ghee day by 6 months of age
Banana, mango, chickoo, Boiled egg yolk, Khichri,
6-9 months Mashed vegetables, Chapati softened in milk, Green 4-5 times a day
leafy vegetables. Add little ghee/oil to all
Fruits, Khichri, Upma, Idli, Chapati, Curd-rice,
9-12 months 4-5 times a day
Vegetables, Egg (boiled/scrambled), Minced meat/fish

• 755 •
(vi) Fruits : Mashed ripe banana, mango, chickoo, apple, etc The Nutritional Requirements for the Elderly
can be given depending on the availability and taste. Provision of good nutrition for the elderly is not as easy as
c) Unmashed solid supplements : When the baby starts it appears. Many physiological, social, economic, medical
cutting his teeth it is time to introduce chopped and solid foods. and psychological alterations take place in the old age, which
Chopped vegetables and minced meat of a coarser consistency directly or indirectly affect the food intake, digestion and
can be used. Bit of potato, well cooked rice or dalia can also nutritional status. The BMR goes down with age and so does
be given. A piece of toast, biscuits, banana, carrots can also the physical activity. These factors dictate the reduction of diet.
be given for healthy teeth and gums. Fruit slices should be Just like every other system the efficiency of gastrointestinal
preferred to fruit juices now. system goes down, resulting in a lower appetite. The elderly
Supplementary Feeds for children aged 1 to 2 years may be lonely and socially aloof, so the zest to cook and enjoy
Cereals : Cereals (wheat or rice) based preparations which the food is lost, thereby compromising with availability of good
child could easily masticate and digest must be encouraged. food intake. The old man may be affected by many chronic
Potato, sweet potato, tapioca and other starchy vegetables must illnesses that restrict his food intake, for example salt has to
be continued. These can be given at least three times a day. be restricted in hypertension, sugar in diabetes, fat in CVD and
proteins in renal disease. The ‘taste’ of food is thus lost and so
Pulses : A pulse or legume preparation must be given at least is the interest. Certain psycho - social factors like loneliness,
once a day, to cater for the protein requirement. lack of family support, feeling of worthlessness, stresses of
Milk : While the breast milk quantity is being tapered off, the daily living and possible economic constraints further limit the
dairy milk must be supplemented, starting from about 200ml intake (6).
to 500 ml a day. Nutritional Requirements
Vegetables and Fruits : Well cooked green leafy vegetables Energy : There has not been any conclusive word regarding
and other vegetables must be given twice a day to the child. energy requirement and recommendation for the elderly.
Fruits must also be given at least once a day. Results of various studies have at best been highly variable.
Eggs : One egg a day, prepared in any form is advisable to Therefore the expert groups have not come out with any special
be given. As discussed earlier, it could be half boiled, boiled, requirements for the elderly. But since it is known that BMR and
poached or in any other acceptable form. physical activity go down in the elderly the energy requirement
Meat : Meat, fish, chicken and their products can also be given might have to be curtailed. Some authorities recommended
as per dietary practices. Easily digestible forms are preferable. energy requirement to be reduced by 11% in elderly men and
Minced meat, keema, mashed, shredded or meat soups can be 10% in women, as compared to young adults (7).
used. Proteins : Lean body mass protein, turnover and protein
Diet for children aged 3 to 5 years : A three year old child synthesis fall with age. WHO/FAO/UNU expert group has
might not be eating much more than a two year one, as the recommended a safe protein intake of 1 to 1.25g/kg per day.
rate of growth in this period (2 - 4 years) is not as fast. So Fats and Oils : Fats and oils are recommended at the same
the mother need not be unnecessarily alarmed as long as it is level as for the young. In case the person suffers from any
following the height weight norms (Table - 13). The principles chronic lifestyle disease e.g. CVD, hypertension, stroke, etc he
of diet are the same as those for a 1 to 2 year child. The only might be advised to restrict fat.
difference might be that a 3 to 5 years child is able to eat a Vitamins : It is felt that the vitamin requirement goes up in
variety of foods as he is capable of chewing and he likes to old age. However no special requirement has been slated for
experiment with new foods. Hence the mother may try and feed them.
him everything that is cooked for the family. Thus the child
Calcium : Calcium along with vitamin D is required for the
adapts to the adult diet. The frequency of feeding the child is
integrity of bones. A deficiency of calcium may lead to
however more as compared to adults. Children routinely need
osteoporosis in the elderly. Sufficient amount of calcium must
mid - meal snacks, couple of glasses of milk, variety of ‘well
therefore be taken every day. A slightly higher amount of
presented’ foods and an early dinner.
calcium is recommended, about 0.8 - 1g per day.
Table - 13 : Expected Height and weight for age (NCHS Iron : The elderly may have lower iron requirements than the
Standards) young. At the same time there might be a higher prevalence
of disorders that might interfere either with iron absorption
Boys Girls (atrophic gastritis etc.) or cause blood loss (hiatus hernia, peptic
Age (yrs) ulcer, haemorrhoids and cancer). Hence their iron requirement
Height Weight Height Weight
cannot be scaled down and it should be the same as for the
(cm) (kg) (cm) (kg)
young.
2 85.6 12.3 84.5 11.8 Diet for the Elderly : Except for a marginal reduction in energy
3 99.1 15.7 93.9 14.1 requirement, the need for other nutrients almost remains the
same. Besides the diet being nutritionally adequate the food
4 102.9 16.7 101.6 16 preparations for the elderly should be tasty, soft and easily
5 109.9 18.7 108.4 17.7 palatable. These basic principles are summarized in Box - 3

• 756 •
and some common preparations to be preferred are listed in also goes by about 8 mg. The demand during lactation is
Box - 4. still higher. The energy requirement goes up by 550 Kcal and
protein and fat requirement by 25 g each. Suitable modification
Box - 3 : Principles of Box - 4 : Foods in diet should to be made through addition of another meal,
Diet for the Elderly to be preferred mid meal snacks and nutrient dense foods. Protein, iron and
vitamin rich foods should be included in diet. It is wise to
Simple but nutritious food
Dalia include fruits, vegetables, whole grains, milk products, meat,
Include green leafy vegetables egg, legumes, nuts, etc. Also include vitamin C rich foods to
Khichdi
Eat plenty of fruits improve iron absorption. Minimise coffee/tea during mealtime.
Upma
Include whole cereals It is advisable to take iron - folate supplement. Don’t take any
Kheer medicines without prescription and abstain from smoking and
Insist on frequent, small meals
Pohe alcohol.
Drink plenty of fluids
Canned foods Infants and children : Weight for weight the infant and children
Avoid fasting require more food than adults. It is advisable to exclusively
Fruit juices
Avoid fried foods breast feed infants till about 6 months. Thereafter they should
Vegetable soups
Consume low salt and sugar be gradually weaned through introduction of fruit juice, cow’s
Meat stew milk, semisolid foods, boiled vegetables, potatoes, eggs and
Food should be easy to cook
fat. As the children grow, so do their nutrient requirements. It
With this background of nutritional requirements in mind, a is wise to keep an eye on the age - weight chart while the child
typical balanced diet, along with the nutrients supplied with it is growing up.
is given in Table - 14. Elderly : It is a challenge to meet the nutritional requirements
of the elderly people for more than one reason. There is not
Table - 14 : Balanced Diet for the Elderly enough research to base our recommendations for various
nutrient requirements. Unlike adults where only the physical
Foodstuff Quantity (raw in gm)
requirements govern the nutritional demand, in elderly the
Males Females social, psychological, economic, emotional and physical needs
Cereals 350 225 are all important when it comes to eating food. Moreover
the biological process of ageing differs in each individual.
Pulses 50 40 The challenges increase with increasing longevity. Illness,
Vegetables 200 150 psychological voids, bereavements all pose varied impact. It
Green leafy vegetables 50 50 is understood that the nutritional requirements for elderly are
almost the same as that for adults. The food must be simple,
Roots and tubers 100 100 easy to cook and more palatable.
Fruits 200 200
Study Questions
Milk and milk products 300 300
Long Question : What are the nutritional requirements elderly
Sugar 20 20 age? Elaborate a plan to meet these requirements.
Fats and oil 25 20 Short Notes : (1) Weaning (2) Meeting Iron demand of a
Approximate nutrient contents of above food items pregnant woman (3) Diet during lactation
Calories 2200 1700 MCQs
1. Which of the following is not true regarding diet for the
Protein 65 g 50 g
elderly : (a) Their poor dentition restricts their food intake
Fat 50 g 40 g (b) The zeal to cook and eat goes down (c) Their food
Calcium 1g 0.9 g requirement is about half that of a robust young adult
(d) There is not enough research to accurately predict RDA
Iron 38 mg 30 mg
for elderly.
Vitamin A (Retinol) 1030 μg 930 μg 2. Which of the following is not true regarding diet during
Thiamin 1.96 mg 1.45 mg lactation : (a) Energy requirement during lactation is
higher than during pregnancy (b) Iron requirement during
Riboflavin 1.78 mg 1.51mg lactation is higher than during pregnancy (c) Vitamin
C requirement during lactation is higher than during
Summary pregnancy (d) Vitamin A requirement during lactation is
Pregnancy and lactation : Many physiological changes higher than during pregnancy
take place during pregnancy and lactation. The nutritional 3. Higher need of vitamin A during pregnancy can be met by
requirement increases substantially during this time. The daily all except : (a) Carrots (b) Cod liver oil capsules (c) Extra
energy requirement increases by 300 Kcal, protein and fat egg whites (d) Extra milk
requirement by 15 g and 10 g respectively. The iron requirement

• 757 •
4. Which of the following is true about diet during pregnancy: References
(a) Salt intake must be minimized to prevent edema 1. Geissler C, Powers H. Human Nutrition.11th ed. Elsevier Churchill Livingstone
(b) Diet before pregnancy has no bearing on health of London. 2005.
2. Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian
neonate (c) Strict weight control helps minimize childbirth foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.
complications (d) One extra meal per day is recommended 3. Venkatachalam PS, Rebello LM. Nutrition for Mother and Child. National
during pregnancy Institute of Nutrition (ICMR), Hyderabad. 5th edition, 2004.
5. Which of these is not true for weaning : (a) Weaning 4. National Institute of Nutrition, Nutritional Requirements and Recommended
Dietary Allowances for Indians; A report of the ICMR, 2004.
means gradually replacing breast milk with other foods (b) 5. Gupta RK. Towards better nutrition of pregnant women in the developing
It should be started at 1 year of age (c) One must start world. Indian J of PSM
weaning with fruit juices and cow’s milk (d) Infant is more 6. Pasricha S, Thimmayamma BVS. Dietary Tips for the Elderly. National
vulnerable to infections during this period Institute of Nutrition (ICMR), Hyderabad. 1st edition, 2005.
7. Rankford RT, Morie P, Steward J. Foundation of normal and therapeutic
Answers : (1) c; (2) b; (3) c; (4) d; (5) b. nutrition. Wiley Medical Publication, New York. 1982.

energy or proteins or both. In these cases deficiency in other

Nutritional Deficiency Diseases
133 of Public Health Importance
nutrients like vitamin A, iron, calcium and riboflavin is also
seen. It is also known that infections like measles and diarrhoea
aggravate PEM. In 1959, Jelliffe introduced the term ‘Protein
Rajul K Gupta Calorie Malnutrition’ (PCM) as there was close association
between the two poles of the syndrome namely, Kwashiorkor
A large part of our population particularly the poor suffer and Marasmus. The term PCM, was later rephrased as Protein
from serious deficiencies in their diet. This might be an Energy Malnutrition (PEM).
actual deficiency or one due to lack of knowledge about food Undernutrition includes underweight (being underweight for
and nutrients. As a consequence of this, several nutritional one’s age), stunted (being too short for one’s age), wasted
deficiencies with clinical manifestations and disabilities are (being dangerously thin), and micronutrient malnutrition
encountered in our country. Most important of them are Protein (being deficient in vitamins and minerals).
Energy Malnutrition (PEM), Anaemia, Vitamin A Deficiency and Magnitude of the Problem
Iodine Deficiency Disorders (IDD) and have been the concern of World : The magnitude of the problem at a global level can be
health authorities in our country for a very long time. Anaemia reckoned from the fact that malnutrition contributes to 60%
is the most prevalent affecting all ages. In India an astounding of the total 10 million deaths of children under five years of
three fourths of all females and more than half of all males age. Its contribution to child deaths is highest during first six
suffer from anaemia. PEM and vitamin A deficiency occur mostly months of life (1).
among preschool children. More than 85% of Indian children
India : As per NFHS-2 (1998-99), 47% of children under three
suffer from some degree of undernutrition (mild, moderate or
years are underweight, 45.5% stunted and 15.5% wasted.
severe), making it a national priority. Vitamin A deficiency is of
India fares poorly even among the South East Asian countries,
grave concern as it causes blindness that is easily preventable.
occupying the third place from the bottom with only Nepal and
Thyroid insufficiency due to iodine deficiency, which affects
Bangladesh faring worse than India. The prevalence of low birth
all age groups results in many a serious condition including
weight continues to be about 30% for last three decades. Low
goitre, impaired metabolism, cretinism, mental retardation and
birth weight babies are more likely to die because of neonatal
deaths (still births).
infections and undernutrition (1). Chronic Energy Deficiency in
Protein Energy Malnutrition (PEM) adults is 39% in females and 37% in males (NNMB 2002) (2).
Malnutrition is a range of conditions occurring when intake of As per the NFHS report of the National Health Profile, 2007,
one or more nutrients doesn’t meet the requirements. Protein considering various parameters, as many as one fourth to half
Energy Malnutrition (PEM) is a malnutrition resulting from the of all Indian children are undernourished in various age groups
deficiency of protein and/or energy in diet. PEM is an important (3). Even during the first six months of life, when most babies
nutritional problem among preschool age children. This are breastfed, 20-30 percent of children are undernourished
leads to various degrees of growth retardation. When growth according to each of the three criteria, namely stunting (or too
retardation is severe, functional deficiencies, like resistance to short a height for age), wasting (or too thin for height) and
infection and poor intellectual development may result. The underweight. However, malnutrition peaks during the first
main cause of PEM is food inadequacy i.e. the deficiency of two years of life. From 11.9% prevalence among 0-6 month old

• 758 •
infants, it reaches to 58.5% in one to two year old children. This
Table - 1 : Classification of PEM (FAO/WHO) (6)
steep rise in malnutrition during the first two years is mainly
due to poor infant feeding practices (1). Among the children Percent of Deficit in
under 3 years of age, 38.4% are stunted, 19.1 are wasted and Type standard Oedema weight for
as many as 45.9% are underweight. The highest number of body weight height
underweight children (under 3 years) is reported from Madhya Kwashiorkor 80-60 + +
Pradesh 60.3%. Other states reporting high percentage of
Marasmic-
underweight children are Jharkhand (59.2%), Bihar (58.4%) <60 + ++
kwashiorkor
and Chattisgarh (52.1%). Mizoram reports the lowest number
of underweight children at 21.6%. Other states reporting low Marasmus <60 0 ++
percentage of underweight children are Sikkim (22.6%), Manipur Dwarfing <60 0 Minimal
(23.8%), Punjab (27%), Kerala (28.8%) and Goa (29.3%) (3). In
Underweight 80-60 0 +
the under-fives year age group, almost half of all children are
stunted, which indicates that they have been undernourished
Marasmus : Conditions conducive to the evolution of
for some time. Twenty percent are wasted, which may result
marasmus typically exist in the lower socio-economic classes
from inadequate recent food intake or a recent illness. Forty-
of the urban community. A low birth weight neonate born to
three percent are underweight, which takes into account both
an economically and nutritionally deprived working woman
chronic and acute undernutrition.
in a setting of ignorance and poverty is most vulnerable to
Adults in India suffer from a dual burden of malnutrition; more marasmus. The weaning is often early and abrupt. The mother
than one-third of adults are too thin, and more than 10 percent stops breast feeding for various reasons. Most often she has
are overweight or obese. Only 57 percent of men and 52 percent to return to work early. She might be suffering from infections
of women are at a healthy weight for their height. like mastitis, etc. which don’t allow breastfeeding to continue.
Undernutrition is particularly serious in rural areas. The The infant might be having an illness (gastrointestinal or
condition is worst in the lower wealth quintiles, among respiratory infections), during which it is not wise to feed the
scheduled tribes and scheduled castes, and among those with child, in the mother’s opinion. Social influences in the form of
no education. More than two out of five women are too thin in peer pressure, advertisements of alternative feeds could also be
Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, and Orissa; major reasons for discontinuing breast feeding. Another quick
similar proportions of men are too thin in Tripura, Madhya pregnancy could change the priority and infant is neglected.
Pradesh, and Rajasthan. Taboos restricting the use of colostrums and breast milk
Overweight or obesity is most common among adults in Punjab, also limit its full utilization. The sheer inconvenience or non
Kerala, and Delhi. These conditions are most common in older availability of a private place to breast feed the child at the
adults, those in urban areas, the well-educated, and those in work place could dissuade the mother.
the highest wealth quintile (3). A typical epidemiological case is illustrated as follows : Let
Etiology and Epidemiology : PEM characteristically occurs in us take a pregnant construction labourer in an urban setting
children less than 5 years of age, whenever the diet is poor in as an example. Being economically deprived she is in a poor
energy and proteins. PEM was earlier attributed to the concept nutritional state. More often than not, she has rapid succession
of ‘protein gap’ (deficiency of proteins in diet), which has now of pregnancies. She delivers low birth weight babies. She
given way to the new etiological theory of ‘Food gap’, wherein breastfeeds the infant for a short duration since she has to
it is not only the deficiency of proteins but inappropriate food return to work at the earliest. The infant is handed over to the
(low in energy density, protein and micronutrients - Vitamin A, elder sibling. This is invariably followed by dirty and dilute
Iron, Zinc) which is poor both quantitatively and qualitatively, formula for feeding. The infant is inadequately fed because
is the chief cause of PEM (5). of ignorance and to limit expenditure. The diet is low in both
proteins and energy. Moreover poor housing/sanitation, lack
Under-nutrition in fetal life, esp. last trimester, lactation of fuel, water and utensils makes it impossible to prepare a
failure, low energy dense weaning foods, incorrectly constituted clean and healthy weaning food. Repeated infections develop
formula, contaminated water and infections (diarrhoea, (particularly gastroenteritis), which are treated by starvation
measles, acute respiratory infections, intestinal worms etc.) for long periods. The child is fed with water, weak tea and rice
also play important role in the causation of PEM. The other water. This forced early, abrupt and faulty weaning takes its
associated social factors are poverty, poor environmental toll on the nutritional state of the infant. The infant ends up
conditions, large families, poor MCH services and poor cooking being Marasmic.
practices. Ignorance and the inability to provide adequate food
also seem to be important contributory factors. Clinical features of Marasmus : Marasmus is most commonly
seen in children aged less than 5 years (most cases are less
Classification of PEM : Even though Marasmus and than 1 year of age in the urban areas). There is failure to thrive,
Kwashiorkor are the two main and polar forms of PEM, irritability or apathy. Many infants are hungry and some
clinically it can be broadly classified into five forms (Table-1). anorexic. Diarrhoea and dehydration are frequent. The weight
These varied syndromes result from the types, severity and is grossly below standards and the child is ‘skin and bones’
duration of dietary deficiency. owing to loss of subcutaneous tissue. The common clinical

• 759 •
features of marasmus are enumerated in Box - 1. A standard Prevention of PEM : “Prevention of PEM is the fight against
text on paediatrics could be consulted for more details on the poverty and ignorance” (7). As was discussed earlier it must be
clinical aspects. appreciated that there is no single shot solution to the treatment
or prevention of PEM. It is a complex problem involving each
Box - 1 : Clinical features of Marasmus of the social, economic, educational, political, administrative,
medical and health dimensions. An integrated effort involving
Constant features
all these and also awareness and a positive attitude towards
●● Growth retardation
the condition might help to limit it. The most vital preventive
●● Wasting of muscles and subcutaneous fat
measures that are executable through the classical health and
●● ‘Wisened old man’s look’
medical infrastructure and classifiable under the traditional
Other features heads of the preventive strategy are enumerated here. Details
●● Hair changes like easily pluckable hair on mitigation of poverty, improving the health infrastructure,
●● Infection provision of health care and hygiene-sanitation facilities,
●● Vitamin deficiency strengthening immunization facilities, making the PDS more
●● No psychomotor changes efficient or provision of nutritional education though extremely
important, are beyond the scope of this book. Hence these
Kwashiorkor : The term Kwashiorkor was introduced by Cicely issues have not been elaborated.
Williams into modern medicine. It comes from language of ‘Ga’ Health promotion
tribe of Ghana, meaning “Sickness the older child gets when
(a) Good ante-natal care
the next baby is born”.
(b) Education on food, hygiene and family planning
If the epidemiological events for the causation of PEM had to (c) Education on the importance of colostrum, diet during
be greatly simplified, while marasmus is seen in an early and lactation
abruptly weaned baby in an urban setting, the other ‘pole’ of (d) Various measures under the ICDS initiative, like good
PEM, Kwashiorkor is typical in an older child who is breast fed nutrition, immunization, education, hygiene and sanitation
for a rather prolonged period and weaned late in a rural setting. etc.
Poverty, insufficient food and land, poor agricultural practices, (e) Promotion of breast feeding
religious issues and taboos compromise the nutrient intake. (f) Good weaning practices, correct time of weaning,
Protein sources like milk, eggs and meat are costly so their importance of low cost weaning foods
supply tends to be inadequate. In some areas Kwashiorkor runs (g) Prevention and control of infections during weaning
an endemic course, when food supply becomes scarce every (h) Improve family diet
year before the harvest season. (j) Correct knowledge on balanced diet
In such children the protein and energy supplies are almost (k) Utilization of family planning practices
always at brink. Frank Kwashiorkor may be precipitated by (l) Hygiene & sanitation
acute febrile infections like ARI, measles, whooping cough or Specific protection
diarrhoea as the nutritional demand shoots up. a) Diet : Protein and energy rich food should be consumed by
Clinical features of Kwashiorkor : Kwashiorkor is most children. Special attention must be paid to diet during weaning.
commonly seen in children aged 2 to 5 years of age. Many Adequate quantities of fruits and vegetables must be included
children of a given locality sharing the same socio-economic in the diet.
milieu may suffer from Kwashiorkor. The child may be brought b) Immunization : The child must be immunized as per the
to the doctor for an underlying infection. Failure of growth national schedule.
may be an early sign. There may be weight loss, anorexia or
Early Diagnosis & Treatment
diarrhoea. Oedema is present, which is more marked on the
lower limbs. Quite often it is grossly present all over the body a) Growth monitoring : Vulnerable children must be
including face. The common clinical features of Kwashiorkor identified. Children must be monitored through growth charts.
are enumerated in Box - 2. Early diagnosis of growth failure must be done and treated as
appropriate.

Box - 2 : Clinical features of Kwashiorkor

Constant features Other features
●● Oedema ●● Hair changes - Flag sign
●● Growth retardation ●● Diffuse pigmentation of skin and dermatoses-- Flaky paint dermatosis
●● Muscular wasting ●● Moon face
●● Retention of subcutaneous fat ●● Anaemia
●● Psychomotor changes ●● Hepatomegaly
●● Associated vitamin deficiencies (retinol, tocopherols, folate, pyridoxin, Vitamin K)
●● Associated mineral deficiencies (iron, potassium, zinc, copper, selenium, magnesium)
●● Associated acute infections

• 760 •
b) Early diagnosis and treatment : Early diagnosis and national development. Overall, it is the most vulnerable,
treatment of infections is also vital. To achieve this, health (poorest and the least educated) who are disproportionately
worker must be alert and mothers should be aware of the signs affected by iron deficiency, and it is they who stand to gain the
and symptoms of common infections. Preparation and use of most by its reduction. See Box - 3 and 4.
ORS should be known to all mothers. The services available
through the IMNCI initiative must be fully utilized. Box - 3 : Facts about Anaemia (9)
c) Medical advice : In extreme and serious cases early medical In developing countries every second pregnant woman
advice and treatment facilities must be available. Hospitalization and about 70% of preschool children are estimated to be
of the case remains the only choice in complicated cases. anaemic.
Rehabilitation : Even if PEM patients are treated well in Anaemia is aggravated by infectious diseases like worm
a hospital setting, many follow up studies have shown that infestations, malaria, HIV and tuberculosis.
they tend to die of the same disease and infections for which
The major health consequences include poor pregnancy
they were treated earlier. It is because the immediate disease
outcome, impaired physical and cognitive development,
in question was treated but the family and community milieu
increased risk of morbidity in children and reduced work
which was responsible for the problem remains largely
productivity.
unchanged. The poverty, hygiene, sanitation, dietary/ feeding
knowledge and practices, taboos, predisposing factors for Anaemia contributes to 20% of all maternal deaths
infection etc remain the same. While it may not be possible for
the medical fraternity to improve the socio-economic condition Box - 4 : Consequences of Anaemia
of the family, but substantial changes can be brought to the
knowledge, attitude and practice about the disease. After an General : Weakness, easy fatigability, lethargy, Inhibition of
intensive hospital resuscitation session, knowledge can be lymphocyte proliferation lowered cell mediated immunity,
reduced neutrophil bactericidal activity, vulnerability to
imparted to the mothers about the disease. Correct feeding
infections, diminished physical and earning capacity, reduced
practices and skills can be taught. Myths and taboos can be
work capacity reduced endurance
busted. These principles can be undertaken in three settings :
(a) Residential Units : Mothers are admitted with their sick Pregnant and Lactating Women : Weakness, diminished
children. The mother gets hands on experience in the practical physical and mental capacity, increased morbidity from
infectious diseases, Increased risk of low birth baby, abortion,
learning of preparation and administration of a therapeutic
premature delivery, intra-uterine growth retardation,
diet for her child with an expert. This demonstration and
Congenial fetal malformations, PPH, maternal mortality
involvement of the mother in her child’s recovery goes a long
way in understanding the problem and mitigating it. Children : Low birth weight, Perinatal mortality, impaired
(b) Day Care Centre : The mother attends the day care centre cognitive performance, motor development and scholastic
achievement, Psychological and behavioural effects like
along with the child where cooking and feeding is taught to the
inattention, fatigue and insecurity
mother. While the child attends every day, involvement of the
mother is partial.
Defining Anaemia : Anaemia is traditionally defined as
(c) Domicilliary Rehabilitation : The expert comes home and the reduced oxygen carrying capacity of the blood due to
assesses the situation as a whole. The mother is then rendered a reduction in its haemoglobin content. The WHO defines
suitable advice with regards not only to feeding but also about anaemia as “a condition in which the haemoglobin content
improving various domestic contributory factors to PEM. is lower than normal as a result of deficiency of essential
nutrients, regardless of the cause of such deficiency”. The WHO
Anaemia
has further defined as to when should the haemoglobin content
Anaemia is a global menace affecting both developing and be considered as low. The level of ‘low’ haemoglobin levels vary
developed countries with major consequences for human with sex, age and physiological status. These are summarised
health as well as social and economic development. It occurs at in Table - 2 .
all stages of the life cycle, but is more prevalent in women esp
pregnant women and young children. In 2002, iron deficiency Table - 2 : Haemoglobin thresholds used to define
anaemia (IDA) was considered to be among the most important Anaemia (10)
contributing factors to the global burden of disease (8). The
numbers are staggering; as many as 2 billion people or over Haemoglobin
Age or gender group
30% of the world’s population is anaemic. This is frequently threshold (g/dl)
exacerbated by infectious diseases like malaria, tuberculosis, Children (0.50-4.99 yrs) 11.0
HIV/AIDS, hookworm infestation and schistosomiasis in
Children (5.00-11.99 yrs) 11.5
some areas. It is a major public health problem. More subtle
in its manifestations than, protein-energy malnutrition, iron Children (12.00-14.99 yrs) 12.0
deficiency exacts its heaviest overall toll in terms of ill-health, Non-pregnant women (≥15.00 yrs) 12.0
premature death and lost earnings. Iron deficiency and anaemia
Pregnant women 11.0
reduce the work capacity of individuals and populations,
bringing serious economic consequences and obstacles to Men (15 yrs and more) 13.0

• 761 •
Anaemia as a public health problem : Globally, anaemia is anaemia. Men at higher risk of anaemia are the widowed men,
considered to be a problem of public health significance when scheduled-tribe men, and men belonging to the lowest wealth
the prevalence exceeds certain levels, as elaborated in Table-3. quintile. In these vulnerable groups the prevalence of anaemia
World : Anaemia is a huge public health problem globally. As goes up to 40% (3).
per the WHO (2008) estimates about half (48.8%) of the entire Etiology : Causation of anaemia is a maze of a multitude of
world population suffers from anaemia. More than 3/4th of all social, cultural, religious, dietary and environmental factors.
preschool children, 1/3rd of all school aged children, 69% of all Poor economic condition, religious practices disallowing certain
pregnant women and 73% of the non pregnant women have nutritious foods, dietary practices like vegetarianism limiting
anaemia. More than 40% men suffer from anaemia (8). food choices, faulty cooking practices discarding nutrients
India : Anaemia is a major health problem in India, especially from food, faulty child rearing practices (premature weaning)
among women and children (See Table- 4). Specific groups enabling predisposition of PEM and anaemia, large families
are elaborated here. The WHO classifies India to be having a limiting food intake and poor environmental sanitation and
‘severe’ level of public health problem in the form of anaemia non availability of sanitary latrines and drinking water, all
(>40% prevalence in all groups - preschool children, pregnant predispose to anaemia either directly or indirectly.
women, non pregnant women) (8). Among the age group of 6 Anaemia is the result of a wide variety of causes that can
and 59 months, the great majority i.e. 70 percent of children are be identified, but more often they coexist. Globally, the most
anaemic. This includes 26 percent who are mildly anaemic, 40 significant contributor to the onset of nutritional anaemia is iron
percent who are moderately anaemic and 3 percent who suffer deficiency so the terms iron deficiency anaemia and anaemia
from severe anaemia. Boys and girls are equally likely to have are often used synonymously, and the prevalence of anaemia
anaemia. Children of mothers who have anaemia are much has often been used as a proxy for iron deficiency anaemia. It
more likely to be anaemic. Although anaemia levels do vary, is generally assumed that most of the cases of anaemia are due
by and large anaemia among children is widespread in every to iron deficiency. Therefore the causes of iron deficiency are
group and every state in India. Even when the mothers were discussed in detail here. These can be enumerated in a simply
Class XII educated and/or economically well off, the prevalence manner as shown in the Box - 5.
of anaemia amongst their children too was 50% (3). a) Inadequate intake of iron : The sources of iron have
More than half of women in India (55%) have anaemia. About been discussed in greater details in the chapter on minerals.
39 % have mild anaemia, 15 % moderate anaemia and 2 percent Poor diet is an important cause of inadequate intake of iron.
severe anaemia. Anaemia is particularly high amongst women While economic constraints make one’s diet poor, it is also the
with no education, women from scheduled tribes, and women ignorance about the dietary sources of iron which also makes
in the lowest wealth quintiles. Pregnant and lactating women even a well to do man’s diet poor in iron. For example it is
too have high prevalence of anaemia (3). generally believed that spinach is a ‘very good’ source of iron.
Among men, while globally the prevalence of anaemia is about But the fact is that it is a poor source as it contains only 1.1mg
40%, only one-fourth of the Indian men are anaemic. Men iron per 100g. On the other hand almost all other green leafy
under 20 and over 40 years of age are more likely to suffer from vegetables like radish leaves (18 mg), rape leaves (12.5mg),

Table - 3 : Classification of anaemia as public health problem (3,8)

Prevalence
Health significance Examples (Countries) Examples (Indian states)
of anaemia
No public health Chile (Non pregnant women),
<4.9% -
problem USA (Preschool children)
Mild public Australia, Israel, UK, USA and
5.0-19.9% -
health problem most Western European countries
Japan, Malaysia, China, Goa, Kerala (pregnant and non pregnant
Moderate public
20.0-39.9% Pakistan and most of the women), Mizoram, Manipur (Non pregnant
health problem
middle east countries women), Delhi (pregnant women)
Severe public India, most of the SE Asian All Indian states, except the categories
> 40.0%
health problem and African countries mentioned in the row above

Table - 4 : India - WHO estimates of anaemia prevalence amongst preschool children and women (8)
Cut off Level of public
Age Prevalence % Estimated Number
haemoglobin health problem
Preschool children (6m-3yrs) <11g/dl 74.3% 8,90,90000 Severe
Pregnant women (15-49 yrs) <11g/dl 49.7% 1,27,99000 Severe
Non-pregnant women (15-49yrs) <12 g/dl 52.0% 13,44,95000 Severe

• 762 •
turnip greens (28.4mg), amaranth species (1.8 -38.5mg), methi months) are remote. Moreover breastfed infants are in a happy
leaves (1.9 mg) and lettuce (2.4) mg all contain high iron. iron state as iron from breast milk is very well absorbed. It is
the preterm and low birth weight babies that have poor iron
Box - 5 : Causes of Anaemia stores. The requirement of folates is also high for the preterm
babies. Preterm babies are thus more likely to develop anaemia
Inadequate intake of iron
at 2-3 months. Babies that are not allowed colostrum intake
●● Poor diet
and are not breastfed are also likely to develop anaemia as
●● Poverty
iron from artificial feeds or animal milk is not well absorbed. A
●● Ignorance
condition “Goat Milk Anaemia” is known in babies that are fed
●● Inadequate folate/vitamin C intake
goat milk as it is deficient in folate.
Poor absorption and bioavailability of iron Prevention and Control of Anaemia : Given the multifactorial
●● Absorption -Only 5% nature of this disease, correcting anaemia often requires an
●● Poor absorption-Non haeme iron (Ferric iron) integrated approach. The benefits of preventing and controlling
●● Inhibitors: Phosphates, phytates, oxalates, fibre anaemia are substantial. Timely intervention can restore
●● Tea (tannin), Eggs (Phosphate), Milk (Calcium) personal health and raise national productivity levels by as
Excessive loss of iron much as 20%. In order to effectively combat it the contributing
●● Normal man (1mg/day) factors must be identified and addressed. Additional iron intake
●● Menstruation (2mg/day) is usually provided through iron supplements to vulnerable
●● IUDs groups, in particular pregnant women and young children.
●● Intestinal worms Food based approaches to increase iron intake through
●● Malaria food fortification and dietary diversification are important
●● Repeated / frequent pregnancies sustainable strategies for preventing IDA in the general
population.
Increased demand of iron
Strategies should also include addressing other causes of
●● Pregnancy
anaemia and should be built into the primary health care
●● Growth
system and existing programmes. These strategies should be
b) Poor absorption and bioavailability of iron : It must also tailored to local conditions, taking into account the specific
be appreciated that the non heme iron (as present in green etiology and prevalence of anaemia in a given setting and
leafy vegetables) is absorbed poorly. Moreover a poor intake population group. The main strategies for prevention and
of vitamin C also limits the absorption of non heme iron, as control of anaemia are as follows :
ascorbic acid acts as a dietary reducing agent converting the 1. Breastfeeding and appropriate weaning : While it is true
non absorbable Ferric (Fe3+) ions into Ferrous (Fe2+) ions. that milk is not a very rich source of iron, but the bioavailability
Similarly concomitant intake of folate also helps in haemopoisis of iron from breast milk is exceptionally good. Breast milk
and thus preventing anaemia. There are certain inhibitors of thus is a source that in itself is adequate to suffice the iron
iron absorption which are inherently present in our diet. For requirement of the young infant, till about 6 months of age.
example phytates are present in fibres and cereals, phosphates Breast feeding is therefore the first step to the prevention of
in milk and eggs, oxalates in vegetables, tannins in tea, calcium anaemia. The iron requirement of a growing infant increases
in milk, etc. All these normal constituents of diet tend to retard by 1 year. It is important to wean the child with iron rich
the absorption of iron, contributing to anaemia. foods. Food stuffs like meat/chicken soups, vegetable soups,
c) Excessive loss of iron : The normal physiological loss jaggery, etc must be included. Iron supplementation must be
of iron per day is about 1mg for men and 2mg for women. considered if necessary. Prevention and control of infections
But there are certain conditions in which this loss becomes and deworming must also be carried out.
excessive and abnormal. Heavy blood loss may be a result of 2. Dietary modification : The diet must be assessed and
abnormal menstruation (menorrhagia, metrorrhagia), parasite suitable dietary modification must be undertaken with a
infections such as hookworms, ascaris, and schistosomiasis. view to increase iron intake. Nutritious diet which includes
Acute and chronic infections, including malaria, tuberculosis, rich sources of iron must be consumed. Use of green leafy
and HIV can also lower blood haemoglobin concentration. vegetables, pulses, non vegetarian foods, ragi, jaggery and
Other conditions like haemorrhoids, peptic ulcers and cancer fruits like custard apple must be promoted. Foods with high
may also result in blood loss causing anaemia. In our context contents of vitamin C (lime, lemons, guava, amla, orange, green
IUD insertions and repeated pregnancies/deliveries are also vegetables, etc.) must be encouraged as vitamin C promotes
frequent causes of anaemia. iron absorption through reduction. Food stuffs that inhibit iron
d) Increased demand of iron and other micronutrients : There absorption like tea, tamarind and high fibre should be spaced
are certain periods in the life cycle when iron requirements are out away from the main (iron containing) meal.
especially high. Commonly this happens during growth and 3. Deworming : Deworming as required, must be undertaken
pregnancy. This has already been deliberated in the previous for all, esp. infants and children.
chapter. 4. Control of infection : Prevention and control of infections
A neonate is born with sufficient iron resources, therefore the through good health care, immunization, early diagnosis
chances that it should get anaemia in the early infanthood (6 and treatment, hygiene and sanitation practices and potable

• 763 •
water provision facilities is an important indirect step towards countries, located in all regions of the world, iodine intake of
anaemia control. the population is insufficient and it is a public health problem
5. Supplementation : Iron supplementation is routinely (11) More than 7% of world population suffers from iodine
recommended for the pregnant women and children, under deficiency. In the developing countries alone, 800 million
the national programme. Details are available on the chapter people are at risk and 200 million suffer from Goitre. As many
on National Nutritional Programmes. Therapeutic iron as 3 million cretins are born. In our neighbourhood other South
supplementation may also be required in moderate to severe East Asian countries like Bangladesh, Bhutan, Indonesia,
cases of anaemia. Myanmar, Nepal, Sri Lanka and Thailand are also prone to
iodine deficiency.
6. Iron Fortification : Trials are already completed at the
National Institute of Nutrition for fortification of certain food India : Even though WHO classifies India as a country with
items with iron. Common salt can be fortified with Ferric-ortho- ‘optimal iodine nutrition’, about 1/3rd (31.3%) of Indian school
phosphate or Ferrous sulphate and Sodium bisulplate. Double age children have a urinary iodine excretion of less than
fortification of salt with iron along with Iodine is also feasible. 100μg/l. This indicates ‘insufficient iodine intake’ and ‘mild
However these fortified foods are still awaiting induction at a iodine deficiency’. This might be true for the country as a whole,
public level. but the fact remains that the ‘sub-Himalayan goitre belt’ is the
world’s most intense Goitre endemic region affecting nearly
7. Nutrition education : It can be well appreciated that
120 million people. More than 55 million people suffer from the
anaemia is not caused solely due to poverty and lack of
condition in this region. The total Goitre prevalence amongst
resources. Ignorance on various facets of dietary intake,
school age children in India is 17.9% (11). The prevalence of
hygiene, sanitation, immunization, dietary interactions is
goitre in an iodine replete population should be 5% or less.
also important and must be dispelled. This could be achieved
through health education. The health education can be carried Lately it has been appreciated that it is not only the sub
out at all levels including children at schools, for housewives, Himalayan regions that are endemic for IDD but some extra
men and pregnant women. Using the locally available foods Himalayan foci close to low lying hills like Chota Nagpur region
that are fresh, nutritious and cheap is also an important part of Bihar, hilly regions of Madhya Pradesh and Chattisgarh,
of the nutritional education. Aravali ranges of Rajasthan, Narmada valley in Gujarat,
parts of Western Ghats (Maharashtra, Kerala and Karnataka),
8. Home gardening : Promoting and utilizing a kitchen garden
Eastern Ghats (Andhra Pradesh and Tamilnadu) and Nilgiris
and poultry can go a long way in having good nutrition and
are also endemic for IDD.
preventing anaemia.
It is estimated that the total population at risk in India is about
9. Care of pregnant and lactating women : Adequate care
200 million and 70 million are estimated to suffer from IDD.
of the pregnant and lactating women can go a long way in
preventing anaemia in them as well as the infant. Clinical Features : IDD may present as a spectrum of disorders
and illnesses throughout the life cycle (See Box-6) (12). Though
Iodine Deficiency Disorders (IDD) goitre is the most visible manifestation of IDD, the spectrum
Iodine deficiency is a major public health problem throughout ranges from abortions, stillbirths and congenital anomalies
the world, particularly for pregnant women and young children. to frank cretinism and mental/physical underdevelopment.
They are a threat to the social and economic development of If iodine deficiency occurs during the most critical period of
community. IDD is the cause of cretinism and a substantially brain development (from the fetal stage up to the third month
increased perinatal mortality. A large proportion of mental after birth), the resulting thyroid failure will lead to irreversible
retardation in infants and young children is attributable to IDD. alterations in brain function. Iodine deficiency might be
In fact, iodine deficiency is the greatest cause of preventable responsible for a mean IQ loss of up to 13.5 points in the
brain damage in childhood. Hence no effort must be spared to population (13). Cretinism is the most extreme and well known
implement measures to eliminate it. manifestation of IDD. Numerically however, subtle degrees
of mental impairment (leading to poor school performance),
Etiology : The content of iodine in water, crops or food materials
reduced intellectual ability and impaired work capacity are of
is a function of the soil content of iodine. Therefore populations
considerably greater significance, in a large number of children
living in areas where the soil has low iodine content suffer
(12).
from iodine deficiency. Heavy rainfall, past glaciation and
snow drain of iodine from the top soil layer. Crops grown in this Indicators for Assessment and Monitoring : Urinary Iodine
iodine depleted soil are devoid of iodine leading to a low dietary Excretion (UI), Total Goitre Prevalence (TGP), radiology,
supply of iodine (11). Although goitre is primarily due to iodine ultrasonography, TSH, T3 and T4 level estimation are useful to
deficiency in some areas, certain chemicals, collectively known assess and monitor the cases.
as goitrogens that are present in some of the habitual foods, Urinary iodine (UI) excretion is a marker of recent dietary
may contribute to the precipitation of iodine deficiency when intake of iodine (over the past 48 hrs.) & therefore, is the
iodine intake is marginal. These are present in vegetables of index of choice for evaluating the degree of iodine deficiency
Brassica family, e.g. mustard, cabbage, etc. & its correction. Iodine concentration in casual urine specimen
Magnitude of the problem provides an adequate assessment of the population iodine
World : It is estimated by the WHO that Iodine nutrition is nutrition. Median urinary iodine is used to classify countries
optimal in 43 countries (including India). Nevertheless, in 54 into different grades of public health significance. Median UI of

• 764 •
 Box - 6 : Clinical Features of IDD through the Life Cycle
Foetus and neonate : Abortions, stillbirths, congenital anomalies, high unexplained perinatal and infant mortality, low birth
weight, neonatal goitre, lethargy, poor feeding, prolonged physiological jaundice. Congenital anomalies like umbilical hernia
and large anterior fontanella.
Infancy & early childhood : Signs of cretinism that include mental deficiency, squint, short stature, hoarseness of voice, deaf-
mutism and motor spasticity characterized by proximal rigidity of both lower and upper extremities and trunk.
Child & adolescent : Poor scholastic performance, retarded mental and physical development. Goitre and/or signs of juvenile
hypothyroidism (growth retardation, mental retardation, hoarse voice). In addition there may be features of puffiness, thickened
and dry skin, dry and rare hair/eyelashes/eyebrows and much delayed sexual maturation.
Adult : Mental and physical underdevelopment. Patients appear to be slow and rather ‘sleepy’. Impaired mental function
and impaired decision making. On examination, an enlarged thyroid may be palpable in normal position of neck (goitre),
equal to the size of terminal phalanx of patient’s thumb or visible in addition to being palpable. There may be symptoms of
hypothyroidism - intolerance to cold, weight gain, somnolence, hoarseness of voice, menorrhagia and non-pitting oedema.

<100 μg/l indicates insufficient iodine intake and hence mild to and total goitre prevalence. To meet the WHO criteria for
severe iodine deficiency. A very commonly used epidemiological monitoring progress towards sustainable IDD elimination, salt
parameter is TGP (Box-7). Iodization coverage or proportion of households consuming
adequately iodized salt should be more than 90% (See Box-8).
Box - 7 : Total Goitre Prevalence (TGP) (12)
The size of thyroid gland changes inversely in response to Box - 8 : Present Status of Salt Iodization
alterations in iodine intake, with a lag interval that varies from a Unfortunately the legal policy on mandatory iodization of
few months to several years. The prevalence of goitre is an index salt has not been consistent. As a result only about half
of the degree of longstanding iodine deficiency and therefore, of all households in India (49% as per NFHS-2 report year
is less sensitive than urinary iodine in the evaluation of a 2000 and 51% as per NFHS-3 report) are using sufficiently
recent change in the status of iodine nutrition. Thyroid size is iodized salt. Use of iodized salt varies greatly by region; it
traditionally determined by inspection and palpation. However, is highest in the northeast region and in some states in the
the evaluation of the prevalence of goitre based on palpation has north. However, now a nationwide ban on non-iodized salt
been questioned because the reproducibility of assessment by is taking effect and the current figures could well be more
palpation is low, especially with the size estimation of smaller encouraging.
glands, particularly in children. But it is still employed as a
useful field tool for assessing goitre prevalence. The prevalence Prevention and Control : The recommended strategy for
of goitre in an iodine replete population is below 5%. IDD control is based on correcting the iodine deficiency by
increasing iodine intake through supplementation or food
Table - 5 shows the revised and simplified classification of fortification. Under the National IDD Control Programme four
goitre. main components of the IDD control strategy are :
1. Use of Iodized salt or oil
Table - 5 : Classification of goitre (14) 2. Iodine monitoring
Classification Description 3. Manpower training
4. Mass communication
Grade 0 Not palpable or visible goitre
Using iodized Salt / Oil : This prevents iodine deficiency.
Grade 1 A goitre that is palpable but not visible Control and prevention of goitre has been principally based
when the neck is in the normal position (i.e. on providing extra iodine to the population through iodised
the thyroid is not visibly enlarged). Thyroid salt distribution or iodised oil injection (in hyper-endemic
nodules in a thyroid which is otherwise not areas). Commonest prophylactic public health measure against
enlarged fall in this category endemic goitre is iodization of salt. Various agents can be used.
Grade 2 A swelling in the neck that is visible when Potassium iodate is most commonly used. Sodium & Potassium
the neck is in a normal position and is iodide can also be used. Iodization of salt is undertaken in a
consistent with an enlarged thyroid when dose of 30 ppm at source so as to render at least 15 ppm at the
the neck is palpated consumer end.
Iodized Oil : Injectable and oral iodized oil are available as
Determining presence of iodine in salt : Presence of iodine oral drops (400 mg/ml) and intramuscular (IM) injections
in salt can be qualitatively determined using rapid test kits (480mg/ml). Single IM injection of iodized oil can protect
(containing starch-based indicator e.g. MBI Kit by UNICEF). One a woman through pregnancy and one year post partum.
drop of this solution placed on salt containing iodine (potassium Oral supplementation is to be repeated every 6 months to 1
iodate) produces a blue/purple color. Coverage of adequately year (See Table - 6). More details are available in standard
iodised salt is an important indicator used for assessment of recommendations (15).
iodine status in a population besides urinary iodine excretion

• 765 •
 Table - 6 : Iodized Oil - Recommended Doses and Duration of Action (15)
Duration of effect of iodine
Age groups Oral iodine (mg) Intramuscular (mg)
3 months 6 months 12 months > 1 year
Women of child bearing age 100-200 200-480 400-960 480
Pregnant women 50-100 100-300 300-480 480
0 - 1 year 20-40 50-100 100-300 240
1 - 5 years 40-100 100-300 300-480 480
6 - 15 years 100-200 200-480 400-960 480
Males 16 - 45 yrs 100-200 200-480 400-960 480

With the wide availability of iodized salt, iodized oil is now Etiological Factors : Vitamin A deficiency is most common in
recommended only for populations living in severely endemic the age group of 1 to 3 years, the preschool children. It results
areas where a quick and definite outcome is required within a from a very complex web of causation involving ignorance,
short period or where there is no access to iodized salt. poverty, infections, lack of food, malnutrition, environmental
Nutritional Education : The importance of iodized salt in and social factors. A compromised state of any one of these
prevention of IDD has to be emphasized repeatedly to the factors could tip the balance leading to vitamin A deficiency.
community. It must be reiterated that only iodized salt must Weaning and Infections : It is often seen to be associated with
be consumed by all. It must be consumed within 6 months weaning. The mothers may not be conversant with the correct
of iodization, as the concentration of iodine diminishes with weaning practices. During weaning the child is offered low
time. The community must be made aware of the fact that vitamin A diet in the form of dilute milk, poor starchy food with
selling of non-iodized salt may attract legal action. Suitable hardly any fruits, vegetables butter or other animal products.
health education methods must be resorted to, for effective It is primarily because of ignorance and economic reasons. The
dissemination of this information e.g. through lectures, road vitamin A content of this poor diet cannot keep pace with the
shows, audiovisual aids, schools and women groups, etc. The high demand of the growing child. Repeated infections during
experiences of IDD patients and their parents may help in this crucial period of weaning, teething and increased exposure
making the community more aware of this malady. to the outside world further puts pressure of extra vitamin A
The other strategies namely iodine monitoring, manpower and other micronutrients on the system. Concomitant protein
training and mass communication are discussed in the chapter energy malnutrition makes the situation worse making the
on national nutritional programmes. child immunologically even more vulnerable to infections.
Consequently attacks of measles, acute respiratory infections
Vitamin A deficiency and diarrhoea further compromise the child’s vitamin A
Vitamin A Deficiency (VAD) is the leading cause of preventable status. This prepares a favourable ground for xerophthalmia
blindness in children. It also increases the risk of disease to flourish.
and death from severe infections. In pregnant women VAD Other Social Factors : These also play an important role in the
causes night blindness and may increase the risk of maternal causation of xerophthalmia. Cultural beliefs on breast feeding
mortality. and weaning practices are vital. Discarding colostrums, early
Magnitude of the Problem or late weaning, restriction of certain food items, excessive
World : Vitamin A deficiency is a public health problem in more dilution of milk, vegetarianism, unscientific management of
than half of all countries, especially in Africa and South-East infections, belief in quacks and unsound indigenous ‘medicine’,
Asia. Young children and the pregnant women bear the major all play an important role in the causation of this problem.
brunt of Vitamin A deficiency in poorer developing countries. While poverty and inability to manage nutritious food could be
Millions of children (esp preschool children) are at risk of a genuine reason, ignorance about the disease and faulty food
xerophthalmia. About 36 countries in South East Asia, Western practices is also rampant and is largely preventable through
Pacific and Africa are severely affected. World - over 256 million nutritional education.
people suffer from preclinical xerophthalmia and 2.7 million Poor Environment Sanitation Practices : Non availability of
from xerophthalmia. As many as 7,00,000 patients develop sanitary latrines, open air defecation, poor hygienic practices
corneal lesions and 3,50,000 become blind of xerophthalmia. and lack of potable water invite infection and disease, which
India : In India it is commonest amongst preschool children have a definite role to play in causation of the condition.
particularly in Andhra Pradesh, Tamilnadu, Karnataka, West Clinical Features : The clinical features of vitamin A deficiency
Bengal and Bihar. The prevalence of Bitot Spots in the 1 to can be divided into two broad groups, namely those concerning
5 years age group is about 1 to 5%. Very few studies report the eyes (xerophthalmia) and the extra-ocular features.
corneal lesions in India (0.05-0.1 per 100 preschool children in Xerophthalmia : Xerophthalmia is the ocular manifestation of
South India) (17) vitamin A deficiency in various clinical forms. Xerophthalmia

• 766 •
assumes extreme importance because of its seriousness may Extra - ocular manifestations : Some extra-ocular
lead to blindness and is preventable. Public health problem of manifestations of vitamin A deficiency are also known.
xerophthalmia can be ascertained by prevalence of the levels of Follicular hyperkeratosis, growth retardation and anorexia are
its various stages amongst preschool children in the community some of them. They respond to vitamin A supplementation.
(Table - 7). Treatment of Xerophthalmia (17) : An established case of
xerophthalmia responds well to treatment with vitamin A. The
Table - 7: Xerophthalmia as a public health problem (18) following regime can be followed :
WHO Prevalence ●● 2,00,000 IU (110mg) of Retinol palmitate (oil miscible
Clinical condition of among vitamin A) is administered orally for 2 days. In cases of
Classi- xerophthalmia preschool persistent vomiting/diarrhoea, water miscible vitamin A
fication children 1,00.000 IU is administered as IM Injection, followed by
XN Night blindness >1% 2,00,000 IU, 1 to 4 weeks later.
●● For infants less than 1 year old or less than 8 Kg weight,
X1A Conjunctival xerosis - half the dose is used.
X1B Bitot’s spots >0.5% Prevention
X2 Corneal xerosis - Dietary modifications should be achieved through promotion
of growth, production and consumption of vitamin A / beta-
X3A Corneal ulceration/keratomalacia
>0.01% carotene rich foods. Rich sources of vitamin A like dark green
(involving <1/3 of cornea)
leafy vegetables, deep yellow/ orange fruits, eggs, milk and
X3B Corneal ulceration/keratomalacia meat must be included in diet.
>0.01%
(involving >1/3 of cornea)
Nutrition education : Educate the community on the
XS Corneal scar >0.05% importance of vitamin rich diet, its regular intake and the
XF Xerophthalmic fundus - harmful effects of its deficiency. Importance of home gardening,
consumption of fresh seasonal fruits and vegetables must be
Bio- Plasma retinol <0.35 μmol/l reiterated. Healthy food preservation techniques must also be
>5%
chemical emphasized. Public meetings, schools and mass media can be
used to the fullest to disseminate these messages.
Night Blindness : Night blindness is classically associated with
vitamin A deficiency. The age group most commonly affected is Fortification of ghee, hydrogenated vegetable oil and butter
the pre-school children. Mother of the child typically complains are being done as a government policy to augment the vitamin
that in the evening child strikes against a stone while playing A status of the community. Technology for the fortification of
and falls down frequently. He is unable to see the contents of sugar, mono sodium glutamate, bread and milk also exists.
his food plate and gropes for food. In a dimly lit classroom he Periodic massive dosage (17) : Vitamin A administration is
can’t see what’s written on the black-board. Night blindness now integrated with immunization program. The first dose of
usually responds rapidly to vitamin A tablets/oil or injections. 100,000 IU is given at 9 months of age along with measles
Conjunctival Xerosis : Conjunctival xerosis is one of the vaccines. Thereafter, the second and subsequent doses of
earliest detectable signs of vitamin A deficiency. It manifests as 200,000 IU are given at 6 monthly intervals till 3 years of age.
thick, wrinkled (vertically folded) conjunctiva with a tendency In all, a total dose of 9,00,000 IU is administered.
to dryness. It is restricted to ‘exposed’ bulbar conjunctiva. The Long term action : Constant nutritional education emphasizing
dryness looks like “Waxy Paint” as there is loss of transparency good diet (including fruits and vegetables), importance of
and no shine in the affected conjunctiva. It is un-wettable, immunization, environmental sanitation, breast feeding, early
classically referred to as a “Receding tide” of the tear drop. The treatment of infections and good maternal and child health
un-wettability is because of the affected epithelium leading to care would go a long way in the prevention of this condition.
reduced goblet cells/mucin secretion from the lachrymal glands. Diseases Due to Excess and Deficiency of Fluorine
The ‘break-up time of tears’ is also reduced.
Fluorine Excess (Fluorosis) : Ingestion of large amounts of
Bitot’s spots : Bitot’s spots are white triangular patches present fluorine occurs when the drinking water contains fluorine in
on the conjunctiva. They resemble flakes of foam or plaster on excess of 3-5 ppm. Such a situation leads to endemic fluorosis.
the surface of the conjunctivae. They are formed due to Vitamin It is associated with dental and skeletal fluorosis. Fluorosis
A deficiency leading to hyper-keratinizing metaplasia of the has been reported to be a health problem in rural districts
epithelium and accumulation of seborrhoeic excretions. of Andhra Pradesh (esp. Nellore, Nalgonda and Prakasham
Corneal xerosis : If the preceding condition (conjunctival districts), Haryana, Karnataka, Kerala, Punjab, Rajasthan and
xerosis) is not treated early, corneal xerosis results. The cornea Tamil Nadu.
becomes pale, lustreless and looses its sheen. This may progress Clinical Features : Fluorosis presents as dental or skeletal
to a state of corneal ulceration and subsequently keratomalacia fluorosis, depending on the water content of fluorine, duration
may ensue. There may be an eventual perforation through and level of exposure.
which the contents of the eye may extrude out and the patient
Dental fluorosis : For a patient to suffer from dental fluorosis,
looses his sight.
the fluorine intake through water has to be moderately in

• 767 •
excess (> 1.5 ppm). Moreover, if this exposure takes place b) General use of refined sugar that was earlier an aristocratic
during calcification of teeth (first 7 years of life), the teeth are delicacy.
more likely to get affected by fluorosis. The mottling of teeth is c) Introduction of roller milled fine flour.
common. The enamel loses its lustre and the texture becomes Further lifestyle changes like introduction and wide use of
rough. There could be brown bands alternating with white sweetened soft drinks, refined wheat flour, excessive use of
chalky patches. Mottling may progress to small pits. Upper sugar, sweets and chocolates, sweetened milk and tea, made
incisors are affected the most, even though all the teeth are the teeth more vulnerable to caries.
vulnerable. Dental fluorosis as such, is not usually associated Host factors : The buffering action of saliva and its ability to
with skeletal fluorosis or impairment of health. reduce acidity helps in preventing caries. Lysozymes present in
Skeletal Fluorosis and Fluoride Poisoning : When the saliva also help in caries prevention. Decreased saliva secretion
concentration of fluorine exceeds 10 ppm, a crippling skeletal due to less chewing, leads to caries.
fluorosis may ensue. This may occur as a result of high fluoride Agent factors : Streptococcus mutans is notorious to cause
content of water (endemic) or as a result of an industrial caries. It flourishes in the mouth and teeth on sugars and
poisoning. As a result there may be heavy deposition of refined carbohydrates.
fluorides in the bone (sclerosis). The condition may begin as
anorexia. There may be sclerosis of spine, pelvis and limbs. The Time : The frequency of consumption of refined carbohydrates
ligaments of spine may be calcified, producing a ‘poker back’. and sugars and the duration for which they stay in the mouth
The tendinous insertion of muscles may be ossified, producing is directly related to the chances of causation of caries.
the characteristic ‘rose thorn’ shadow in the X-Ray. Substrate and diet : The substrate for the bacteria is defined
Genu valgum : Scientists working at the National Institute of by the diet one eats. Refined carbohydrates and sugars are
Nutrition, Hyderabad found new form of fluorosis characterized fermented by the bacteria and produce caries. Sucrose, fructose,
by genu valgum and osteoporosis of the lower limbs in some glucose, xylitol and other sweeteners all cause caries. Strongly
districts of Andhra Pradesh and Tamilnadu. This was seen acidic drinks (sweetened, aerated drinks) consumed frequently
in people subsisting on sorghum (Jowar) as staple. It was can predispose to caries. A sharp increase in caries is seen in
concluded that jowar promoted a higher retention ingested the developing countries with the increasing consumption of
fluoride in the body. sugars. Firm fruits like apples have scouring action that reduces
the chances of caries. Cheese increases pH and also saliva
Prevention : In the endemic areas, fluoride is present in flow, inhibiting bacteria. Chewing betel increases saliva flow
excess in water and if the community is dependent solely on and lime content of pan also increases the pH thus preventing
that water, it is not easy to prevent the condition. It becomes caries.
even more difficult because there are no household methods to
remove fluoride from water. However the following preventive Fluoride : The water content of fluoride at a rate of 0.5 to 1
measures are suggested : ppm prevents caries. In areas where fluoride content of water
is low the prevalence of caries is high. Addition of fluoride to
1. Changing water source : Running surface water has lower water can prevent caries in these situations.
fluoride content as compared to ground water. The community
should shift from ground water (wells) to running water (rivers) Prevention
if possible. Ideally the water should have a fluoride content of Reduction of sugar intake : Since sugar intake has a bearing
less than 0.5ppm. on dental caries it is advisable to reduce sugar consumption.
2. Defluoridation : There is technology available that can The following measures could be useful :
be used to remove fluoride from water. An Indian technology a) Reduce sugar in diet. Avoid adding sugar to milk, tea
called as the Nalgonda technique is an accepted defluoridation and coffee. No added sugar to be made available. Reduce
technique. It involves sequentially adding lime and alum to consumption of sweets, chocolates and cold drinks.
water. It is then followed up with flocculation, sedimentation b) No sugar should be added to infant/baby foods/pediatric
and filtration of water. medicine, fruit juices, vitamin preparations
c) Sugar added to jams, jellies, cold drinks must be reduced
3. Avoiding additional fluoride : Any additional fluoride
to the minimum,
intake must be avoided in endemic areas, as through fluoride
d) Sugar free snacks and drinks must be made available
tooth pastes for children up to 7 years of age.
Promotion of dental hygiene : It is important to appreciate
Fluorine Deficiency - Dental Caries
and promote dental hygiene. Regular brushing and dental
Epidemiology : Communities subsisting almost exclusively checkups are important in prevention of dental caries.
on meat, like the Eskimos (raw walrus meat and fish), Masai
Fluoridation of water supplies : In areas where fluoride levels
tribes in Kenya (milk, raw blood and milk) have little caries.
are less than 0.7 ppm, it is advisable to add fluoride to raise
Caries occurs among people who adopted the British dietary
its level optimally. This single measure is known to reduce the
habits throughout the world. Medieval records suggest that
caries incidence by half.
dental health was much better then. Altered dietary habits took
a severe toll on dental hygiene in the past century or two. The Professional dental care : Besides regular dental examination,
dietary changes thought to be important are : dentists help in prevention and deterioration of caries through
a) Decline in milk consumption. filling cavities, cleaning, removing calculus, removing
overcrowding of teeth through orthodontic treatment etc.

• 768 •
Application of topical fluoride solution and sealants is also the habitual foods, like vegetables of Brassica family (mustard,
effective. Good school dental hygiene services are also very cabbage etc.). The ‘sub-Himalayan goitre belt’ is the world’s
useful. most intense goitre endemic region affecting nearly 120
million people. The total population at risk in India is about
Summary 200 million and 70 million are estimated to suffer from IDD.
Four important nutritional deficiency disorders are Protein Clinical Features of IDD through the Life Cycle can be divided
Energy Malnutrition (PEM), Anaemia, Vitamin A Deficiency into Foetus and neonate (Abortions, stillbirths, congenital
and Iodine Deficiency Disorders (IDD). Anaemia affects three anomalies, high unexplained perinatal and infant mortality,
fourths of all females and more than half of all males. PEM and low birth weight); Infancy & early childhood (mental deficiency,
vitamin A deficiency occur mostly among preschool children. squint, short stature, hoarseness of voice, deaf-mutism
Vitamin A deficiency is an easily preventable cause of blindness. and motor spasticity); Child & adolescent (Poor scholastic
Thyroid insufficiency due to iodine deficiency, results in many performance, retarded mental and physical development,
a serious condition including goitre, impaired metabolism, Goitre) and in Adult (mental and physical underdevelopment,
cretinism, mental retardation and deaths (still births). goitre, intolerance to cold, weight gain, menorrhagia). Urinary
PEM contributes to 60% of the total 10 million deaths of Iodine Excretion (UI), Total Goitre Prevalence (TGP), radiology,
children under five years of age. The cause is diet poor in ultrasonography, TSH, T3 and T4 level estimation are useful to
energy and proteins latest concept being of ‘Food gap’, wherein assess and monitor the cases. National IDD Control Programme
it is not only the deficiency of proteins but inappropriate food has four main components : Use of Iodized salt or oil, Iodine
(low in energy density, protein and micronutrients - Vitamin A, monitoring, Manpower training and Mass communication.
Iron, Zinc) which is poor both quantitatively and qualitatively. Vitamin A deficiency (VAD) is the leading cause of preventable
PEM is classified into Kwashiorkor, Marasmic- kwashiorkor, blindness in children. It also increases the risk of disease and
Marasmus, Dwarfing and Underweight. Marasmus is death from severe infections. It is commonest amongst preschool
characterised by Growth retardation, wasting of muscles and children particularly in Andhra Pradesh, Tamilnadu, Karnataka,
subcutaneous fat. Clinical features of Kwashiorkar include West Bengal and Bihar. The causes include weaning infections
oedema, growth retardation, muscular wasting, retention and poor environmental sanitation. The clinical features
of subcutaneous fat and psychomotor changes. Prevention of vitamin A deficiency include those concerning the eyes
of PEM includes Health promotion (Good ante-natal care, (xerophthalmia, night blindness, conjunctival xerosis, Bitot’s
education on food, hygiene and family planning, good weaning spots, corneal xerosis, corneal ulceration and keratomalacia)
practices). Specific protection measures are adequate Diet and the extra-ocular features. Prevention measures are dietary
and Immunization. Growth monitoring, early diagnosis and modifications (dark green leafy vegetables, deep yellow/ orange
treatment of infections and Hospitalization of the case are fruits, eggs, milk and meat), nutrition education of community,
measures of Early Diagnosis & Treatment. Rehabilitation of fortification (of ghee, hydrogenated vegetable oil and butter)
a PEM case requires substantial changes in the knowledge, and periodic massive dosage.
attitude and practice about the disease. Fluorosis is a condition resulting due to Ingestion of large
Anaemia is a global public health menace affecting over 30% of amounts of fluorine when the drinking water contains fluorine
world population. The health implications range from General in excess of 3-5 ppm. Dental and skeletal fluorosis are two
symptoms like : weakness, easy fatigability, lethargy, reduced forms known. Preventive measures are changing water source,
work capacity, reduced endurance to pregnant and lactating defluoridation and avoiding additional fluoride for at least
women suffering increased risk of low birth baby, abortion, next seven years.
premature delivery, intra-uterine growth retardation, and in Fluoride deficiency leads to dental caries. The water content
children suffering from low birth weight, impaired cognitive of fluoride at a rate of 0.5 to 1 ppm prevents caries. Other
performance, motor development and scholastic achievement, measures are reduction of sugar intake (reduce sugar in diet,
inattention, fatigue and insecurity. Anaemia threshold is 11.0 avoid adding sugar to milk, tea and coffee, reduce consumption
for young children and pregnant women, 12.0 in Non pregnant of sweets, chocolates and cold drinks, no sugar should be
women and 13.0 in men over 15 yrs. added to infant/baby foods/pediatric medicine, lowering sugar
Anaemia can be due to inadequate intake of iron, poor added to jams, jellies, cold drinks to the minimum); Promotion
absorption and bioavailability of iron, excessive loss of iron of dental hygiene (regular brushing and dental checkups);
and increased demand of iron. Measures for prevention and Fluoridation of water supplies (where fluoride levels are less
control of anaemia are Breastfeeding and appropriate weaning, than 0.7 ppm) and professional dental care.
Dietary modification (Use of green leafy vegetables, pulses,
non vegetarian foods, ragi, jaggery and fruits like custard Study Exercises
apple to be promoted), deworming & control of infection, iron Long Questions : (1) Define PEM (Protein Energy Malnutrition).
supplementation, iron fortification and nutrition education. Explain in detail etiology, classification, management and
Iodine deficiency is a major public health problem throughout prevention of PEM (2) Describe in detail epidemiology of
the world, particularly for pregnant women and young children Anaemia in India. Elaborate on community measures for
causing avoidable pregnancy losses and mental retardation/ prevention of Anaemia in Pregnant and lactating women
cretinism. Iodine deficiency in soil is main cause in addition (3) Explain the process of assessing level of Iodine in salt.
to certain chemicals (goitrogens) that are present in some of Describe various control and prevention measures undertaken

• 769 •
by National Iodine deficiency Disorder Control Programme (10) Hb Threshold (mg%) to label Anaemia in Non-pregnant
(4) What are various grades of Xerophthalmia used to assess women (≥15.00 yrs) is _____________ (a) 13.0 (b) 12.0 (c)
Vitamin A deficiency? Explain the preventive measures against 10.5 (d) 11.0
Vitamin A deficiency in Pre-school children (5) Describe in (11) For a patient to suffer from dental fluorosis, the fluorine
detail the Epidemiology of Fluorosis. intake through water has to be at least (a) > 1.5 ppm
Short Notes : (1) PEM (2) Kwashiorkar (3) Marasmus (4) (b) 1.0 ppm (c) 0.5 ppm (d) 5.0 ppm.
Food Gap (5) Prevention of PEM (6) Classification of anaemia (12) Poker Back, Rose Thorn appearance on Chest X-Ray
as public health problem (7) Prevention & Control of anaemia and Genu Valgum are features of _____________ .
(8) sub-Himalayan goitre belt (9) Goitrogens (10) Urinary (a) Hypervitaminosis D (b) Hypervitaminosis A (c) Skeletal
Iodine Excretion (11) Treatment of Xerophthalmia (12) Dental fluorosis (d) Congenital Hypercalcemia.
Fluorosis (13) Prevention of Dental Caries Answers : (1) b; (2) b; (3) d; (4) a; (5) b; (6) c; (7) d; (8) d; (9)
MCQs c; (10) b; (11)a; (12) c.
(1) Jelliffe gave the ___________ term in year 1959 (a) PEM (b) References
PCM (c) Food Gap (d) Marasmus. 1. Report of the Working Group on Integrating Nutrition with Health for the
(2) The highest number (60.3%) of underweight children (under XI Five Year Plan (2007-2012 Government Of India Ministry Of Women And
Child Development November 2006.
3 years) is reported from (a) Bihar (b) Madhya Pradesh (c) 2. Diet and Nutritional Status of Rural Population. NNMB Technical Report
Uttar Pradesh (d) Jharkhand No.21, National Nutrition Monitoring Bureau National Institute of Nutrition,
(3) In _______________ child is ‘skin and bones’ owing to loss Indian Council of Medical Research,Hyderabad-500 007
3. National Health Profile 2007; International Institute for Population Sciences
of subcutaneous tissue (a) Kwashiorkar (b) Stunting (c) (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-
Nephrotic Syndrome (d) Marasmus 3), 2005-06, India : Key Findings. Mumbai : IIPS.
(4) Term ‘Kwashiorkor’ was introduced by __________into 4. K R G Nair, Malnourishment among Children in India : A Regional Analysis.
Economic and Political Weekly. September 15, 2007
modern medicine (a) Cicely Williams (b) Jelliffe (c) Ghai (d)
5. Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian
Barbar Mc Klintok foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.
(5) Anaemia contributes to ________ % of all maternal deaths 6. FAO/WHO 1971. Expert Committee on Nutrition, 8th report. WHO Tech
(a) 10% (b) 20 % (c) 5% (d) 30% Report Series no. 471.
(6) It is generally believed that spinach is a ‘very good’ source 7. Passmore R, Eastwood MA. Human Nutrition and Dietetics. 8th ed. Churchill
Livingstone, ELBS London. 1986.
of iron. But the fact is that it is a poor source as it contains 8. Worldwide prevalence of anaemia 1993-2005 : WHO global database on
only __________ mg iron per 100g (a) 5.5 (b) 6.0 (c) 1.1 (d) anaemia / Edited by Bruno de Benoist, 2008.
10.0 9. WHO, Micronutrient deficiencies Iron deficiency anaemia.http.WHO%20
Book%20Resources/Minerals/anemia%201st.htm. accessed on 11 Aug 2008.
(7) Apart from India, other South East Asian country/ies prone
10. Iron deficiency anaemia : assessment, prevention, and control. A guide for
to iodine deficiency is/are _______________ (a) Myanmar programme managers. Geneva, World Health Organization, 2001 (WHO/
(b) Thailand (c) Sri Lanka (d) All of these. NHD/01.3).
(8) It is estimated that the total population at risk in India 11. WHO Iodine status worldwide : WHO Global Database on Iodine Deficiency,
2004.
is about ________ million and ________ million are 12. Ghai OP, Gupta P, Paul VK. Ghai Essential Paediatrics, 6th ed. CBS Publishers,
estimated to suffer from IDD (a) 20 & 7 (b) 100 & 35 New Delhi. 2006.
(c) 40 & 14 (d) 200 & 70. 13. Bleichrodt N, Born MP. A meta-analysis of research on iodine and its
relationship to cognitive development. In : Stanbury JB, ed. The damaged
(9) For infants less than 1year old or less than 8 Kg weight, the brain of iodine deficiency. New York, Cognizant Communication, 1994 : 195-
dose of Vit A used is ­­­­­_________ (a) 4,00,000 IU (110mg) 200.
of Retinol palmitate (oil miscible vitamin A) administered 14. WHO / UNICEF / ICCIDD. Assessment of iodine deficiency disorders and
monitoring their elimination. Geneva, 2001, WHO/NHD/01.1
orally for 2 days (b) 2,00,000 IU (110mg) of Retinol
15. WHO. Standard Treatment Guidelines. WHO and AFMC, Pune. 2008
palmitate (oil miscible vitamin A) administered orally 16. Micronutrient deficiencies : Vitamin A deficiency; http ; WHO%20Book%
for 2 days (c) 1,00,000 IU (110mg) of Retinol palmitate 20Resources/Vitamins/vitA%201st.htm; dated 11 Aug 2008
(oil miscible vitamin A) administered orally for 2 days 17. Vijayaraghavan K. Vitamin A Deficiency. In. Textbook of Human Nutrition.
(d) 2,00,000 IU (110mg) of Retinol palmitate (oil miscible 2ne edition. Ed. Bamji MS, Rao NP, Reddy V. Oxford & IBH Publishing Co
PvtLtd. New Delhi 2003.
vitamin A) administered orally for 1 day 18. World Health Organisation. Vitamin A -Technical Report Series No. 672.
Geneva, 1982.

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 Immaculate personal hygiene of the cooks is of prime
Public Health Aspects of Food importance in the prevention of food borne infections. Infective
134 Hygiene & Sanitary Regulation organisms from all sources can be passed to food by hands. All
of Eating Establishments cooks should take a thorough bath before starting daily work,
keep their hair and nails clipped short and invariably scrub
and wash their hands with brush, soap and water after every
Rajul K Gupta visit to the latrine or urinal and before handling food or raw
rations. As far as possible, touching food with bare hands must
While food is the most important item to sustain life on this be avoided. There should be access to toilets, hand washing
planet, next only to oxygen, it is a potent source of pathogens, facilities and wash rooms for the kitchen staff. The cooks must
toxins and disease. A food borne disease is one where the agent be subjected to regular medical examinations for communicable
is toxic or infectious, and is transmitted to the body through diseases that have a potential to be transmitted through food
food. Detailed discussions on the epidemiology and prevention/ (e.g. wounds, boils, diarrhoea). Those found positive must be
control of specific food and water borne diseases have been immediately excluded from kitchen duties and treated. Since it
made in the section on communicable diseases of this book is not possible to detect carriers from a medical examination, it
and readers are advised to refer to the same. In this chapter, is worthwhile doing a stool examination as well. They should
we would discuss the details of prevention and control of food also be vaccinated against the enteric group of fevers.
borne infections. Kitchen hygiene and sanitation : Besides personal hygiene,
General Principles it is vital to have an immaculate kitchen hygiene as well. The
storing, cooking and all working surfaces must be cleaned after
Procurement and Storage each session of cooking. Utensils, equipment and mops, etc
Procurement : Food should be procured from a reliable supplier. should also be in a good shape. More details are discussed in
The hygiene standards maintained by the supplier should be another section of this chapter.
noted, such as cold and chilled storage, separation of raw and Cooking Practices : The following healthy cooking practices
cooked foods, handling of raw and cooked foods, cleanliness of must be adhered to :
premises and equipment. No more food should be purchased
1. Food must be ‘fully’ cooked and not merely cooked
than the amount which can be stored in the available deep
partially.
freeze cabinet or refrigerator (4°C).
2. Food must be cooked rapidly and consumed quickly.
Non-vegetarian foods : Raw and cooked meat and poultry, Otherwise refrigerate at the earliest (store cooked food
milk, cream, and fish should be bought in quantities sufficient below 4°C).
for one day only. Meat and fish should not be refrigerated for 3. Reheating of food must be avoided. If it is essential to
more than three days. reheat, the food must be heated to beyond 60°C for at least
Dry and canned foods : Dry foods and canned foods should 5 minutes, ensuring that heat penetrates to the core of
be bought in reasonable quantities. Avoid overstocking; food. A mere warming of food is not good enough.
there is danger from vermin and deterioration where storage 4. Insist on consuming fresh and hot food.
facilities are poor. These products should be stored in a dry, 5. Use of pressure cookers, microwave, frying and grilling are
well ventilated storeroom. safer cooking methods as compared to inadequate boiling,
Refrigerate perishable foods : Meat, poultry, dairy products, roasting or warming.
fish, and cooked rice must be refrigerated. Store raw and cooked Serving of food
meat and poultry separately to prevent cross-contamination. 1. Avoid prolonged exposure of susceptible foods to warm
The temperature of the refrigerator should be 1-4°C. environment. This will encourage rapid bacterial growth
Storing non-perishable food : Non-perishable food must be and deterioration of food. Keep cold food cold, below 5°C.
stored in a storeroom. It should be kept cool, well ventilated, 2. Avoid warm storage of cooked food. Keep hot food hot,
and dry. Adequate precautions must be taken for rodents, flies above 63°C or else below 4°C.
and cockroaches. Surfaces of shelves, walls and floors should 3. Do not reheat cold food to store in a warm holding
be easy to clean. apparatus (hot cupboard, hot case, casserole). Place only
hot food in such equipment, that too for a short while
Deep freeze unit : For longer storage Deep freezer is used. A before consumption.
temperature of -18°C is desirable. 4. Minimize handling of cooked foods with bare hands. Use
Vegetables : Vegetables should also be procured on a daily suitable kitchen tools.
basis. They must be kept in a cool dry storage place away from 5. Use new clean paper/cloth for wrapping and covering
direct sunlight. Most vegetables can be refrigerated. food.
Food Handlers’ Hygiene : Cooks should be provided with 6. Keep animals and insects out of the kitchen.
special clothing consisting of 4 aprons, 4 caps (or pugrees), 4 Sanitation of Some Specific Foods
shirts, 2 shorts, 2 trousers to wear while on duty. A clean set of
jharons (mops) should be available to the cooks every morning. Some foods require special attention. These are mainly the non
Facilities for scrubbing hands with brush and washing with vegetarian foods and fresh salads.
soap and running water should always be available.

• 771 •
Poultry : Poultry may harbour food-poisoning organisms on the proof structures.
skin, offal and inside the carcass. Thus care should be taken To prevent outbreaks of milk borne diseases hygiene of cattle,
where and how birds are dressed. Surfaces and utensils should personnel, equipment, process (of milching and pasteurization),
be well cleaned after use, and hands should be washed well as well as sanitary packing and delivery should be ensured.
after handling the raw materials. Clothes should not be used to A periodical medical examination of personnel, inspection
wipe carcasses either inside or outside, or to cover them. Frozen of premises and equipments, veterinary inspection of cattle,
meat and poultry should be thawed properly before cooking scrutiny of the process in the dairy, inspection of functional
Sausages : Sausages, raw scraps, and minced meat may be efficiency of the farm, depot and plant, and laboratory tests for
contaminated with salmonellae. Great care should be taken purity and quality of pasteurization are required to be carried
when preparing sausages for cooking. If they are pricked the out. These measures should ensure the following :
fork should be washed immediately with hot water. Sausages Care of Cattle : The quality and the quantity of milk not only
should be well cooked. depends upon the particular breed but also on the care that is
Meat : Dishes should be prepared fresh from raw meat. If devoted to the cattle. The milk yield also depends on comfort,
there is likely to be any delay in using cooked meat, steaming feeding, watering, and cleanliness; hence a clean, airy, cool
under pressure is the best way to ensure the destruction heat- and spacious cattle shed is of prime importance. Ample water
resistant organisms; it is a safe method of cooking. If left-overs supply for drinking, to wash the cattle sheds and bathe the
are used after warming, they must be cooked thoroughly to cattle should be available. Fodder, cottonseed, oilcake, bran
boiling point to destroy contaminants and toxins which may and meal consisting of a coarsely crushed mixture of grains
have been formed. Spores on the outer surfaces of meat are must be given to each animal. Stores should be rat proof. Sick
more likely to survive if not well cooked. So it must be cooked animals must be immediately isolated and contacts segregated.
thoroughly and eaten freshly cooked. It must not be allowed Cattle should be inspected by a veterinary surgeon at least once
to cool slowly and stored at atmospheric temperature, as that a month. Preventive inoculation against common diseases
promotes rapid multiplication of bacteria. must be ensured.
Salads and fruits : Salad vegetables including spinach, Cow Sheds : The cow shed should be well drained and higher
cabbage and lettuce could have been grown in sewage farming. than the surrounding ground. The floor area per cattle head
Salads and cut fruits (which cannot be peeled), should be should be minimum 6 m2. The walls should be of reinforced
scrubbed and washed well, preferably with water containing concrete and whitewashed inside. Good cross ventilation
hypochlorite. is essential. The shed should be well lit. The whole flooring
Cooked rice : Cooked rice should not be stored without should be of impervious concrete. The sheds should be washed
refrigeration. every day and cleaned twice a day. They should be sprayed with
insecticide once a week.
Milk/eggs : Milk should be consumed after pasteurization or
boiling. The most hygienic way to consume eggs is to boil them Disposal of Cattle Dung and Sullage : All channels carrying
and eat. sullage and liquid cattle dung should always be made of
concrete. Semisolid cattle dung, a potent source of fly breeding,
Health education : There should be a continuous endeavor
should be removed daily to a cow dung depot made of concrete
to educate the kitchen staff and public at large regarding food
and situated at least 200 m away from the cattle sheds. Anti-
hygiene and its practice.
fly measures must be ensured.
Milk Hygiene Health of Workers : Medical inspection of the employees should
There is a potential of disease causation through milk when be carried out very regularly and frequently, strict attention
it is not handled hygienically and therefore it is important to being paid to personal cleanliness. A regular immunization
care for milk hygiene. The milk hygiene
begins at its source of production namely Table - 1 : Diseases conveyed through milk
the dairy farm. Milk can become a good
nidus for many organisms (2). Some Disease Organism Reservoir/Source
common diseases conveyed through milk Tuberculosis M tuberculosis (bovine) Cattle
are summarized in Table - 1. Brucellosis B abortus / melitensis Cattle, Goat
Sanitation of Dairy Farms : Dairy farms
Q Fever Coxiella burnetti Cattle
should ensure a pure, wholesome and
protected milk supply. A dairy consists Septic Sore throat Streptococcus pyogenes Cattle, milk handlers
of the farm, the milk depot and the Food Poisoning Staphylococcus aureus Cattle, milk handlers
pasteurization and bottling/ packing
Diarrhoea and dysenteries Shigella, E histolytica Milk handlers
plant, staff changing rooms, and a
manure disposal yard. The dairy proper Cholera Vibrio cholerae Water, milk
has milk receiving, pooling, cooling and Enteric fever Salmonella species Milk
blending room. A pasteurization plant
Viral hepatitis, polio Hepatitis A, Polio viruses Milk
should also be integrated. All these are
housed in permanent, solid, fly and dust Diphtheria Corynebacterium diphtheriae Milk

• 772 •
against enteric group of fevers must be ensured. All cases of (d) Ultra high temperature (UHT) Method : Milk is rapidly
illnesses, especially diarrhoea, dysentery, enteric fever, infected heated usually in two stages, the second stage being under
fingers or boils, running nose or ears, sore throat, or cough pressure, between 125º to 150º C for a few seconds only. It
must be attended to. Exclusion of carriers of communicable is then rapidly cooled and packed / bottled as quickly as
diseases should also be rigidly enforced. possible.
All indoor workers should scrub their hands thoroughly with (e) Pasteurization in Bottles : The filled bottles can also be
soap, hot water and a nail brush and change into their working pasteurized. They are well sealed and heated by a shower of
clothes including cotton masks. All workers should have hot water or steam. The simplest method is to place the milk
adequate sanitary and bathing facilities. They should wash bottles in water-bath brought to 63ºC held there for 30 min
their hands with soap and water before entering the processing and then chilled. The theoretical risk of contamination after
premises or milking. pasteurization is entirely eliminated.
Pasteurization Supervision of Pasteurization Process : The pasteurization
Boiling kills the microorganisms but is likely to adversely affect process needs constant supervision and the following are the
the quality, taste and flavour of milk, as milk constituents are most important factors to ensure efficient pasteurization :
heat-labile. Pasteurization involves rapidly heating milk (to (a) Raw milk must be clean and free from extraneous matter.
less than the boiling point), maintaining it uniformly over a (b) A pasteurization chart should show the range of and the
definite period and rapidly cooling it. This destroys most of period for which the temperature, as specified for the
the pathogenic microorganisms, reduces the total quantity of method, was maintained.
all the microorganisms without affecting its inherent qualities (c) Milk must be protected from contamination during cooling
(taste and flavour). It may not sterilize milk but makes it and bottling / packing; unprotected open coolers are
non-infective, retains its nutritive and aesthetic qualities and undesirable.
improves its keeping quality. The important pathogens that (d) Excessive foaming of milk must be avoided as the
are destroyed by pasteurization of milk are M tuberculosis, B temperature of the foam is too low to kill pathogens
abortus, Streptococci and Staphylococci and the non-lactose and may even encourage the growth of thermophilic
fermenting pathogenic organisms of the Salmonella-Shigella organisms.
group. The subsequent rapid cooling of the heated milk inhibits (e) The apparatus must be efficiently cleaned and sterilized
the multiplication of any viable residual microorganisms or of after each day’s work.
the ones subsequently gaining access to the liquid. The low (f) Besides ensuring efficient supervision, the process of
temperature must be maintained till the milk is consumed. pasteurization should be checked from time to time by the
The nutritive value of pasteurized milk remains reasonably colorimetric phosphatase test as described earlier.
satisfactory. Its fat, protein, calcium, phosphorus, and vitamins (g) If there is any doubt, about the effectiveness of
A and D contents are not affected. There is a 10% loss of pasteurization, the issue of such milk must be reconsidered.
vitamins B and 20% loss of vitamin C. Pasteurization improves It is much safer for the consumer to assume that the milk
the keeping quality of milk, reduces the number of bacteria, and he receives is untreated and is therefore boiled rather than
destroys tuberculosis bacilli and other pathogenic organisms to enjoy a false security.
except spores and thermoduric bacteria. However, milk with Inspection of Milk : Inspection of milk involves physical and
a high bacterial count in a raw state will not pasteurize so laboratory tests. Objectives of inspecting fresh milk are to
efficiently as clean milk. Pasteurized milk can be preserved for detect visible dirt, deterioration, adulteration, nutritive quality,
8 to 12 hours at 18°C. keeping quality, and to ascertain efficiency of pasteurization.
The physical tests involve the inspection and taste of milk. The
Methods of Pasteurization : The methods of pasteurizing
interpretation is given in Table - 2.
milk are as follows :
Laboratory Tests
(a) Holder (Vat) method : This method consists of heating the
milk to the temperatures between 63ºC and 65.5º C and holding Specific Gravity : The specific gravity of milk should be 1.029
it in large tanks at that temperature for 30 min before cooling to 1.033 but milk diluted with water can be readily restored to
it rapidly to 5°C. Milk gets heated efficiently and pathogenic its normal specific gravity by adding sugar or cornflour.
bacteria are killed with certainty. From these holding tanks Chemical Tests : A further chemical analysis is necessary to
the milk runs directly to the cooler and then to the packing / detect adulteration.
bottling machine through a closed system. (i) Gerber’s Test : Gerber’s Test is carried out for estimation
(b) Continuous Flow Method : This method is the modification of fat.
of the Holder method. The milk is first heated to 63ºC or more (ii) Total Solids : These are estimated by the evaporation of
and then led through a series of heated metal coils so that whole milk in a water bath and then weighing the dried residue
the milk remains at that temperature in the apparatus for 30 Solids Not Fat (SNF) are estimated by deducting the fat value
minutes. from the total solids.
(c) High Temperature Short Time (HTST) Method : In this (iii) Methylene Blue Test : It is carried out for testing the
method milk is heated to 72°C for 15 seconds and then rapidly keeping quality and bacterial contamination in the milk. The
cooled to 4ºC. basis of the test is that the dye is reduced and decolourised

• 773 •
 Table - 2 : Interpreting Physical Tests of Milk Inspection
Visual Inspection Likely Cause Interpretation
Ropy milk or slimy Disease of the udder or contamination with Lactis vascosus. Not acceptable
milk
Blue milk Infection of animal due to tuberculosis or Ps cyanogena. Not acceptable
Red milk Crushed udder Not acceptable
Highly coloured Presence of colostrum. Acceptable
Dirty milk Manurial dust from the flanks and tail of the cow, or dirt in the Not acceptable
container
Taste Likely Cause Interpretation
Altered taste Feeding of the cow (e.g. with turnips). Acceptable
Medicinal taste Cow is being administered some drugs Not acceptable
Souring of milk Likely bacterial fermentation Not harmful, but not acceptable either

by the bacterial enzymes. The rate of reduction is an index of Meat hygiene

the extent of bacterial contamination. One ml of methylene
Meat has got high nutritive value but it deteriorates fast. That
blue solution of 1 : 300,000 strength is added to 10 ml of milk
is why it is notorious for severe bacterial infections and food
sample in a test tube and then incubated at 37 ºC in a water
poisonings. Meat hygiene is therefore extremely important at
bath or incubator. The mixture should not decolourise within
all levels of food processing.
5½ hours. If kept at room temperature above 37 ºC it should
not decolourise within 4½ hours. Inspection of Meat
(iv) Phosphatase Test : This test is meant for ascertaining Fresh Meat : The common signs of deterioration can be elicited
the efficiency of pasteurization and depends on the fact that by the following methods (3).
the enzyme phosphatase is destroyed by the pasteurization (a) Smell : The outside of the carcass should be smelt. A foul
temperatures; but not completely destroyed at a lower smell is a reliable indication of decomposition.
temperature, or in a shorter period than that required for (b) Appearance and Firmness : Fresh meat is firm and elastic.
pasteurization. Milk containing as little as 0.25 percent of raw Decomposed meat loses its firm elastic consistency and tends
milk in the properly pasteurized milk still contains detectable to become soft and slimy.
quantities of enzyme. The test is performed by addition of
(c) Colour : It should be uniform. On decomposition the fat
disodium phenyl-phosphate to pasteurized milk. The enzyme
becomes pale and the muscle appears dark brown to black.
phosphatase, if present, splits up the phenol by means of a
Discoloured patches may emerge with time.
phenol test reagent which gives different shades of blue colour
depending upon the amount of phosphatase enzyme present. (d) Skewer Thrust Test : A skewer must be thrust into the
The colour is matched against the standard colours in a substance of the meat and should be smelt. Meat with an
Lovibond colorimeter. Pasteurized milk must not contain more unpleasant smell is unfit for consumption.
than 2.3 Lovibond units. Fresh Fish : The common signs of deterioration are as
(v) Bacteriological Tests : These are rarely carried out follows:
as a routine but when indicated, are used for detection of (a) Smell : It is probably the most important test of soundness.
M tuberculosis, B abortus or some other bacteria. Under such Fish with an unpleasant smell should be rejected, even if all
circumstances 100 ml of milk is centrifuged at 3000 rpm for other tests are in its favour.
half an hour. Deposits of centrifuged milk also can be cultured (b) Appearance : When freshly caught the gills are bright pink,
for other organisms in appropriate media such as the Wilson but after death they rapidly become darker and in a matter of
Blair medium for the enteric group of organisms and the an hour or so assume a liver colour. The longer the fish is kept,
tellurite medium for C diphtheriae. the darker are the gills.
Inspection of Dairies and Milk Depots : The dairy should be (c) Firmness : The flesh should be firm to touch, not rapidly
inspected in a definite sequence and with a view to scrutinize separated from the bones, and should not tear easily. If flesh
all details in the process of production of milk / milk products, pits readily under pressure, decomposition must be suspected.
their wholesomeness, quality and safety for consumers. All the
concerns described above should be covered. Sampling of milk (d) Colour : It should be uniform. There should be no evidence
may be carried out periodically at the dairy farm, milk depot of discoloured patches on the skin. These are usually seen first
and also at various points on the consumer line. The tests for along the line of the backbone.
nutritional ingredients, adulteration, pasteurization, bacterial (e) Eyes : These should be prominent and not sunken, collapsed
contamination and keeping may be specifically requested as or dull.
indicated.

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(f) Floatation Test : If not eviscerated, a sound dead fish sinks Floor and walls : Special notice should be taken of the floor
in water while a decomposed one floats, belly up. and general cleanliness of the place where the carcasses are
Tinned Meat and Fish dressed. Floor should be made of impervious concrete. The
interior walls should also be of smooth concrete, which should
During canning the interior of the tin and its contents are
be lime washed frequently.
subjected to heat, though an absolute sterility is not achieved,
but the growth of remaining live organisms and spores is so Drains : Concrete channels should drain all liquid waste
inhibited that hermetically sealed cans should normally remain from the lairs and the slaughter room to a place of disposal
sound for several years. Under tropical conditions, the rate of outside, through covered drains. All the drains must be cleaned
deterioration is somewhat accelerated and spoilage may result frequently. The manholes must also be frequently checked.
even in an intact tin. The date of packing and the recommended Drains must be in a good state of repairs as damaged/broken
last date for usage, must therefore always be kept in mind. The drains are unhygienic.
acidity of preservative sauce may cause erosion of the tin and Waste disposal : The liquid waste should be run into a
eventually results in pin point leaks. This may lead to bacterial water carriage sewer. All solid refuse should be burnt in the
infection. incinerator.
Employees : The employees must preferably be permanent.
Tins / Cans to be Viewed with Suspicion They must wear clean clothing and be free from communicable
●● Damaged, dented or rusted tins diseases. They must undergo initial and periodical examination.
●● Leaking tins They must also take routine immunization.
●● Excessively convex tins Inspection of Slaughter House : A regular inspection of
●● ‘Blown’ tin (owing to the formation of gas from slaughterhouses is essential to ensure that it does not become
decomposition) a focus for the spread of infections. The abattoir must be
●● A bulging tin under pressure (‘Springer’) inspected regularly and thoroughly. The most important points
●● Tainted, foul smelling or bad taste of contents to note are :
●● If in doubt, subject to laboratory analysis (a) The structural soundness of the building. The construction
of the floor which should be made of cement concrete.
Poultry : Although it is the custom in temperate climates (b) The fly proofing, rat proofing and dog proofing of the
to allow poultry and game to hang for some days in order to premises.
improve flavour and tenderness, this is usually not practicable (c) The method of disposal of offal, blood, animal excreta and
in India. Fresh poultry have bright prominent eyes, the feet are discarded animal tissues.
limp and pliable, the flesh moderately firm and the skin pale. (d) The sanitation of the lair.
Staleness is shown by stiff and dry feet, dull and collapsed eyes, (e) The spaciousness of the separate slaughtering, skinning
soft and flabby flesh and probably a greenish discolouration and hanging rooms and their ventilation.
around the crop. (f) Availability of water for maintaining the sanitation.
Slaughter House Sanitation (g) The maintenance of equipment of slaughtering, skinning
and handling and finally the personal hygiene of the
Filthy slaughter houses are always a menace to the public
workers.
health due to large collection of offal undergoing putrefaction
and the continuous flow of blood, urine and faecal matter in the Sanitary Inspections & Suggested Standards
surrounding areas. A poorly managed slaughter house emanates for Food Catering & Eating Establishments
rotten smell and it becomes a source of disease and nuisance
A high standard of tidiness and cleanliness of all premises of
to the public. Fly breeding and contamination of meat are the
the catering and eating establishments should be ensured. The
two major health hazards. Thus, for proper sanitary control, all
following important aspects must be monitored :
slaughtering should be carried out in well maintained, licensed
public slaughter houses (abattoirs) wherein hygiene rules must (a) Kitchen premises - General Principles : The entire kitchen
be followed strictly. A good slaughter house should conform to premises should be spacious, lighted, fly proof, rat proof, airy
these basic standards (3) : and spotlessly clean at all times. The kitchen complex should
have a separate cooking room (actual kitchen), a storeroom for
Design : The slaughter house should be well ventilated and
fresh provisions, a preparation room, a scullery and a room for
totally fly proof. It should have sufficient running water supply.
the cooks’ clothing. The design of a kitchen must be planned
Adequate provision should be there to deal with blood, offal
with the principles of hygiene in mind with regard to the sources
and waste animal products. It should be fitted with scaffolding
of food-poisoning bacteria, importance of hot and cold storage
having chrome plated hooks for dressing of animals.
and prevention of cross-contamination. So far as possible there
Building : The slaughter house should be built with brick and should be separate work areas for raw and cooked food.
concrete and well protected against rodents, cats and dogs.
Floors : Floors must have non-slip surfaces, should be
A concrete boundary wall is desirable. Adequate toilet/wash
impervious to moisture and easy to clean. There should be a
and hand-washing facilities (with soap and water) must be
provision to raised or move the equipment to allow floor to be
available.
cleaned underneath.

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Walls : Walls should also be impervious walls that reduces Preparation room should be supplied with hot and cold water
condensation and is easy to clean. The wall and floor junctions for which foot operation is preferable. A soap dispenser, kept in
should be covered for easy cleaning, and equipment should be a hygienic condition is also a must. A nail brush with plastic
fixed away from the wall to allow for cleaning. or nylon back and bristle should be available. Hand drying
Ceiling : Ceiling should be smooth, should resist condensation, should be done using individual methods such as paper towels.
and easy to clean. Provision for exhaust/chimney-vents must Common towels may cause cross infection.
be made. (d) Store Room : A separate fly proof and airy store-room
Lighting : Lighting must be good, both natural and artificial, for raw fresh food stuffs should be provided. Raw foodstuffs
particularly over the work and preparation areas, sinks and should be kept in baskets/ crates ensuring free circulation of
cooking equipment. Shadows must be avoided. air and stacked on shelves. A cool room or refrigerator must
be available where fresh fruits, vegetables, milk and curd can
Ventilation : Natural and mechanical ventilation is necessary
be stored. Meat, fish and poultry should be kept refrigerated
to prevent a rise in temperature, smoke and humidity.
or frozen. Grains, pulses, flour and other dry stuff should be
Conveniences : Toilets should not open directly into food- kept in racks, away from the walls, either in neatly tied bags or
preparation rooms. Foot-operated flushes are desirable. Wash in boxes in a separate well ventilated store-room. Equipment
basins should be available in or adjacent to the toilet. and utensils should be stored separately. A room for the cooks
(b) Kitchen proper : The kitchen should be sufficiently large. A clothing and other necessaries should be provided separately.
properly constructed cooking range is recommended. This will (e) Scullery : The scullery should be dry, clean and tidy. Sinks
not only economize the consumption of fuel but also keep the should be adequate, and draining boards should be sufficient
kitchen clear of smoke. The kitchen should be fly proof and well and clean All utensils after use should be thoroughly cleaned,
ventilated. It should be meticulously clean and tidy. The floor washed, dried and kept in clean places. Tables should be
should be well cemented and free from cracks and crevices. scrubbed with washing soda and water twice a day using a
The cooking range should be flanked with platforms for cooks hard brush.
to sit and for prepared food to be kept, awaiting removal to a
(f) Dining Room : The dining room should be clean, fly proof,
food serving hatch, racks or hot-plates. Chapati baskets must
well lit and ventilated. While serving food, it should not be
be lined with clean cloth which is washed daily. All food should
exposed to flies or dust. It should be presented in a manner that
be kept covered.
will enhance the acceptability or appeal, and reduce wastage.
Kitchen equipment : Ease of cleaning is an important factor in An effort should be made to supply hot food. A hot plate should
selecting all surfaces, equipment, and utensils. The following be incorporated in the serving hatch or platform.
facts must be kept in mind :
(g) Washing Arrangements : Efficient washing-up
(1) Keep surfaces, equipment and utensils clean and in good arrangements are necessary to clean and remove bacteria
repair; they should not be old or worn. from all dining room and kitchen equipment. The essential
(2) Slicing machines, mincing machines, and can openers provisions are :
require frequent and thorough cleaning; they must be easy
(1) Good layout of washing-up area.
to dismantle and reassemble. In-plant cleaning may be
(2) Correct temperature of wash and rinse water.
necessary for fixed parts of equipment.
(3) A good detergent suited to the type of water.
(3) Use separate boards for raw meat, cooked meat, and
(4) Orderly methods of work in rinsing, stacking, racking, and
vegetables.
storage.
Choose appropriate materials for ease of cleaning; for example,
Methods of Washing the Crockery, Cutlery and Utensils
synthetic and/or natural rubber hardened with plastic fillers,
high molecular weight, medium-density polyethylene, or ●● One Sink Method : This is commonly used but is an
phenolic fibre laminates. For cleaning, use hot water and a inefficient method since crockery and cutlery may still be
detergent combined with or followed by a disinfecting agent contaminated with bacteria.
such as hypochlorite; avoiding cloths and using disposable ●● Two Sink Method : It is suitable for domestic as well as
paper instead. for large scale use. The dishes are rinsed, scraped, and
wiped off, with paper. Food particles are removed. Utensils
(c) Preparation Room : Preparation room is meant for the are then washed in hot water, (46-50°C) with measured
preliminaries of cooking such as peeling, cutting and washing detergent. They are rinsed in racks in hot water at 77-82°C.
of food. Provision of fly proofing and good ventilation is Both wash and rinse waters should be changed as soon
necessary. The preparation of vegetables should always be done as they become soiled or cold. They must be dried before
on a zinc-topped table or granite slabs fitted with a chopping storage.
board on it rather than on the floor. The peeling and refuse ●● Dish washing machine could also be used.
should be deposited directly in a covered refuse bin. A meat ●● Mops and cloths : They harbour bacteria and can
chopping block preferably of a special hardened plastic (high contaminate hands, equipment and cutlery. They require
density polypropylene) must be provisioned that is thoroughly daily washing and disinfection preferably by heat. Paper
washed and cleaned after use. It must be disinfected with a should be used in place of dish cloths and towels.
suitable agent (e.g. hypochlorite) and covered with a layer of
powered salt and dried in the sun.

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(h) Waste disposal (ground glass or metal fragments). These potential hazards
Within the kitchen : Scraps of food attract bacterial growth and measures to control them are identified.
and vermin. It is therefore important to dispose off the waste 2. Identify critical control points. These are points in a food’s
correctly. Waste must be collected in pedal-operated bins which production from its raw state through processing and
can be emptied regularly and washed out or in paper or plastic transport to consumption at which the potential hazard
bags on pedal-operated stands. Bags can be sealed and put into can be controlled or eliminated. Examples are cooking,
dustbins, incinerated, or collected by the local refuse collection cooling, packaging, and metal detection.
service. 3. Establish preventive measures with critical limits for
each control point. For a cooked food, for example, this
Outside the kitchen : Sufficient waste bins or paper or plastic
might include setting the minimum cooking temperature
sacks must be provided to prevent over spilling. Bins with well-
and time required to ensure the elimination of a harmful
fitting lids should be placed in the shade on a stand (10 to 12
microbes.
inches) high above a concrete area with drainage which can be
4. Establish procedures to monitor the critical control
easily cleaned. Plastic bags with lids should be wall-mounted
points. Such procedures might include determining how
to give good ground clearance for hosing down. Bins should be
and by whom cooking time and temperature should be
kept as dry as possible.
monitored.
(j) Vermin and fly control : Rats, mice, flies, cockroaches and 5. Establish corrective actions to be taken when monitoring
ants are the most common pests. If premises does not provide shows that a critical limit has not been met--for example,
food and shelter infestation can be prevented. For details on reprocessing or disposing of food if the minimum cooking
extermination the chapter on entomology may be referred to. temperature is not met.
Control of Flies 6. Establish procedures to verify that the system is working
(1) Do not provide a breeding ground such as uncovered refuse properly for example, testing time-and-temperature
bins. Bins should be kept as dry as possible. recording devices to verify that a cooking unit is working
(2) Destroy flies by insecticidal spraying of the refuse area in properly.
summers to prevent breeding. 7. Establish effective record keeping : This would include
(3) Prevent access to kitchen and food by fly-proof windows, records of hazards and their control methods, the
doors and ventilators. Food must be kept covered. monitoring of safety requirements and action taken to
(4) Electrical fly killers will kill flies without the hazards correct potential problems.
associated with aerosol sprays. Summary
Cockroaches
Prevention of food borne infections and food poisoning can be
These are active at night. They get attracted to warm places, achieved through appropriate steps taken at the all levels of food
such as heating pipes. The hiding places (cracks and crevices) processing i.e. production, supply, procurement, processing of
which provide shelter must be sealed off. Close-fitting lids raw food, transport, cooking, storage, distribution and finally
prevent access to food. The area should be treated with suitable serving and eating of food. Immaculate personal hygiene of
insecticide. cooks, design and hygiene of the kitchen premises, appropriate
Sprays and other insecticide formulations storage of food and healthy cooking practices are vital for
These must be used with great care in the kitchen premises prevention of food borne diseases.
Pyrethrum spray is relatively safer to be used in this setting. Milk and meat are also potential sources of various food borne
diseases. Adequate hygiene measures should be implemented
Hazard Analysis and Critical Control Points through their entire course of procurement and processing.
(HACCP) Sanitation of dairy and slaughter house is of paramount
HACCP is an approach to food safety focusing on identifying and importance in achieving this aim. Pasteurization of milk
controlling critical points in the food production and distribution is the process of rapidly heating, maintaining it uniformly
chain that may lead to food hazard. HACCP incorporates a set over a definite period and rapidly cooling it thus destroying
of food safety strategies specific to the tasks and settings of most of the pathogenic microorganisms. Various methods of
the food chain. These strategies apply to farmers working in pasteurizing milk are: Holder (Vat) method, Continuous Flow
the field to those responsible for food handling and production Method, High Temperature Short Time (HTST) Method, Ultra
before it reaches the consumers table. Food handlers at all High Temperature (UHT) Method. Various methods and tests
levels are trained to implement key strategies to eliminate or are used to monitor pasteurization.
control food borne infection triggers at critical points in the
‘operation’.
Study Questions
Long Question : Enumerate the hazards of an unsanitary
Principles of HACCP : The standard approach to HACCP has
kitchen. What measures would ensure adequate kitchen
been specified by the Codex Alimentarius, 1997, and follows
hygiene of a large eating establishment?
the following seven basic principles :
Short Notes : (1) Botulism (2) HACCP (3) Golden principles
1. Analyze hazards : In a setting of food hygiene the hazard
of food hygiene (4) Pasteurization (5) Hygiene inspection of
could be biological, (microbes); chemical (toxin); or physical
meat

• 777 •
MCQs 5. Which of these is the ideal method of disposing off solid
1. Which is true for mushrooms : (a) It is a nutritious food refuse from slaughter house : (a) Incineration (b) Land
(b) Some mushrooms could cause food borne disease fill (c) Sell it off to a contractor and get some money
(c) Some mushrooms could cause food poisoning (d) All of (d) Chemical treatment
the above Answers : (1) d; (2) d; (3) c; (4) d; (5) a.
2. Which of the following is generally not a source of food
borne diseases (a) Dust (b) Skin infection (c) Home References
1. Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and
preserved food (d) Fruits Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.
3. Pasteurization destroys (a) All pathogenic organisms 2. Frank JF, Barnhart HM. Food and Dairy sanitation. In : Last RJ (Ed) : Maxcy
(b) Some pathogenic organism (c) Most pathogenic Rosenau Public Health and Preventive Medicine. Appleton-Century-Crofts,
USA. 12 th Ed 1986; Chap 18 : 765 - 806.
organisms (d) No pathogenic organisms
3. Public Health & Preventive Medicine for the Armed forces. 8th Ed 2000.
4. Which of these insecticides is relatively safe for kitchen Department of Community Medicine, Armed Forces Medical College, Pune,
use : (a) Abate (b) Sodium Hypochlorite (c) Baygon India
(d) Pyrethrum 4. Food Poisoning and Food Hygiene. Hobbs BC, Roberts D. 5th Ed. Edward
Arnold, London. 1989.

Current Nutritional Deficiency Status

135 Nutritional Programmes in India The nutritional state of the country still remains much below
the desirable levels. Even though the agricultural production
Rajul K Gupta may be good, it does not automatically ensure enough nutrition
of masses, owing to various reasons. These could be as diverse
In the less fortunate parts of the world, immense food related as poverty, lack of food security and ignorance.
problems are a painful reality. Every day 800 million people The figures speak for themselves. More than one fourth (26.1%)
in the developing world, ie 18% of the total world population, population is below poverty line. As many as half (49%) of
have to sleep hungry. In South East Asia, one out of four rural and more than one third (36%) of rural Indian children
persons go hungry. In Sub Saharan Africa the condition is are underweight. A staggering 2.2 million are afflicted with
still worse; one third of the population does not get enough cretinism and 6.6 million are mildly retarded. Nutritional
food. World over, 175 m children (under five years of age) are blindness affects 7 million children in India, mainly because of
underweight. As many as two billion women and children are vitamin A deficiency.
anaemic, 250 million children suffer from xerophthalmia, two Many a challenges remain before us as far as nutritional
billion people are at risk of Iodine deficiency…; the magnitude adequacies are concerned. National programmes reflect the
of the problems related to nutritional inadequacies is colossal. concern of the government of India towards the problem and is a
Interventions by India way to bridge this inadequacy. Various nutritional programmes
have been conceived over the past five decades with an aim of
Over the past five decades India has been able to achieve self
improving the nutritional state of our country. These have met
sufficiency in food production, through various interventions.
with reasonable degree of success. A brief outline of some of
Green revolution brought about an exponential increase in
the more important programmes is given here.
agricultural production, laying the foundation of self sufficiency.
The government of India launched and improved the Public Direct Interventions : The Nutritional
Distribution System, thereby facilitating the easy accessibility
of food grains to the common masses at an affordable price.
Programmes
The various nutritional programmes are being run by different
Research in the field of nutrition was strengthened with the
ministries. These programmes are listed below :
augmentation of the ICMR governed National Institute of
Nutrition (NIN) at Hyderabad and the CFTRI at Mysore. In this Ministry of Social Welfare
series of events, various direct interventions were introduced ●● ICDS programme
through National Nutritional Programmes in the late 1960s and ●● Balwadi nutrition programme
early 1970s. In addition certain interventions were inherently ●● Special Nutrition programme
built up within other (non nutritional) programmes to improve Ministry of Health and Family Welfare
the nutritional status of community. ●● Prophylaxis against nutritional anaemia

• 778 •
●● Vitamin A prophylaxis programme mg elemental iron and 250 microgram folic acid for 100 days.
●● Iodine Deficiency Disorders Control programme Adolescents will be provided the same dose as that for adults.
Ministry of Education Adolescent girls will be given priority.
●● Mid Day Meal programme The distribution of the tablets is carried out through the Primary
Balwadi Nutrition Programme Health Centres, MCH Centers in Urban areas and the ICDS.
The Balwadi Nutrition Programme was initiated in 1970 by Critique : It is generally agreed that the programme has failed
the Ministry of Social Welfare. It was meant for the children to make any impact on the anaemia scene in the country. The
from rural areas, in the 3 to 6 years age group. It was run incidence of anaemia has hardly changed over the past decade,
through Balwadis. Meals were provided to the children with an as is clear from the comparison of figures from NHFS II and
aim of catering for 300 Kcal and 10 to12 g protein per day for III. Some of the important causes of the poor outcome of this
each child. The Balwadis had also endeavored to provide pre- programme are summarized in Box - 1.
primary education to the children.
Box - 1 : Causes of Poor Outcome of National Nutritional
Special Nutrition Programme
Anaemia Prophylaxis Programme
Special Nutrition Programme was also started in 1970 by the
Ministry of Social Welfare. This programme was operational in Poor perception of the problem (of anaemia) by the
the urban slums and tribal areas in addition to the rural areas. population.
It had a wider scope than the Balwadi Nutrition Programme Inadequate outreach of target population.
as it not only benefited children from 1 to 6 years but also the
Poor compliance.
pregnant women. It provided supplementary nutrition for 300
days in a year. Children obtained food, providing 300 Kcal and Medicine supply & stocks inadequate and poor quality.
10 to 12 g protein. Pregnant women were provided with food Knowledge of functionaries and beneficiaries poor.
supplementing 500kcal and 25 g protein. This programme has
slowly been merged with the ICDS in most of the states. No attention given to educational and training components
of programme.
Applied Nutrition Programme
The Applied Nutrition Programme was introduced as a pilot Evaluation system not implemented.
project in Orissa in 1963, which was extended later to other
states. It had focused on production of more vegetables and Achieving Control of Iron Deficiency : The following actions
fruits and ensuring their consumption by children, pregnant are required to achieve control of iron deficiency :
and lactating women. Nutritional education was also a thrust 1. Better appreciation of the problem by the community and
area. Kitchen gardening, poultry, bee-keeping etc. were also care givers.
encouraged. 2. Better organisation of primary health services to effectively
render iron supplementation.
National Nutritional Anaemia Prophylaxis 3. Strengthening of the supplementation programme.
Programme 4. Nutrition education with respect to Do’s and Dont’s of iron
The programme for Prophylaxis against nutritional anaemia was nurtures.
started in the year 1970, during the fourth 5-year plan (1969- 5. Development of suitable fortificant and its effective
74) by the Ministry of Health and Family Welfare to prevent implementation.
nutritional anaemia in mothers and children. Distribution of 6. Active involvement of medical community especially the
the Iron-Folic Acid tablet (IFA tablets) to pregnant women and nutritionists, haematologists, internists, paediatricians,
children under 12 years of age is an important component of obstetricians and community medicine specialists to
this programme. combat iron deficiency.
Doses and Formulations : Women (pregnant, lactating and 7. Joint action by the Government, NGOs, medical and
family planning acceptors) are given one tablet of iron and folic biomedical scientists, agriculturists and planners.
acid containing 100mg elemental iron and 0.5mg folic acid. 8. Using biotechnology for enhancing iron and ferritin
Children in the age group of 1 to 5 years are given one tablet contents of foods like soyabean and other seeds.
iron containing 20 mg elemental iron (60 mg ferrous sulphate) The experience from other countries teaches that long term
and 0.1mg folic acid daily for a period of 100 days. Recently measures for control of anaemia are more effective. The most
(2007) the government of India recommended that infants (6- promising intervention is fortification of food items with
12 months should also be included in the programme and a iron over long periods. These food items can be as varied as
liquid formulation must be incorporated for children for easy salt, sugar, milk, cereals, etc. India has already perfected the
dispensing for children between 6-60 months. Dispersible technology of double fortification of salt with iodine and iron.
tablets must also be used, which are easy to use under the Nutrition education is also another long term measure that is
‘programme conditions’. likely to change the face of anaemia if followed well.
There is another recent recommendation to include school National Programme for Prophylaxis against Blindness
children (6 to 10 years of age) and adolescents (11 to 18 years in Children due to Vitamin A Deficiency
of age) also in the programme. Children will be provided 30 The deficiency of Vitamin A continues to be a public health

• 779 •
problem in India. Many surveys indicate the prevalence of 2005 under the PFA Act, to be effective from mid 2006.
Bitots spots to be higher than 0.5% and night blindness in the The quality control of iodized salt is also important. Testing
range of 0.7-2%. The solution is to supplement oral vitamin A kits for spot qualitative analysis of iodine in salt have been
to children. Vitamin A Prophylaxis Programme was started by developed. The iodine content of salt at production and
the Ministry of Health and Family Welfare in 1970 with this consumption levels should be 30 and 15 ppm respectively.
aim. National Institute of Nutrition (NIN), Hyderabad rendered Iodized salt has been introduced in the public distribution
the necessary technical assistance. system of most of the states.
The aim of the programme was to decrease prevalence of IDD Monitoring : Continuous monitoring of the IDD status is
Vitamin A deficiency form the current 0.7% to less than 0.3%. vital to observe the progression of the condition. This is carried
The 10th five year plan had set a target to eliminate vitamin A out through various surveys. Iodine in salt and urinary iodine
deficiency as a public health problem and decrease prevalence excretion are also monitored. IDD monitoring laboratories
of night blindness to below 1% and Bitots spots to less than have been established at district levels in 17 states. A national
0.5% in children of 6 months to 6 years of age. reference laboratory has been set up at National Institute of
Dosage : Under this programme a total of 9 lakh IU of Retinol Communicable Disease at New Delhi.
palmitate is administered orally in 5 doses. The first dose of Manpower Training : Various institutions run courses for
1 lac IU is given at 9 months, starting along with the measles manpower training in various facets of IDD control. Workers
vaccine followed by the second dose at 15 months of 2 lakh IU. are trained in goiter survey methodology and laboratory
This is followed by another 3 doses of 2 lakh IU at 6 monthly technology with respect to iodine level monitoring in urine and
intervals, till the age of 3 years (ie 1 lakh IU at 9 months and salt, etc.
2,00,000 IU each at 15 to18,24,30 and 36 months of age).
Health Education and IEC Activities : Government provides
Implementation : The vitamin A doses are being administered fund to run IEC campaign to increase awareness on consumption
by Anganwadi workers under the supervision of ANM. of iodized salt intake. Endemic districts are under operation of
The programme is being implemented through the RCH IEC activities through 268 units of Directorate of Field Publicity.
programme. Doordarshan is also used for IEC campaigns. Global IDD
Critique : This programme has significantly contributed to day is celebrated on 21st Oct. The misconceptions regarding
our endeavour of elimination of Vitamin A deficiency in India. consumption of iodized salt are also managed through the IEC
The morbidity has steadily declined. Integration of vitamin A campaign.
administration with RCH and immunization programme has Critique : It was conceived that universal iodization of salt
made it logistically much simpler and practical to implement. will root out IDD. But that has not really happened, even
Some episodes of deaths of children following vitamin A intake after a decade of ‘universal iodization’. It is primarily because
has brought the programme to disrepute. There is however no of the fact that we have not been able to achieve universal
scientific explanation of mortality even after administration of immunization, which was the main pillar of the programme.
double the recommended dose of vitamin A. The media must The priorities and policies of the state governments have been
refrain from sensationalizing these news stories without solid varying, and in the bargain the iodization status of salt suffers,
scientific evidence. The health community too, must counter it compromising the programme. There is a ban on the sale of
through health education campaigns. un-iodized salt but the same has to be ensured through various
Iodine Deficiency Disorders (IDD) Control Programme administrative mechanisms of respective states.
National Goitre Control Programme was launched in 1962. The allocation of funds is very small in comparison to other
In1992 the programme was renamed as National Iodine national programmes, since the priority attributed to it is
Deficiency Disorders Control Programme. The components of lower. There have been ‘roadblocks’ in the transportation of
the programme are : salt through the railways. These administrative problems have
a) To conduct surveys to establish magnitude of the problem to be sorted to enable a smooth programme. Cost of iodized
b) Provision of Iodized salt salt too is a constraint for poor society in India. Only a strong
c) IDD monitoring and committed political and bureaucratic will could help the
d) Manpower training programme succeed.
e) Health Education (IEC) activities Midday Meal Programme
Surveys : Surveys have proved beyond doubt that it is not only It was Madras Presidency in the year 1923 that started the
the Sub Himalayan Goiter belt but almost all states of India concept of providing cooked meals to children studying in
are endemic for IDD. More than 200 million people are living corporation schools of Madras city. It was expanded to a larger
at risk of IDD. scale in 1961, thus India became one of the first countries
Provision of iodized salt : The orders on banning sale of non- to have started the Midday Meal Programme, then called as
iodized salt have not been consistent over the past few decades. the School Lunch Programme. Other states also joined in
The exact policy on ban has been fluctuating. Moreover it was and programmes run by Gujarat and Kerala are also widely
at the convenience of the states to implement the order. As a acclaimed. In 2001, a landmark decision was given by the
result some states have been following a strict ban and others honourable Supreme Court of India, which made it mandatory
not. The Ministry of Health and Family Welfare again issued a for all government primary schools to provide cooked meals.
notification banning the sale of non-iodized salt in November The primary aim of the programme was to provide at least

• 780 •
one nourishing meal to the school going children per day. The This programme has a major nutritional component :
objectives were : ●● Supplementary nutrition to children below 06 years of age,
●● It served as an incentive for the children to attend school. nursing and pregnant mothers from low income families.
●● To reduce dropouts from school. ●● Nutrition and health education to all women in age group
●● To improve the nutritional status of the child of 15 - 45 years.
There are certain additional advantages of the programme ●● Referral of serious cases of malnutrition or illness to
too. It also serves as an opportunity to impart basic health / hospitals.
nutritional education to children. Moreover some local women Services : The Scheme provides many services in an integrated
get employment to cook food for the mid day meal. manner through community-based workers and helpers. The
It must be remembered that the programme provides a services are provided at a centre called the ‘Anganwadi’. The
supplement, and not a substitute to the food eaten at home. Anganwadi, literally a courtyard play centre, is a childcare
This meal provides one third the total daily energy requirement centre, located within the village. A package of following six
and half the need of proteins (300Kcal and 8-12 g of proteins). services is provided under the ICDS Scheme :
The central government (Ministry of Education) supplies the 1. Supplementary nutrition
full quota of grains to the states. Food that could be cooked 2. Non-formal pre-school education
easily, available locally and at low cost is preferable. To avoid 3. Immunization
monotony it is desirable to change the menu frequently. 4 Health Check-up
Critique : The mid day meal concept was a noble one as it 5. Referral services
primarily serves the underprivileged rural primary children. 6. Nutrition and Health Education
The sustainability of the programme however depends on the The three services namely immunization, health check-up and
political will, community participation and prudent running referral are delivered through public health infrastructure i.e.
of the programme. The programme has to be saved from ill- the Sub Centres, PHCs and CHCs under the MoHFW.
publicity which it sometimes attracts through news of food-
poisonings associated with the programme. The standards can Target Groups & Service Provider
be improved through a sustained improvement of quality of Services Target Group Services Provider
service.
Anganwadi
Integrated Child Development Services (ICDS) Children below 6
Supplementary Workers (AWW)
years; pregnant and
The Integrated child development program (ICDS) was initiated Nutrition & Anganwadi
lactating mothers
by the government of India on 2nd October 1975 by the Helper (AWH)
Ministry of Social Welfare. It is the world’s largest early child Children below 6
development program. It was initially started in 33 blocks Immunization* years; pregnant and ANM/MO
(1975) but now it encompasses 6500 blocks, employing more lactating mothers
than 6 lakh Anganwadi Workers (AWW) and equal number of
helpers. It is providing its outreach services to 33.2 million Children below 6
Health Check-
children and 6.2 million pregnant and lactating women. It years; pregnant and ANM/MO/AWW
ups*
is an inter-sectoral programme which seeks to directly reach lactating mothers
out to children, below six years, especially from vulnerable Children below 6
and remote areas and provide early childhood education, Referral years; pregnant and AWW/ANM/MO
health and nutrition along with the care of the women in the lactating mothers
reproductive age group (women of 15-45 years, pregnant and Pre-School
lactating women). Currently, services under the scheme are Children 3-6 years AWW
Education
being provided to about 562.18 lakh beneficiaries, comprising
of about 467.18 lakh children (0-6 years) and about 95 lakh Nutrition & Women (15-
AWW/ANM/MO
pregnant and lactating mothers through a network of about Health Education 45 years)
7.48 lakh Anganwadi Centres. * AWW assists ANM in identifying & mobilizing the target group to health-

Objectives of ICDS : centres

1. Lay the foundation for proper psychological development

Supplementary Nutrition : This includes supplementary
of the child
feeding and growth monitoring; and prophylaxis against
2. Improve nutritional & health status of children 0-6 years
vitamin A deficiency and control of nutritional anaemia. All
3. Reduce incidence of mortality, morbidity, malnutrition and
families in the community are surveyed, to identify children
school drop-outs
below the age of six and pregnant and nursing mothers. They
4. Enhance the capability of the mother and family to look
avail of supplementary feeding support for 300 days in a year.
after the health, nutritional and development needs of the
By providing supplementary feeding, the Anganwadi attempts
child
to bridge the protein energy gap for the beneficiaries.
5. Achieve effective coordination of policy and implementation
among various departments to promote child development Growth Monitoring and nutrition surveillance are two important
activities that are undertaken. Children below the age of three

• 781 •
years are weighed once a month and children 3-6 years of age ICDS Staff : Anganwadi Worker, a lady selected from the local
are weighed every quarter. Weight-for-age growth cards are community, is a community based frontline voluntary worker
maintained for all children below six years. This helps to detect of the ICDS Programme. She is also an agent of social change,
growth faltering and helps in assessing nutritional status. mobilizing community support for better care of young children,
Besides, severely malnourished children are given special girls and women. She is assisted by Anganwadi helpers. She
supplementary feeding and referred to health sub-centres, reports to the supervisor. Child Development Project Officers
PHCs as and when required. (CDPOs) and District Programme Officers (DPOs) are the officers
Supplementary Nutrition Norms : Nutritional supplements directing the programme within a block. Besides the Medical
are provided to the extent indicated in Table - 1. Officers, the Lady Health Visitors (LHVs) and Auxiliary Nurse
Midwife and Female Health Workers from nearby Primary
Table - 1 Health Centres (PHCs) and Sub-Centres work in an integrated
manner with the ICDS functionaries to provide health, medical,
Calories Protein immunization and referral services.
Beneficiaries
(cal) (g)
Administration of the Scheme
Children below 3 years 300 8-10 Location : The administrative unit for the location of ICDS
Children 3-6 years 300 8-10 Project is the Community Development Blocks in rural areas,
Severely malnourished Children on tribal blocks in tribal areas and ward(s) or slums in urban
600 16-20 areas. For the purpose of working out the estimated number
medical advice after health check-up
of beneficiaries, a rural/urban Project is assumed to have a
Pregnant & Lactating (P&L) Mothers 500 20-25 population of 1 lakh and tribal project 35,000. One Anganwadi
Centre normally caters to 1000 population in a rural/urban
Non Formal Pre-School Education : This component for the
project and 700 population in a tribal project.
three-to six years old children in the Anganwadi is directed
towards providing and ensuring a natural, joyful and stimulating Sparsely populated hilly/desert areas : There is provision
environment, with emphasis on necessary inputs for optimal for setting up an Anganwadi in every village or hamlet having
growth and development. The early learning component of the a population of 300 or more sparsely populated hilly/desert
ICDS is a significant input for providing a sound foundation areas. Very small villages/ hamlets with a population of less
for cumulative lifelong learning and development. It also than 300 are covered by the adjoining Anganwadi.
contributes to providing the child the necessary preparation Finances : ICDS is a centrally-sponsored Scheme implemented
for primary schooling and offering substitute care to younger through the State Governments/UT Administrations with 100%
siblings. financial assistance for inputs other than supplementary
Immunization : Immunization services are delivered by the nutrition which the States were to provide out of their own
Ministry of Health and Family Welfare under its Reproductive resources. From 2005-06, it has been decided to extend support
Child Health (RCH) programme. The ICDS only tends to facilitate to States up to 50% of the financial norms or 50% of expenditure
these services through a reiteration of the family to attend the incurred by them on supplementary nutrition, whichever is
immunization clinic at the relevant centre. In addition, the Iron less.
and Vitamin “A” Supplementation to children and pregnant Mini-AWCs : Mini-Anganwadis can be set up to cover the
women is also facilitated. remote and low populated hamlets/ villages in tribal blocks
Health Check-ups : This includes health care of children less having a population between150 to 300.
than six years of age, antenatal care of expectant mothers and Anganwadi Workers : Anganwadi Workers (AWWs) and Helpers
postnatal care of nursing mothers. These services are provided (AWHs) are “honorary workers” from the local community who
by the ANM/ Medical Officers from Sub-Centres and Primary come forward to render their services, on part-time basis, in
Health Centres. The various health services include regular the area of child care and development. Anganwadi Workers
health check-ups, immunization, management of malnutrition, & Helpers are the grass roots functionaries to implement the
treatment of diarrhoea, de-worming and distribution of basic ICDS Scheme. AWWs & Helpers, being honorary workers, are
medicines etc. paid a monthly honoraria as decided by the Government from
Referral Services : During health check-ups and growth time to time. At present the AWW get about Rs 938 to1063
monitoring, sick or malnourished children, in need of prompt (depending on qualification and experience) and AWH gets
medical attention, are referred to the Primary Health Centre Rs. 500 per month as honorarium.
etc. The Anganwadi worker has also been oriented to detect Critique : The ICDS programme has largely been a successful
disabilities in young children. endeavour of the government of India. Given the very large
Nutrition and Health Education : Nutrition and Health scope of the beneficiaries (about 6 crores) and about 15 lakh
Education is a also an important element of the work of the AWW and AWH working in extremely diverse environs of states
Anganwadi worker. This enables women in the age group with varied ideologies, diverse terrains and constraints, there
of 15-45 years to look after their own health, nutrition and has to be criticism of the scheme in some quarters. The aim of
development needs as well as that of their children and families the scheme was to reduce the incidence of mortality, morbidity,
in a better way. malnutrition and school dropouts, which has been achieved to
a great extent. There is a criticism that the beneficiaries only

• 782 •
visit the centre only during the meal timings. But provision of the scheme.
nutrition too has been an objective of the programme. Infant Short Notes : (1) Mid day meal programme (2) Anganwadi
Mortality Rate (IMR) has declined from 110 in 1981 to 58 per worker (3) Iodized salt (4) Services under National Nutritional
thousand live birth in 2004. Similarly, under-5 mortality has Anaemia Prophylaxis Programme (5) Supplementary Nutrition
declined from 161 in 1983 to 87 in 2003. Various surveys have under ICDS
revealed that there has been significant impact of the scheme.
MCQs
Many non-monetary benefits like insurance, incentives,
preference in other jobs (teachers) have been given to the 1. Mid day meal programme offers (a) Half of daily protein
AWW and AWH. There is certainly a scope of enhancing the and one third of calorie requirement (b) Half of daily
honorarium offered to these grass root workers. protein and half of calorie requirement (c) One third daily
protein and half of calorie requirement (d) One third of
Summary daily protein and one third of calorie requirement.
After independence the government of India took many 2. To a child under 3 years of age, ICDS provides : (a) 300
initiatives to ensure food security for the country. National Kcal energy and 8-10 g protein (b) 300 Kcal energy and
nutritional programmes were a firm step in that direction. 16-20 g protein (c) 500 Kcal energy and 8-10 g protein
Ministry of Social Welfare runs the ICDS programme, Balwadi (d) 500 Kcal energy and 16-20 g protein.
nutrition programme and special nutrition programme. 3. In rural areas, the administrative unit for the location
Ministry of Health and Family Welfare runs the programmes of ICDS Project is (a) Gram Panchayat (b) Community
for prophylaxis against nutritional anaemia, vitamin A Development Blocks (c) District head quarter (d) Primary
prophylaxis programme and the iodine deficiency disorders Health Centre.
control programme. The mid day meal programme is run by 4. Which of the following is not run by the Ministry of
the Ministry of Education. The programmes have achieved Health and Family Welfare (a) Prophylaxis against
improvement in the nutritional status of the children, pregnant nutritional anaemia (b) Vitamin A prophylaxis programme
and lactating women. More specifically the ICDS programme (c) Iodine Deficiency Disorders Control programme
that has a strong nutritional component can be termed as a (d) ICDS Programme.
successful programme. 5. Which of these is not carried out at the Anganwadi centre
(a) Supplementary nutrition (b) Non-formal pre-school
Study Exercises education (c) Immunization (d) Nutrition and Health
Long Question : What are the objectives of the ICDS scheme? Education.
Discuss the benefits offered to various vulnerable groups under Answers : (1) a; (2) a; (3) a; (4) b; (5) c.

materials at a large administrative level e.g. at the national

Nutritional Assessment and
136 Surveillance of a Community
level.
Various methods are available for the assessment of nutritional
status. These are enumerated in Box - 1. These can be further
Rajul K Gupta sub-classified into direct and indirect methods of nutritional
status assessment.

Assessment of Nutritional Status of Box - 1 : ABCD… of Nutritional Status Assessment

Individuals and Communities
Anthropometry
Aims of Assessment of Nutritional Status
The assessment of nutritional status is carried out with the Biochemical & lab methods
following aims :
Clinical assessment
●● To map out distribution and geography of nutritional
disorders Diet survey
●● To identify high risk groups with respect to nutritional
vulnerability Ecological studies
●● To assess various epidemiological factors for nutritional
deficiencies Functional assessment
●● Make recommendations to rectify shortcomings leading to
G - - Vital statistics
nutritional deficiencies
●● To project for financial allocations and budget for food

• 783 •
Direct Assessment of Nutritional Status disease process. Biochemical changes, on the other hand can
The term ‘direct assessment’ refers to methods in which be expected to take place prior to clinical manifestations. Hence
individuals or communities are investigated directly. The tests that can be conducted on easily accessible body fluids
various methods that are available for the direct assessment (blood and urine), can help to detect disease at a sub-clinical
are summarized in Box - 2. level even in a community setting.

Box - 2 : Direct Assessment of Nutritional Status Table - 1 : Signs ‘strongly suggestive’ of dietary deficiency
or excess
Clinical signs
Suggested nutrient
Laboratory Tests Deficiency Sign
abnormality
●● Biochemical
Pale conjunctiva Iron
●● Haematological
●● Parasitological Bitot’s spots Vitamin A
Biophysical Methods Angular stomatitis Riboflavin
Anthropometry Spongy, bleeding gums Vitamin C
Bilateral edema (young children) PEM
Assessment of Nutritional Status using Clinical Signs :
Thyroid enlargement Iodine
Clinical examination is a widely practiced direct method to
assess the nutritional status of individuals and communities. Bilateral epiphyseal enlargement Vitamin D
Assessment of clinical signs is based on the examination for of wrists
changes believed to be related to inadequate or excessive Suggested nutrient
nutritional intake, that can be observed in superficial tissues Sign of Excess
abnormality
(skin, eyes, hair, mouth) or in organs close to the surface
(thyroid, skull). Mottled enamel Fluoride
Caution with Clinical Examination : The cheapness and Dental caries Sugar
the relatively easy organization of clinical examination
for nutritional assessment, might sometimes lead to the Available laboratory tests : Three groups of laboratory tests
assumption that the method is simple, can be quickly mastered are available, namely, haematological tests, parasitological
by a beginner, and yield results that are quick to interpret. But tests and biochemical tests. The haematological tests include
this is not the case. This method has got its own limitations, the commonly done hemoglobin estimation, parasitological
advantages and disadvantages. Expertise is required to select tests would include stool examination for intestinal parasites
it as a valid method in a given situation, to conduct it and to and biochemical tests include many tests like the urine
interpret the results obtained. examination for albumin, sugar, etc. Advanced biochemical
test are taken up for vitamin, minerals and enzyme estimations
Classification of Clinical Signs : Based on their importance as well, that indicate nutritional status. Normal range of some
with regard to suggesting a nutritional etiology the clinical of these tests is given in Table - 2.
signs can be classified into three groups (1) :
Assessment of Nutritional Status through Anthropometry :
Group 1 - Potentially Nutritionally Significant (Signs Nutritional anthropometry is the measurement of human body
‘strongly suggestive’ of dietary deficiency or excess) : at various ages and levels of nutritional status. It is based on
Some signs are strongly suggestive of a particular nutritional the principle that appropriate measurements should reflect
deficiency or excess e.g. Bitot’s spots (Vitamin A), Flag sign any morphological variation occurring due to a significant
(PEM). A list of these is summarized in Table - 1. functional physiological change. For example, a low Fat Fold
Group 2 - Signs that are of probable nutritional significance Thickness reflects a shift in energy balance. The advantages
: There are some signs that are of uncertain nutritional of anthropometry are that it is simple, quick to do, easy to
significance. These have to be appreciated and interpreted in reproduce and objective. In some cases it identifies even
correlation with the case. e.g. Xanthomata eye might indicate subclinical changes resulting from nutritional variations.
high blood cholesterol, Corneal scar (previous infection, trauma, Common Methods of Anthropometry : The common
malnutrition, avitaminosis A), Fissure tongue, recession of anthropometric methods should be quick, simple and easy to
gums, transverse ridging of nails, etc. reproduce. Minimum training should be required to conduct
Group 3 - Signs that have no nutritional significance : the measurement. The commonly used methods are : Height;
These signs are not nutritionally significant but required to Crown-heel length and standing height; body weight, mid
be differentiated from other nutritionally relevant signs. e.g. upper arm circumference; and fat fold thickness. Head and
pterygium (an insignificant sign) is to be differentiated from chest circumference are measured for children under five years
Bitot’s spots, geographic tongue, pyorrhea. of age.
Assessment of Nutritional Status using Biochemical and Body Weight : Body weight is the commonest and simplest
Laboratory Methods : We have seen previously that clinical anthropometric measure used for the evaluation of nutritional
signs are often non specific and develop rather late in the status. It is a reflection of total body mass comprising of all

• 784 •
body constituents. It is measured for both children and adults. affected by long standing nutritional deprivation. A short or
Definite body weight standards are available to us. Body weight retarded height is thus indicative of chronic food insufficiency
is an indicator of ‘current’ nutritional status of the individual, over a longer duration, unlike a reduced weight which indicates
as weight fluctuates with nutrition. Unlike height which is a short term nutritional deprivation or infection.
irreversible, it reflects the nutrition state of the present day.
It is therefore a useful indicator for acute disorders. Small Box - 3 : Precautions while measuring weight
illnesses like childhood diarrhoea is also good enough to alter
Use the right balance. Avoid bathroom scales.
the weight, it is thus a sensitive indicator.
Weight must be taken in minimum clothing.
Measurement of Weight : The ideal weighing instrument is the
lever actuated balance or a beam balance. The balance must Remove shoes before weight is recorded.
have a least count of not more than 100g. Balances using a The zero-error must be checked and corrected before using
‘spring’ are not advisable as the spring loses its tension due a machine.
to prolonged use and an error is inevitable. Commonly used
It is advisable to record weight in the morning (in basal
bathroom scales are based on the ‘spring’ principle, thus they
conditions)
must be best avoided for scientific work. The balance which
is in use must be calibrated frequently for best results. The These precautions must be applicable in a standardized
precautions to be taken while measuring weight are given in manner for all subjects (within a study group)
the Box - 3.
Measurement of Height : In young children, height is referred to
Height : Height is an indicator of the linear growth of the
as length or Crown-heel length in young children who cannot
individual. It is widely accepted that height is determined
stand with ease (say up to 2 years of age). An infantometer
genetically. Environmental factors, most importantly nutrition
is use to measure their recumbent ‘length’ (in lying position).
and morbidity determine the extent to which the genetic
In adults and older children, the height is measured using a
potential will be harnessed, to achieve the maximum possible
vertical measuring rod, the Anthropometric rod.
height. Growth retardation resulting from any environmental
factors like infections, malnutrition, etc. result in a retarded The subject should remove his shoes and stand erect. He must
height, resulting in stunting (or short stature). Height is keep his heels together and toes apart. He must look straight.

Table - 2 : Normal range of some biochemical tests (2)

Nutrient Test Normal (Acceptable) Low (Medium risk) Deficient (high risk)
Albumin (g/100ml)
Serum levels >3.5 2.8-3.4 <2.8
for age 6-17 yrs
Vitamin A (μg/dl) Serum levels >30 20-30 <20
Vitamin D (ng/ml) Serum levels
of 25-Hydroxy >10 05-10 <5
cholecalciferol
Vitamin E Ratio of serum
>0.8
vitamin/total lipids
Vitamin K *PIVKAS accumulation If PIVKAS accumulates
Prothrombin time Delayed **
Thiamin 100μg/24 hrs or 65μg/g
Urinary thiamin
creatinine
Riboflavin Urinary Riboflavin 80μg/g creatinine
Niacin 2-Pyridone to NI-methyl
1 to 4 <1
nicotinamide ratio
Vitamin B6 Vitamin B6 urinary
<20μg/g creatinine
excretion
Pyridoxic acid excretion <0.5mg/day
Folic Acid Serum folate (ng/ml) >6.0 3.0-5.9 <3
RBC Folate (ng/ml) >160 140-159 <140
Vitamin B12 Serum B12 (pg/ml) <80
Ascorbic acid Plasma (mg/dl) >15 08/15/09 <8
* PIVKAS: Protein Induced by Vitamin K Absence. ** Prothrombin time is a functional test

• 785 •
He stands against the anthropometric rod kept at his back, physiological, nutritional and health status of the individual.
placed perpendicular to the ground. The investigator standing Anthropometric Measurement of Body Fat : Fat fold thickness
to the left holds the subject’s chin with his left hand and the
Anthropometric measurement of body fat can be carried out
occiput with the right little finger in the Frankfurt horizontal
at various subcutaneous sites. These sites are commonly
plane (an imaginary line joining the tragus of the ear to the
undertaken : Two sites on the trunk namely sub scapular and
eye). The moving head piece of the anthropometric rod is
supra-iliac and three sites on the extremities namely triceps,
brought down and placed on the head with little pressure, in the
thighs and mid calf. Biceps fat fold is also done. The fat fold
saggital plane. The reading is taken. Average of three readings
thickness at triceps is the most sensitive (to socioeconomic
is recorded. The disadvantage of height as a measure of
changes) and most reliable (indicator of obesity).
nutritional status is that it doesn’t indicate present nutritional
status of the individual, but indicates only the past history of Fat fold at triceps is the commonest measure. It is carried
a chronic disease. out at the dorsal side at the same mid point where MUAC is
measured. The skin fold is picked up between the thumb and the
Mid-Upper Arm Circumference (MUAC) : Mid-upper arm
forefinger 1 cm above the midpoint, taking care not to include
circumference indicates the muscle development. Since poor
the underlying muscle. The tips of the skin fold calipers must
muscle development is seen in PEM, the lower MUAC indicates
be applied at the mid point at a depth equal to the skin fold.
poor nutrition. MUAC correlates well with weight, weight for
The skin fold is held gently in the left hand throughout the
height and clinical signs of malnutrition. It can be used to
measurement. Average of two measurements must be taken.
calculate the mid arm muscle circumference using a simple
formula, if the value of fat fold at triceps is also estimated Head and Chest Circumference : Head and chest circumferences
simultaneously. The mid calf circumference can also be used are measures used in children. A neonate is born with a bigger
instead of MUAC. head. The chest grows faster than the head in a normally
nourished child in the 2nd and 3rd years of life. As a result, the
The mid-upper arm circumference is measured on the non-
chest circumference overtakes the head by about 1 year of age.
dominant arm (left arm in case of right handed subjects and
In a child suffering from PEM, the chest grows at a lower rate
vice-versa) of the subject. The mid point between the tip of the
and it remains smaller than the head even till 2 ½ to 3 years of
acromion (of scapula) and olecranon process of ulna is located
age. This indicates a poor state of nutrition.
with the arm flexed at the elbow. It should be marked with a pen.
The arm is now held hanging freely by the side of the subject Head and chest circumferences are measured using a fiberglass
and a fiberglass tape is placed gently but firmly embracing the tape. Head circumference is taken at the supraorbital ridges
arm without ‘squeezing’ the soft tissue, at the point marked in of the frontal bone (just above the eyes) in front and the
pen. The reading is taken to the nearest millimeter. most protruding point of the occiput in the back. The chest
circumference is taken at the level of the nipples in mid
Interpretation : The usefulness of MUAC is based on the
inspiration.
principle that MUAC remains almost constant between 1 to 5
years of age (increasing only approx 1.5 cm between 1 and Classification of Nutritional Status Based on Anthropometric
5 years of age). Thus fair degree of standardization can be Parameters
achieved even if the age is not known in a preschool child. A Weight for age : There are standard weights laid down for a
cut off point of 12.5 cm is taken. MUAC of less than 12.5 cm particular age. Thus a given child’s weight (for his particular
is taken as low. To make the procedure of measurement even age), is compared to the ‘standard’ weight of a ‘normal’ child.
simpler and usable at the grassroot level, Shakir introduced This standard is taken as per the 50th centile of the Boston
a simple tricoloured tape in 1975, called as the Shakir’s tape. standard. The Gomez classification is one of the commonest
The red colour in the tape (which fell in the less than 12.5 cm classifications used to classify malnourishment into various
zone) marked Danger, yellow or white colour, fell in 12.5-14 cm grades.
zone marked Caution and green colour more than 14.0 cm is
Weight of child
considered as OK or normal. Weight for age(%) = X 100
Weight of 'normal child' of same age
MUAC can be used as an efficient technique for screening large
population of children for malnutrition. Children thus screened, The grades as per Gomez classification are given in Table - 3.
can be subjected to further anthropometric measurements
and other (Clinical/biochemical) tests for specific nutritional Table - 3 : Gomez Classification
deficiencies.
The biggest advantage of using the MUAC is that it is easy to Malnutrition grade Weight/Age (%) of normal
conduct and it is age independent till about 5 years of age.
A modified tape (Shakir’s Tape) can be used easily even by a Normal >90%
village health worker.
Grade I (Mild) 75 – 89 %
Body Fat : Body Fat indicates reserve of energy in the body.
The quantity of fat present subcutaneously at various sites Grade II (Moderate) 60 – 74 %
indicates the gross nutritional status of the person. The
thickness of fat can be correlated to the body content of fat. Grade III (Severe) < 60 %
Fat distribution in and around the body varies with age, sex,

• 786 •
The Indian Academy of Paediatrics (IAP) classification on the Table-6:Grades of obesity based on BMI (WHO, 1998) (3)
other hand puts the degree of malnutrition into four grades
(Table - 4). This classification is used by the ICDS in India. Risk of co-
BMI Classification
morbidities
Table - 4 : Indian Academy of Paediatrics (IAP) < 18.5 Underweight Low
Classification 18.5-24.9 Healthy/normal weight Average
Malnutrition grade Weight/Age (%) of normal 25 – 29.9 Pre-obese (Overweight) Mildly increased
Normal > 80% 30 – 34.9 Obesity Class I Moderate
I Grade 70-80% 35 - 39.9 Obesity Class II Severe
II Grade 60-70% > 40 Obesity Class III Very severe
III Grade 50-60%
IV Grade <50% The guidelines have been revised and made more stringent
lately for Asians, considering the fact that Asians (esp.
Weight for height : The weight for height classification doesn’t South East Asians including Indians) are more susceptible to
take age into consideration. Weight is also related to height. metabolic syndrome. These are summarized in Table - 7.
Many a times age is not known. Weight for height is an age
independent parameter. It is a good prognostic indicator of Table - 7 : Grades of obesity for Asians (5)
severe PEM and an index of current nutritional status. Weight BMI Classification Risk of co-morbidities
for height of less than 80% of normal is considered to indicate
< 18.5 Underweight Low
wasting in preschool children.
18.5-23 Normal weight Increasing but acceptable
Wasting and Stunting : In the Waterlow classification weight
for height and height for age are used to classify children as 23 – 27.5 Pre-obese Increased
normal, wasted, stunted and wasted and stunted. Children >27.5 Obese High
with low weight for height are considered as wasted and those
with low height are ‘stunted’ (Table - 5). Dietary Assessment for Nutritional Status
A nutritional survey is never complete without a diet survey.
Table - 5 : Wasting and Stunting - Waterlow
We may be able to find out that there is a nutritional deficit
classification
through clinical, laboratory or anthropometric methods, but
Weight for Height Nutritional in order to find out if this nutritional deficiency is because of
Interpretation
height for age status diet and which particular diet/nutrient, we have to invariably
Normal Normal Normal Normal resort to a diet survey. It is thus an integral part of nutritional
survey. A diet survey objectively defines importance of diet in
Low Normal Wasted Acute malnutrition various health state and disease (2). Diet survey is nothing but
Normal Low Stunted Nutritional dwarf the scientific assessment of food consumption, and using this
Low Low Wasted and Acute on Chronic data for various purposes including assessment of nutritional
stunted malnutrition status.
Methods : Various methods are there to undertake diet
Body Mass Index (BMI) : Body Mass Index (BMI) is the ratio of surveys. These are appropriate in different settings (6) and are
weight in Kg to square of height in metre. summarized in the Box - 4.
Mass (Kg)
BMI = Box - 4 : Methods of Diet survey
Height (m)
2

It gives an indication of the nutritional status, esp. obesity. Food balance sheet method
Now-a-days in context of lifestyle diseases, BMI is taken as an Inventory method
indicator of risk of cardiovascular diseases as well.
Weighment method
BMI does not measure the body fat but relates well with the
degree of obesity. The categories of obesity as pronounced by 24 hr Recall method (Questionnaire method)
the WHO are depicted in Table - 6. A BMI of 25-30 is considered Dietary score method
as a warning sign and may warrant intervention, especially in
Food Frequency Questionnaire method
the presence of additional risk factors. A BMI of 30 or higher is
generally considered the point at which some form of treatment Duplicate sample (chemical analysis) method
is required. Obesity Class III i.e. BMI >40 or morbid obesity, is
a medical condition that impairs a person’s overall health and Diet Balance Sheet Method : This method is used when
therefore requires medical attention. information regarding availability and consumption of food is
required at a macro level like at the global, national, region or
state levels. The total food supplies available and used up at a

• 787 •
given level are taken into account in this method. Effectively The method : Weigh the raw food before cooking. It is
the difference between receipt (of food various sources) and preferable to weigh the food again after cooking. A conversion
expenditure over a given period of time gives the food consumed factor is arrived at. For example let’s assume that the weight
by population. The consumption per capita/day is worked out of raw rice is 100 g. The weight of cooked rice becomes 400g.
as : Thus a conversion factor of 100/400 or ¼ is arrived at. In other
words 1 g cooked rice represents 1/4 g of raw rice. Or if a person
Food consumed by population eats 400g cooked rice it is equivalent to 100g of raw rice. The
Mid yr pop x 365 nutrient contents of raw rice are extracted from standard Food
Composition Tables. The same process is employed to estimate
These figures are used for various types of planning and
the nutrient contents of all food preparations.
budgeting, namely plans for agriculture, fertilizers, productions,
imports and Public Distribution System (PDS). The method Ideally both, raw and cooked foods must be weighed. But if
has got certain demerits. It is a gross method. Secondly the it is not possible to weigh the cooked foods an approximate
consumption of rich and poor is equated and averaged out conversion factor can be taken. Obviously this will lead to
when this method is used. It gives the consumption pattern but some degree of error. Another alternative is to measure the
doesn’t include purchasing power of the individual. volumes of raw and cooked foods and subject them to weight
conversions. In practice measuring volumes of cooked portions
Inventory Method : As mentioned earlier the inventory method
actually eaten by the individuals is easier than weighing the
is carried out at an institutional level, on a homogenous group
portions eaten. The volumes can be converted into weights
as present in a hostel, jail, mess, army barrack, orphanage etc.
and subsequently into nutrients, through standard tables. The
It is essentially done from books. Amounts of various food
merits of this method are that it accounts for the non edible
stuffs available as per records are taken into consideration. The
parts of food as well. The wastage is also taken into account.
balance of various food items is again checked after a reference
This method is more accurate than the inventory method. The
point of say 7 days (one week).
demerit is that it is a very cumbersome, time consuming and
Individual consumption / day = tedious process as it involves weighing of all foods.
24 hour Recall (or Questionnaire) Method : The 24 recall
Stocks at beginning of week - Stocks at end of week (questionnaire) method is a relatively easy method based on
No. of individuals x No. of days the recall capabilities of the individual over a period of the past
24 hours. Since it is a short term retrospective method it is
The Merits are that it is fast, much easier, less cumbersome and more prone to errors.
faster than the weighment methods. It is also fairly accurate. It
A set of cups and ladles standardized for volume are used. The
may not indicate an accurate individual food consumption but
housewife is asked about the types of food items prepared at the
is fairly satisfactory for the purposes of planning.
time of breakfast, lunch and dinner. The raw ingredients used
The Demerits are that it doesn’t account for wastage. Secondly, for cooking each meal are noted. The cups are exhibited to the
it gives only the mean individual consumption but actual housewife. The cooked food items are noted in terms of these
individual consumption is not reflected. Thirdly, the estimates cups. The intake of each food item by the specific individual in
are as good as the food records made available. Lastly, the the family is also assessed by using these cups.
results will be affected if the subjects are eating some food
The method is fairly accurate. It take lesser time than the
stuff obtained from any source other than the common kitchen
weighment method. However, the disadvantage is that the
under question.
method is based on recall capability of the respondent so there
Weighment Method : In this method the foods are actually is a likelihood of ‘inaccurate recall’ and error in derivation of
weighed using a grocer’s balance. Both raw and cooked food nutrients. A fair degree of cooperation is to be sought from the
are weighed. In community surveys (at a family level), the raw respondent. The process is a cumbersome.
food is weighed rather than the cooked food, since weighing
Food Frequency Questionnaire (FFQ) Method : Food frequency
cooked food is not acceptable to the families. In an institution
questionnaire (FFQ) method is based on the principle as to how
however, the cooked food can also be weighed, since cooking is
frequently an item is consumed over a period of time. It is an
carried out at a central kitchen. While using weighment method
epidemiological technique used to study the meal patterns and
at a family level the following points are important :
dietary habits of people. It can be used to assess the specific
1. Convince the housewife of the need of the survey for the dietary intakes during pregnancy, lactation, etc. It can even be
benefit of the family conducted through post. For example a FFQ may read “In one
2. Avoid holidays/fares/festivals/feasts as the dietary practice week how often do you consume the following items….”
of these days does not reflect the actual dietary practices.
3. It should be carried out for 3 to 7 days consecutively. Item Frequency (Consumption Per Week)
4. At least two visits a day for lunch and dinner have to be Meat 1 2 3 4…..
made. GLV 1 2 3 4…..
5. Two investigators should be available - one talks and Sprouts 1 2 3 4……
weighs and the other records observations.
6. Any pets, breast fed children, guests etc. should be This filled up questionnaire is then analysed, using pre-decided
considered. values of for nutrients for different food items.

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Nutritional Surveillance Purpose of surveillance Data source
It is clear from the earlier chapters that the state of nutrition Health and development Household survey
of an individual or a community depends on a variety of planning
(unrelated) factors. These could be as diverse as the ‘health’
of the crops, state of rainfall, GDP, per capita income, efficiency Data from records Programme management
of the public distribution system, availability of food and the and evaluation
health state of the community. Interviews and records Timely warning and
Given this dynamic and ever changing state of availability and intervention programme
use of food, it is vital to keeping a constant watch over all these Rainfall, prices, employment Health system surveys
factors concerning nutrition, in order to continuously assess
the situation, give an early warning and take appropriate ●● Define food supply system. The food can be obtained
decisions that will lead to improvement in the nutritional mobilizing the existing stores, through national and
status of population. This on-going process of constant international aid, improving the agricultural production,
scrutiny of the nutritional situation and factors influencing etc.
them and its application in the public health interest is termed ●● Obtain the data, analyse and provide feedback to decision
as nutritional surveillance. The word was used first in 1974 makers. Finally, evaluate the nutritional surveillance
with respect to drought relief, during a World conference in system.
nutrition. A nutrition surveillance programme was developed
Nutritional Rehabilitation
for the developing countries 1976. The term has been used
extensively by the UNO since 1980. The process of nutritional The cases of severe malnutrition are treated in a hospital
surveillance finds the following applications : setting. Such a treatment no doubt, does make the child
survive; it doesn’t guarantee that he will live a life free of
a) It provides inputs for health and development planning
malnutrition and disease in future. Besides only medical,
b) It is useful for programme management and evaluation
additional inputs like those of social, physical, psychological
c) It provides timely warning and intervention to prevent
and emotional rehabilitation have to go in, if the child is to live
(short term) food consumption crisis and plan for long
a life of positive health.
term action
Principle : More often than not it is seen that after a short spell
Steps : The various steps of nutritional surveillance are :
in the hospital, once the child returns back to the original social
a) Identify community/population
milieu, the condition recurs. The child either dies or becomes
b) Data collection
extremely vulnerable to subsequent infections, malnutrition,
c) Data transit
disease and death. The basic principle of nutritionally
d) Data processing
rehabilitating a child is not only to treat his malnutrition and
e) Interpretation
related acute complications, but to prevent a recurrence of the
f) Responses and Planning
condition.
g) Improvement
h) Further implementation Methods : The process of rehabilitation is to be dove-tailed
with treatment. It can be undertaken at three levels, depending
Methodology of Nutritional Surveillance : The methodology of
on the severity of the condition and the facilities available.
the nutritional surveillance can be outlined through answering
the following basic questions : (a) Hospital : The child is hospitalized in severe cases or when
●● What is the problem? → Define & describe the type of he has concomitant complications. Special standardized dietary
nutritional problem e.g. malnutrition (acute or chronic), regimes (intensive feeding with high proteins and energy dense
micronutrient deficiency, etc. diets) are required to be instituted and continued for a long
●● Who is at risk? → Describe the population groups affected time to come. Systematic education of parents in food selection
by area, socioeconomic status, biological/physiological and cooking has also to be imparted. The standardized dietary
status, etc. regimes and specific nutritional education It is initiated in the
●● Why is this population at risk? → Identify the causal factors. hospital but is required to be followed up either at the day care
These causes could be immediate (non availability of food, centre or at home.
poor health, etc) or of long standing nature like unequal (b) Day Care Centre : A day care facility is an intermediate
resource distribution, poor sanitation and infections. arrangement between the hospital and home. Children who are
●● Where to get the data from? → Identify the data sources. not required to be admitted to a hospital or those who have
These will depend on the purpose for which surveillance been discharged from the hospital are expected to visit the
has been undertaken. day care centre. This centre may be run by a health worker
who is trained in preparation of special feeds for malnourished
children and who could educate the mothers on preparation
of special feeds suitable to the particular child (as discussed
in last paragraph). Any health facility like an anganwadi
centre, sub-centre or a PHC can be used as a day care centre.
The advantage of a day care centre (over hospital) is that it

• 789 •
is cheaper; the mother can spend the day at the centre under of acute malnourishment. This can be achieved through
supervision of a trained health worker, learn sufficient skills appropriate measures begun at the hospital. Subsequently the
in specialized feeding and child-craft, in an informal setting, child may be managed at a day care centre or at home.
closest to her home environment and really imbibe it.
Study Exercises
(c) Domiciliary : In case the child is not severely affected, after
medical consultation, he can be treated at home. He could also Long Questions : (1) Enumerate the various methods for
be one who has been weaned off a hospital or a day care set- nutritional assessment. Describe any one in detail. (2) What is
up. To maintain health of child it is important that the mother nutritional surveillance? Outline the methodology of nutritional
is trained in handling the ‘special’ nutritional needs of this surveillance. (3) What are the various anthropometric
child. techniques available to assess nutritional status of a 5 year
old child? How can weight for age be useful to ascertain
Summary malnutrition in this child?
The condition of the body resulting from intake, absorption Short Notes : (1) Mid Upper Arm Circumference (2) 24 hour
and utilization of food and the effect of pathological factors is recall method (3) FFQ (4) Using BMI to assess CED in adults
termed as nutritional status. (5) Disadvantages of using clinical signs for nutritional status
Nutritional status is assessed too map out distribution and assessment
geography of nutritional disorders, identify high risk groups MCQs
and to assess various epidemiological factors for responsible 1. All can indicate nutritional status except : (a) Fall in weight
for nutritional deficiencies. It is also an administrative tool (b) Falling hair (c) Failure to gain height (d) Flag sign
used to allocate budget for food materials at a large scale. 2. All are signs of PEM except (a) Flag sign (b) Unilateral
The important methods are anthropometry, biochemical and pedal edema (c) Low weight for age (d) Dermatoses
laboratory methods, clinical assessment, diet survey, ecological 3. Stunting is __________ weight for height but _________
studies, functional assessment and indirect assessment from height for age : (a) Normal; Low (b) Low; Normal (c) Low; Low
vital statistics data. (d) High; low
There are clinical signs that may be ‘strongly suggestive’ of 4. Acute malnutrition may be indicated by : (a) Stunting
dietary deficiency or excess (e.g. Bitot’s spots), of probable (b) Wasting (c) Stunting and wasting (d) All of the above
significance (e.g. corneal scar) and those that are of no 5. Which of these is not true for nutritional surveillance :
nutritional significance (e.g. pterygium). Clinical signs might (a) It is an ongoing process (b) It can be used as a nutritional
develop rather late and are subjective and non specific. survey technique (c) It is a close scrutiny of events related
Biochemical tests on the other hand give objective and to nutritional changes (d) It provides timely warning for
quantitative indication of nutritional status, but these are action
costly and instrument intensive. Match the following
Anthropometry remains the sheet anchor of nutritional
Age Suitable anthropometric measure
assessment. Weight, height, head and chest circumference,
MUAC and fat fold thickness are the common anthropometric 6. New born (a) MUAC
parameters used. Many derived parameters like the BMI, 7. 3 years (b) Weight
weight for age, weight for height, etc are also used in different
situations. 8. 42 years (c) BMI

Various methods of diet survey are used to ascertain as to what 9. 8 years (d) Head & chest circumference
an individual or a group of people are eating. This indicates 10. 1 ½ years (e) Weight for age
the deficiency of nutrients in the diet and thus appropriate
measures can be suggested to improve it. The main methods Answers : (1) b; (2) b; (3) a; (4) b; (5) b; (6) b; (7) a; (8) c;
Food balance sheet method are inventory method, weighment (9) e; (10) d.
method, 24 hour recall method (Questionnaire method), dietary
score method, food frequency questionnaire method and References
1. Jelliffe DB, Jelliffe EFP. Community Nutritional Assessment. Oxford University
duplicate sample (chemical analysis) method. The inventory Press. 1989.
method, weighment method and 24 hour recall method are the 2. Bamji MS, Rao NP, Reddy V. Textbook of Human Nutrition. 2nd ed. Oxford &
most commonly used dietary survey methods. IBH Publishing Co Pvt Ltd, New Delhi. 2003.
3. World Health Organization, 1998. Obesity. Prevention and managing the
Nutritional Surveillance is an on-going process to keep a global epidemic. Report of the WHO Consultation on obesity. WHO, Geneva.
constant watch over all the nutrition related factors, in order to 4. Based on James WPT, ferro-Luizzi, Waterlow JC. Definition of chronic energy
continuously assess the situation, give an early warning and deficiency in adults—Report on working party of the intervention dietar
energyconsultation group. Am J Clin Nutr., 42; 969-981,1988.
take appropriate actions. 5. Astrup A. Obesity. In : Human Nutrition, Editors : Geissler C, Powers H,2005,
Nutritional Rehabilitation aims at re-establishing the severely 380-395.
6. Thimmayamma BVS, Rao P. Diet Survey Methods. ICMR. National Institute
malnourished child medically, nutritionally and psychologically of Nutrition, Hyderabad.
into the family and society. The aim is to prevent a recurrence

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 Food Processing, Food Box - 1: Some Common Food Processing Techniques
Adulteration, Food Additives, Peeling and skinning (fruits and vegetables)
137 Preservatives, Food Toxicants Mincing (meat)
and Food Fortification Liquefaction (fruit juice)
Fermentation (Soy, beer, cocoa)
Baking (cakes, pastries, bread)
Rajul K Gupta
Sprouting (cereals, pulses)
Food Processing Steaming (rice)
Food processing is the technique used to transform raw Boiling (vegetables)
ingredients into food or to transform food into other forms Carbonation (beer, soft drinks)
for consumption. It can be done either at home or by the food
Packaging (most commercial foods)
processing industry.
Aim of Food Processing : Food processing is aimed at Canning (juices, fruits, fish)
improving the colour, appearance, palatability, taste, texture, Sauce and ketchups (tomato)
keeping quality and marketability of food. Food processing Brewing (tea)
makes the food attractive and many a times makes it a long-life
food product. Foods used in certain special situations can not Chopping or slicing (vegetables)
be used without processing. Some of these situations can be Pureeing (vegetables and fruits)
space travel, high altitude expeditions, disaster aid situations,
Pickling (vegetables)
combat missions by soldiers, etc. Some common food processing
techniques are enumerated in Box-1. Emulsification
Processing helps to remove toxins, eases marketing and Cooking (most foods)
distribution of foods. In addition, it increases seasonal Frying (French fries, pakories)
availability of many foods, enables transportation of delicate
Grilling (chicken)
perishable foods across long distances and makes many kinds
of foods safe to eat by de-activating spoilage and pathogenic Pasteurization (milk)
micro-organisms. Food processing techniques are also used Spray drying (milk powder)
to add extra nutrients such as minerals and vitamins to food
preparations. Dehydration (fish, vegetables, soup powders)

Disadvantages of Food Processing : Food processing can Jam and jelly (fruit, vegetables)
sometimes lower the nutritional value of foods. Some vitamins Wines and ciders
are very sensitive to heat and are lost on cooking (e.g. vitamin Freeze drying (meat)
C). Some water soluble vitamins can be lost on washing with
water. Food additives such as colours, flavouring agents
and preservatives, used while processing the foods, may be Box - 2 : Some Commonly Used Food Additives (Emulsifiers,
unhealthy. Some are known to be allergic or even carcinogenic. Stabilizers, Thickeners and Gelling Agents) * (1)
Processed foods (like junk foods) often have a higher ratio of Name Food
calories to other essential nutrients than unprocessed foods,
Lecithins Chocolates, margarine, potato snacks
and may provide empty calories. Processing also increases the
prices of food products. Citric Acid Pickles, dairy products, baked products
Food Additives Tartaric Acids Baking powder
The concept of adding “non-food” substances to food products Alginic Acid Ice creams, desserts
is not new. Pickling preserves the food articles such as mango, Agar Ice cream, soups, tinned ham
lime etc. for fairly long periods by the addition of salt and spices.
Salt and spices were the traditionally used food additives. Gums Ice creams, soups, confectionery
These can be considered as natural additives. Pectin Jellies
With industrialization, increasing demand of ‘ready to eat * A list of antioxidants and preservatives is given in the next
food’ and use of modern techniques, the food processing section
industry is relying heavily on chemical additives. The food
additives improve taste, flavour, texture and colour. They also Definition : Food additives are the non-nutritious substances
help increase the shelf-life of food. Now a days majority of the added intentionally to food, generally in small quantity, to
processed foods contain some food additive or the other. Some improve the basic properties of food like its appearance, flavour,
commonly used food additives are enumerated in Box - 2. texture etc.

• 791 •
Food additives can be classified into the following two broad c) Preserving the appearance, colour and texture of food
categories : Methods of Food Preservation : Preservatives are centuries
1. Additives deliberately added to food old. Since ancient times, salt has been used to make pickles,
a) Colouring agents e.g. saffron, turmeric. cure meats and fish. Sugar has also been added to fruits to
b) Flavouring agents e.g. vanilla essence conserve them. Herbs, spices and vinegar have also served as
c) Sweeteners e.g. saccharin, cyclamate preservatives for centuries. These early preservatives (sugar
d) Preservatives e.g sorbic acid, sodium benzoate (details and salt) produce food environments of high osmotic pressure
given in next section) that deny bacteria the conditions needed by them to propagate.
e) Acidity imparting agents e.g. acetic acid etc. Jams and jellies are preserved as solutions of high sugar
f) Thickening Agents e.g. alginate (from seaweed) and casein content.
used in ice creams, cheese, yogurt etc. The Modern Day Preservatives could either be natural or
g) Emulsifiers: Keep water and oil mixed together. e.g. lecithin, synthetic.
monoglycerides and diglycerides are used in margarine, Natural Food Preservation : As discussed earlier salt and
baked goods and ice cream. sugar are the commonest natural preservatives. Another group
h) Anti-Oxidants : Prevent spoilage, flavor changes, and of natural preservatives target enzymes in fruits and vegetables
loss of color caused by exposure to air e.g. Vitamin C and that continue to metabolize even after they are cut. For instance
Vitamin E. lemon juice contains citric and ascorbic acids which inhibit the
These are generally considered safe for human consumption. action of enzyme phenolase that turns cut surfaces of apples
However, certain preservatives such as nitrites and nitrates can and potatoes brown.
lead to the production of toxic substances, e.g. nitrosamines Anti-Oxidants : Anti-Oxidants not only preserve foods through
that have been implicated in cancer etiology. preventing spoilage but also limit flavour changes and loss
2. Contaminants : They get incorporated incidentally through of colour caused by exposure to air. Vitamin C and Vitamin E
packing, processing, farming practices (insecticides) or other are used as antioxidants. Other antioxidant preservatives are
environmental contaminants. compounds like BHA (Butylated Hydroxyanisole).
Provisions of Law Applicable to Food Additives : The use Anti-microbial Preservatives : Anti-microbial preservatives
of food additives is subjected to government regulations inhibit the growth of microbes. Benzoic acid, sulfur dioxide and
throughout the world. In India two regulations viz. the ethanol have long been used as preservatives. Other common
Prevention of Food Adulteration Act (PFA Act) and the Food anti-microbial preservatives are calcium propionate, sodium
Products Order are in vogue. The PFA Act has been discussed nitrate, sodium nitrite, sulphites, sulphur di-oxide, sodium
separately. Use of food additives that are not permitted by law bisulphite, potassium hydrogen sulphite, disodium EDTA.
is considered to be an adulterant. In case the quantity of the Microbes as preservatives : All microorganisms are not
food additive exceeds the permissible limit then also the food harmful. Some microbes are responsible for the production and
is considered adulterated. It is also required by law that the preservation of certain foods. Microbial action is a part of the
nature and quantity of the additive shall be clearly printed production of cheese and flavouring agents. Sauerkraut is both
on the label that is affixed to the container. Whenever any processed and preserved by lactobacilli. Yeast cells ferment
extraneous colouring agent is added to a food article, the words sugars, producing alcohol and help to preserve them.
‘Artificially Coloured’ shall be printed on the label.
Irradiation: Food irradiation using radioactive rays or high-
At the international level, FAO/WHO have established the intensity X-rays or streams of electrons is a modern method
Codex Alimentarius Commission as its principal organ. of food preservation. It has the advantage of preserving food
Protection of the health of consumers is the primary aim of while in their packets. There is minimal person-to-food contact
this commission. reducing the possibility of contamination. Food is not required
Food Preservatives to be exposed to chemical preservatives which may be harmful.
It is not possible to consume food immediately on production Irradiation extends the shelf lives of foods such as strawberries,
as we don’t have access to farm fresh food all the time. If we potatoes, onions, grains, etc. Irradiation does not make foods
can’t consume the food quick enough, the food tends to get radioactive, but may cause changes in food colour or texture.
spoilt. As soon as a food is harvested or cooked, the process Some commonly used food chemical preservatives are
of food spoilage sets in. The enzymes and other chemicals enumerated in Box - 3.
(e.g. acids and alcohols) present in foods initiate the process Health Concerns on Food Preservatives : There have been
of deterioration. Micro-organisms (bacteria and fungi) are the health concerns with many chemical additives like colouring
prime agents that cause spoilage under suitable conditions. and flavouring agents. Preservatives are also not untouched
Environmental factors like heat and humidity enhance the with these fears. Some modern synthetic preservatives have
process of spoilage. Once spoilt the food no more remains fit become controversial because they have been shown to cause
for consumption and may lose its original nutritive properties respiratory or other health problems. Sulfur dioxide (often
as well. Preserving food therefore becomes imperative. used to preserve wines) is irritating to the bronchial tubes of
Preservation is undertaken with the following aims: persons who have asthma, and nitrites have been implicated
a) Increasing the keeping quality of food as carcinogens. Some preservatives are known to cause allergic
b) Preserving its nutritional characteristics reactions including anaphylactoid reactions.

• 792 •
 been developed at the National Institute of India, Hyderabad
Box - 3 : Commonly Used Food Preservatives (1)
in India for the twin fortification of salt with iodine and iron.
Preservative Food Some initiatives taken by the Government of India on food
Antioxidants fortification are given in Box - 4.
Ascorbic acid Beer, soft drinks, fruits, meat, powdered
milk Box - 4 : Some Facts on Fortification - Initiatives by the
Government of India
Tocopherols Vegetable oils
Wheat flour (atta) : In February 1970, the Government of
Gallates Vegetable oils, fats, margarine India launched a programme in Bombay for fortification
BHA and BHT Fats, margarine in baked products of atta with vitamins and minerals, and for increasing the
protein content by admixture with edible groundnut flour.
Other Preservatives
Edible oils: Fortification of Vanaspati (hydrogenated oil)
Sorbic Acid Cheese, yogurt, soft drinks
with vitamin A has been made compulsory (2,500 IU of
Acetic Acid Pickles, sauce vitamin A and 175 IU, vitamin D per 100 g of Vanaspati) by
Lactic Acid Sauce, confectionery the Government or India.
Propionic acid Bread, cakes, flour Common salt: Under the PFA act common salt has to be
fortified with iodine (commonly potassium iodate) in a dose
Benzoic Acid Soft drink, pickles, fruit products, jams
of 30 ppm at production site and 15 ppm at consumer end.
Sulphur dioxide Soft drinks, fruit products, beer, cider,
wine Choosing a Food Vehicle and a Fortificant : While choosing
Nitrites Cured meats, cooked meats and meat an ideal food vehicle the following aspects are considered:
products a) The food should be consumed by all population groups
that is at risk of the particular nutritional deficiency.
Nitrates Meat products, cheese
b) The food should be used regularly and in consistent
amounts by the entire population at risk.
Food Fortification
c) Taste, appearance and smell of the food should not change
Food Fortification is the process by which a nutrient is added after fortification.
to commonly eaten foods to improve the quality of the food.   d) The fortificant should remain stable under extreme
WHO has defined food fortification as “the ­process whereby conditions such as cooking, food processing, delivery and
nutrients are added to foods in relatively small quantities to storage.
maintain or improve the quality of diet of a group, a community, e) The food should not be consumed in amounts that would
or a population.” Fortification is the addition of nutrients at present a risk of consumption at toxic levels of the
levels higher than those found in the original or in comparable fortificant.
foods. The food that carries the nutrient is referred to as the f) The food should not increase the cost of food.
food vehicle; and the nutrient added is the fortificant.   Benefits of Food Fortification
Fortification of food is a public health measure aimed at a) It effectively prevents major micronutrient deficiencies at a
reinforcing the usual dietary intake of nutrients with additional small cost.
supplies to prevent/control some nutritional disorders. A food b) Fortification does not require change in the dietary habits
fortification program is usually undertaken when there is a of the population.
widespread and consistent nutritional deficit in the population’s c) It can be implemented relatively quickly and can be
diet. Food fortification has been commonly used as a method sustained over a long period of time.
to control micronutrient deficiencies. d) It being a population based approach, benefits all.
The term food enrichment is used for replacing nutrients lost e) It is a very cost-effective approach.
in processing. It occurs with grains, as some vitamins and
Food Adulteration and the Prevention of Food
minerals are lost in the milling process.
Adulteration Act (PFA)
The Need for Fortification : One of every four people in the
world suffers from micronutrient deficiencies. Globally, the Food is a substance consumed for eating or drinking (except
key micronutrient deficiencies are that of iodine, vitamin for water and drugs). Unscrupulous traders use the practice
A and iron. These vitamins and minerals are referred to of adulteration for their ulterior motives. Any material which
as micronutrients because the body needs them in minute could be used for adulteration is called as an adulterant.
quantities for normal growth and development. All these major Commonly it is believed that adding a substandard stuff to
micronutrient deficiencies can be overcome at a community level food (e.g. water to milk) is adulteration, but as per the law the
by the simple process of fortification. Some of the fortification word adulteration has a much wider connotation.
programmes of demonstrated effectiveness are: iodization of The Prevention of Food Adulteration (PFA) Act was enacted
salt for combating endemic goitre, fortification of vanaspati by the parliament in 1954. The PFA Rules were framed by an
ghee, butter and milk with vitamins A and D and fluoridation expert body called the ‘Central Committee for Food Standards’
of water to prevent dental caries. Recently, technology has in 1955. Various amendments have been made in the act since
then.

• 793 •
Objective : The PFA Act was enacted with the main objectives the shopkeeper / vendor are taken. In case the shopkeeper/
of : vendor refuses to put his signature, an independent witness
a) Ensuring pure & wholesome food is made to sign. In case the witness also refuses to sign, the
b) Protecting against fraudulent & deceptive trade practices food inspector endorses a certificate to this effect. The sample
Adulteration is divided into three parts, they are packed and sealed. The
sample number one is submitted to public analyst under
An article is deemed adulterated if ‘it is not of the nature, intimation to the local health authority (The local health
substance or quality as demanded by the purchaser; if the food authority is an officer appointed by the government through a
contains other substances that affect injuriously the nature, gazette notification to be the in charge of health administration,
substance or quality of food; if the food is substituted by an in a given area. Generally this responsibility lies with the
inferior or cheaper substance; or if any constituent of the food municipal/cantonment health administrators). The 2nd and
has been abstracted; or if it contains any poisonous ingredient, 3rd samples are kept as reserve samples and are deposited with
the food is said to be adulterated’ (PFA Act). Some common the local health authority for safe custody. Sample analysis is
food adulterants are enumerated in Box - 5. carried out by the local government public analyst. The report
is submitted to the local health authority. In case the sample
Box - 5 : Some Common Food Adulterants is found to be adulterated suitable action is taken by the court
Food Item Adulterant of law. The vendor can apply to the court, within 10 days to
Cereals Mud, grit get the reserve sample, kept in the custody of the local health
authority, analyzed at the relevant Central Food Laboratory,
Dal Kesari dal, dyes for confirmation. For the purpose of this reconfirmation four
Dhania Horse dung reference laboratories have been established and notified by
the government of India. These labs have been allocated a
Black pepper Papaya seeds
zone of responsibility and certain predefined regions/states/
Chilli Brick powder union territories are dependent on them. These laboratories are
Tea Gram husk located at Mysore, Kolkata, Pune and Ghaziabad (Box - 6).
Milk Water
Box - 6 : Central Food Laboratories (CFL) and States
Mustard seeds Prickly poppy seeds Dependent on them
Sweets Non permitted colours Central Food
Dependent states
Ghee Vanaspati Laboratory
Mysore Gujarat, Himachal Pradesh, Haryana, Punjab,
As per the PFA Act the following acts amount to adulteration UP, Maharashtra
of food:
Kolkata North Eastern states, Orissa, Andaman &
a) If any article has been prepared, packed or kept under
Nicobar
unsanitary conditions whereby it has become contaminated
or injurious. Pune AP, Delhi, J&K, Karnataka, Kerala, Rajasthan,
b) If the article is filthy, putrid, rotten, decomposed or from Tamil Nadu
a diseased animal or vegetables; or is insect infested or is Ghaziabad Bihar, Goa, MP, West Bengal
otherwise unfit for human consumption.
c) It is obtained from a diseased animal. Punishment : Following the hearing, the court awards a
d) Contains a non prescribed colouring matter or sentence to the guilty. A minimum imprisonment of 6 month
preservative. to a maximum of life imprisonment (in cases of grievous hurt
e) The mal-practices like mixing, substitution, concealing or death) can be awarded. The court may also impose a fine of
the quality, misbranding, selling decomposed food, adding Rs 1000 to Rs 5000.
toxicants, extracting food material or giving false labels
also amount to adulteration. Food Toxicants
Process : Whenever an instance of food adulteration comes Even today there is always a lurking fear that some antisocial
to the notice, a food sample is collected from the site. The elements might poison a source of water. While such acts are
sample can be collected by a government functionary like the deliberate, a toxic or poisonous substance might be present as
food inspector or even by the consumer (1986 amendment). an integral component of a foodstuff. In a small dose it may not
The consumer/purchaser can get food analyzed, provided the have any significant toxic effect, but in a larger dose or when
vendor is informed of this intent and the purchaser pays fees to consumed over a prolonged period it may even be fatal. Many
the designated laboratory to carry out the analysis. possible toxic effects of foods are known. Table - 1 indicates
Sample collection, disposal and analysis : The food inspector the great variety of ill effects that natural food poisons might
expresses his intent of collecting the sample and getting it have.
analyzed under the PFA Act to the vendor in advance. The cost
of food item (sample) is paid to the vendor. The signatures of

• 794 •
 of Neurolathyrism occurring in epidemic proportions in some
Table - 1 : Some Possible Toxic Effects of Common Foods
given regions, but now no outbreaks are reported, only sporadic
(2)
cases occur in certain areas.
Active toxic
Food stuff Effects on Lathyrus Sativus (Kesari dal) : Lathyrus sativus is also
ingredient
referred to as Teora dal, Lak dal, Batra, Matra, etc. It looks
5-Hydroxytrypta- Central or and like Arhar dal (toor dal) red gram or bengal gram. However
Some bananas mine, adrenaline, Peripheral its seeds are triangular in shape and greyish in colour. It is
noradrenalin nervous systems cheaper and a rich source of protein.
Some types In 1962 a neurotoxin, β-N-Oxayl Amino-L-Alanine (BOAA) was
Tyramine Blood Pressure
of cheese isolated from the common vetch (Vicia Sativa), which frequently
Almond, cassava Cyanide Tissue respiration grows as a weed in Lathyrus sativus. In 1963, another toxin
β-N-oxayl-L-α,β di-aminopropionic acid was isolated from the
Some fish/meat Nitrosamines Cancers seeds of Lathyrus sativus. Both of these can cause neurological
Mustard oil lesions in primates. These toxins are neuro-exitants and can be
adulterated with Sanguinarine Epidemic dropsy removed by soaking in hot water and rejecting it.
argemone oil Clinical Features : If more than 30% energy is obtained from
Kesari dal Beta Oxayl Amino Kesari dal for more than six months, the signs and symptoms
Neurolathyrism
(Lathyrus) Alanine and others may appear in the form of spastic paralysis. The condition is
known as Lathyrism. It is most commonly seen in men in the
Brassica species Glucosinolates,
Goitre age group 15-45 years. The onset of Lathyrism is sudden, often
(seeds) thiocyanate
preceded by exertion or exposure to cold. A patient may find
Gastrointestinal himself paralyzed on getting up in the morning. Sometimes
Green potato Solanine
upset backache and stiffness of legs precede the paralysis of legs.
Mushrooms The condition is spastic paralysis of lower limb.
(A muscaria, Various toxins CNS effects The underlying pathology is the toxin induced degeneration of
A phalloides) spinal motor tracts (pyramidal tracts) and sclerosis. The motor
Groundnuts Aflatoxin Aflatoxicosis nerves to muscles of trunk, upper limbs and sphincter are
spared. The sensory system is also not involved.
Lathyrus Toxin The patient may pass through progressive stages of severity. In
The ancient Indian text ‘Bhava Prakasham’ describes the the latent stage the patient may be apparently healthy. In the
Kesari dal and neurolathyrism. Hippocrates has also described mild stage there is stiffness and weakness of legs, exaggerated
it in the pre-Christian era. Lathyrus and related pulses (‘tares’) knee and ankle jerks and clonus may follow. As the disease
were poorly regarded even in the Biblical times, as is clear from progresses the gait may be affected and the patient walks with
a quote from the Bible. bent knees on tiptoe. The legs may become crossed and patient
may develop scissor gait. The patient may be able to walk
Cantani coined the term lathyrism in Italy. In India too Lathyrus
only with one stick and later with two sticks. Later on when
sativus is deliberately sown with wheat in the dry districts. If
paraplegia develops, walking may become impossible. Later
the rains are good, wheat overgrows the lathyrus (and it is not
the patient has to support his body on his hands, buttocks and
harvested), but if rain fails and there is poor crop of wheat, a
heels for moving about (crawling stage). In the most severe
reasonable crop of lathyrus is reaped. Lathyrus is a tasty and
stage patient can only move on ‘all fours’, supported by his
high protein pulse. If eaten in small quantities it probably does
hands. Many patients might be left with no other alternative
not cause toxicity. If consumed in larger amounts (providing
but to resort to beggary.
more than 50% of energy) a severe disease of the nervous
system may result, leading to spastic paralysis. Some landlords Detection of Toxin : The toxin can be detected through
(zamindars) used to pay their labourers in kind, the form of laboratory methods using the ninhydrin reaction, which
Kesari dal and not in cash. In this situation Kesari dal used gives a purple colour. Electrophoresis and biological methods
to become the staple diet for these poor people and a cause of (bioassay in animals) can also be used.
neurolathyrism. Neurolathyrism is a crippling disease of the Prevention : The condition is preventable if pulse is removed
nervous system characterized by gradually developing spastic from diet, at the earliest. Use of the legislation of Prevention of
paralysis in lower limbs, occurring mostly in those consuming Food Adulteration act to limit the consumption of crop must be
a pulse, Lathyrus sativus in large quantities. In animals a encouraged. In case the crop has to be consumed, the toxin can
variant of the disease i.e. osteolathyrism affecting skeletal be removed by steeping. At the household level, steeping can
system is seen. be done by soaking the pulse in hot water for 2 hours. Water
The disease is seen in some European, African and Asian is then drained and pulse is dried in sun. The disadvantage of
countries. Cases are reported from Spain, Algeria, Ethiopia, using this method is that the taste and nutrients are lost to an
Mexico, Afghanistan and India. In India it is seen in some extent. At a large scale, parboiling can be done. The process
districts of Madhya Pradesh, Maharashtra, UP, Bihar, Rajasthan, is the same as used for parboiling rice. Soaking the pulse
Assam and Gujarat. Old literature reports thousands of cases overnight in lime water and subsequently boiling or cooking it

• 795 •
also helps in removing the toxin. produces alkaloids of the clavine group that has milder toxicity
High dose vitamin C (1000 mg/day) prophylaxis for few weeks than ergotamine. Claviceps fusiformis infestation leads to
is also found to be useful. Nutritional education in the form nausea, vomiting, abdominal cramps and drowsiness. The
of abstaining from the use of crop or using it in the manner recovery is usually complete.
prescribed above would be useful in preventing the consumption Fusarium
of toxic crops. Bringing about social changes in the form of Fusarium incamantum is another field fungus affecting crops
improving the socioeconomic status would also help people not like sorghum, rice and maize. It is seen in the subtropical
to fall prey to the toxic dal. and temperate regions. The fungus produces toxins like
Aflatoxicosis deoxynivalenol and fumonisin which are responsible for certain
The first known outbreak of Aflatoxicosis probably occurred clinical symptoms like vomiting and diarrhoea. The episodes of
in England in 1960, among young turkeys. Turkeys fed on mouldy ragi poisoning in India (1929) and Alimentary Toxic
infested groundnut meal had hepatitis and enteritis. The Aleukia (haemorrhagic rash, bleeding nose, leucopenia) seen in
groundnuts concerned were harvested, stored and processed in Russia during the Second World War were due to fusarium.
high humidity conditions. The toxic effects were produced by Detection of Mycotoxins : Many sophisticated methods
a fungus Aspergillus flavus, a mould contaminating the nuts. are available for the detection of Mycotoxins. Thin Layer
Human cases have not been rare since then. Chromatography (TLC), Radio-immuno Assay (RIA) and ELISA
Causative Agent : Aspergillus flavus or another species tests are available. Several rapid kits are also available for
Aspergillus parasiticus are storage fungi that affects foods in detection of aflatoxicosis, etc.
poor storage conditions of high temperature (30-37°C) and high Prevention : Four broad groups of steps should be taken (3):
humidity, as is common in the rainy season and during floods 1. Plant Breeding : Cultivating varieties of rye, bajra, millets,
and cyclones. and wheat resistant to disease (ergotism) can radically
Foods Infested : The fungus Infests improperly stored foods minimize the problem.
like maize, groundnut, soya, sorghum, rice, wheat, sunflower, 2. Good agricultural practices during pre and post harvest
tree nuts, spices and even milk and cheese. period : Good pre-harvest agricultural practices like avoiding
Toxins : Brightly fluorescing furanocoumarin compounds water stress, minimizing insect infestation, are effective in
known as the ‘aflatoxins’ are known to be responsible for reducing aflatoxin contamination in groundnuts and maize.
the condition. Aflatoxin B1 is the most potent known natural Good post harvest and storage conditions for grains and nuts
hepatocarcinogen. Another toxin Aflatoxin G1 is also known. are also of paramount importance. These foods must be stored
They are known to cause hepatitis (jaundice), ascitis, portal under ideal humidity and temperature conditions. Appropriate
hypertension, liver cirrhosis and hepatocellular carcinoma. drying, storage and reducing the chances of moisture entry
Ergotism in the stores also limit the probability of contamination with
storage fungi. If contamination does occur the infested grains
While aflatoxicosis is a storage fungus, Claviceps fusiformis can be removed using the floatation method in which the grain
and Claviceps purpura are field fungi. Crops get infested in is allowed to float in 20% salt water. The infested grains floats
flowering or seeding stages. Bajra, rice, sorghum, wheat and and can be easily removed. Air floatation and hand picking
rye get commonly affected. Ergotamine is the toxin responsible techniques can also be used.
for the clinical symptoms of nausea, vomiting, abdominal
cramps, muscular cramps, giddiness, burning, itching and 3. Detoxification : Ammonia process is being used to detoxify
gangrene of digits and limbs. aflatoxin affected groundnuts and remove the mycotoxin. The
detoxified product is available only for animal feeds and is not
Epidemics of aflatoxicosis were known as St. Anthony’s fire in suitable for human consumption.
France in the 11th century. The disease was referred to as ‘fire’
because of the intolerable burning pain in the limbs, which 4. Health Education: The community must be educated about
became black and shriveled (gangrenous) and eventually the ill effects of the conditions and the importance of the
dropped off. The legend also goes to say that the condition preventive measures described above.
used to improve when the patients visited the St Anthony’s Epidemic Dropsy
shrine located a distance away. The patients probably improved Several cases of epidemic dropsy were reported from many states
because of the discontinuation of consumption of ergot affected of India as recently as in the year 1996. Similar outbreaks have
cereals, as they shifted to the new location (of the shrine). been occurring off and on in the past as well. It was discovered
Epidemics were common in many European countries like by Indian scientists in the early twentieth century that the
Germany, Poland, England and Russia till the late eighteenth condition is attributable to contamination of mustard oil with
century, when it was related to the consumption of fungus argemone oil. Subsequently the toxic alkaloid sanguinarine
(Claviceps purpura) infested rye. Besides the symptoms was isolated from argemone oil and was chemically analysed.
enumerated above, convulsions, palsies and discordant It was also determined that sanguinarine interferes with the
movements were also known, indicating the affliction of the oxidation of pyruvic acid, which is responsible for the dropsy.
nervous system. The Claviceps fusiformis infestation of bajra The Prickly poppy plant grows indiscriminately and wild in
in India is a milder clinical entity as compared to the more India. It has large prickly leaves and bright yellow flowers
severe classical European variant described above. This fungus (some species have white flowers as well). Argemone mexicana

• 796 •
is the species most commonly incriminated. The argemone Food Fortification is the process whereby nutrients are added
seeds closely resemble mustard seeds. They mature with the to foods in relatively small quantities to maintain or improve
mustard crop and may be harvested together. Argemone seeds the quality of diet of a group, a community, or a population.
(or oil) can be mixed with mustard to deliberately adulterate it. Addition of iodine to salt is the most well known example of
The contamination may sometimes be accidental. fortification.
Clinical Features : As the name suggests, the patient gets Study Exercises
generalized swelling manifested as bilateral pedal edema of
sudden onset. Patient may get diarrhoea. In advanced stage Long Question : What is the role of the PFA Act? Describe as
patient gets dyspnoea and signs of congestive cardiac failure to how a food sample can be obtained from a shop and how is
(CCF). If not treated death may ensue. A mortality rate of 5 to it dispatched.
50% has been reported. Short Notes : (1) Fortificant (2) Neurolathyrism (3) Common
Detection of Toxin : mycotoxins (4) Epidemic dropsy (5) Aims of food processing
(a) Nitric Acid test: When nitric acid is added to a sample of MCQs
oil, a brown orange colour emerges, indicating the presence of 1. Vanilla essence is a food : (a) Additive (b) Fortificant
argemone oil. The sensitivity of this test is low. It is positive (c) Supplement (d) Toxicant
only if at least 0.25% of argemone oil is present in the sample. 2. Which of the following is not a mycotoxin : (a) Aflatoxin
(b) Sanguinarine (c) Deoxynivalenol (d) Fumonisin
(b) Paper chromatography: Paper chromatography is a test
3. PFA Act was enacted in the year : (a) 1950 (b) 1954
with much higher sensitivity, detecting argemone oil even at
(c) 1962 (d) 1986
0.0001%.
4. _______ can take a food sample under the PFA act :
Prevention : The growth of argemone plant must be discouraged (a) Consumer (b) Health inspector(c) Anyone authorized
and the plants must be weeded out. Unscrupulous traders under the gazette (d) Any of the above
deliberately adulterating argemone oil to mustard oil must 5. _________ are not to be used for preservation of foods :
be tried under the PFA Act. Early detection and institution of (a) Irradiation (b) Bacteria (c) Antibiotics
control measures must be encouraged to limit the severity and (d) Antioxidants
further spread of morbidity. Educating and making the public Match the following
aware of the problem and likely solutions will also go a long
way in preventing the condition.
Food item Role
Summary 6. Papaya seeds (a) Flavouring agent
Food processing is the technique used to transform raw 7. Sanguinarine (b) Adulterant
ingredients into food or to transform food into other forms
for consumption. The basic aims of food processing are to 8. MSG (c) Fortificant
improve the colour, appearance, palatability, taste, texture 9. Salt (d) Toxicant
and keeping quality of food. Food processing includes various 10. Iodine (e) Vehicle
techniques like pickling, fermentation, baking, Pasteurization
and canning. Loss of nutrients (in some cases) could be a major Answers : (1) a; (2) b; (3) b; (4) d; (5) c; (6) b; (7) d; (8) a;
disadvantage of food poisoning. (9) e; (10) c.
Food additives are the non-nutritious substances added
intentionally to food, generally in small quantity, to improve References
1. Gandy JW, Madden A, Holdsworth M. Oxford handbook of nutrition and
the basic properties of food like its appearance, flavour, texture, dietetics. Oxford University Press, 2007, New Delhi
etc. Almost all processed foods contain food additives. 2. Passmore R, Eastwood MA. Human Nutrition and Dietetics. 8th ed. Churchill
Livingstone, ELBS London. 1986.
Food preservatives are used to increasing the keeping quality, 3. Bamji MS, Rao NP, Reddy V. Textbook of Human Nutrition. 2nd ed. Oxford &
preserving the nutritional characteristics, appearance, colour IBH Publishing Co Pvt Ltd, New Delhi. 2003.
and texture of food. There are few natural food preservatives
known. The synthetic ones include certain preservatives like
antioxidants and other chemicals.

• 797 •
 and so is death. Starvation and malnourishment are common.
Nutrition during Special Malnutrition leads to infection esp. in children and this vicious
Situations : Disasters, Fairs and
138 Festivals, Community Feeding of
cycle is deadly.
The effect of disaster is not the same on everyone. Vulnerability
Children of people to disaster depend on the severity and duration of
disaster, degree of preexisting poverty, failure of the population
to get timely food, aid, work and wages. In case the prevailing
Rajul K Gupta disaster conditions like conflicts continue, the recovery can not
be expected to occur. The physiological groups most vulnerable
There might be certain situations wherein nutrition assumes to the consequences of disaster in general and poor nutrition
special importance and has to be catered for in a different in particular are the young children, pregnant and lactating
manner. The resources required may be different and those women, the sick, disabled, and the elderly.
available may be limited, in that given situation. There may
The requirement of food during disaster depends on the
be many such states; few selected important situations are
number and age distribution of people, their mean heights and
discussed in this chapter.
weights, physical activity levels, environmental temperatures
Nutrition during Disaster Situations and the malnutrition and (ill) health status (1,2). The energy
requirements for disaster situation is summarised in Table - 1.
History is replete with the instances of disasters and their
inevitable implications on human nutrition. May it be the Bengal
Table - 1 : Energy requirements for disaster situation (2)
or the Irish famines (in which millions died of starvation) or
even a prolonged military conflict, it is the common population Male Female Combined
Group Age
that suffers the most and starves in extreme cases. (Kcal) (Kcal) (Kcal)
Unfortunately the epidemiology of the nutritional consequences Under 5s 0-4 1320 1250 1290
of a disaster unfolds in a pathetic manner. Irish famine can be Children 5-9 1980 1730 1860
taken as a typical example (See Box - 1).
Adolescents 10-14 2370 2040 2210
Box - 1: A Peep into the Genesis of Nutritional Problems Adolescents 15-19 2700 2120 2420
in a Disaster through the Irish Famine Adults 20-59 2460 1990 2230
It was an unassuming fungal disease, the potato blight, which Elderly > 60 2010 1780 1890
initiated the Irish famine, as “potato rotted in the ground,
there was horrible stench all over”, the poor farmers lost all Pregnant/ 285/500 285/500
and they had no money to buy food. They became idle and lactating (extra) (extra)
unemployed and out of work, since they subsisted only on the Whole 2080 (say
2250 1910
potato crop! Sanitation suffered and diseases like dysentery, population 2100)
diarrhoea and Scurvy took on. Cholera epidemics were a
common place. Due to extreme cold and wet winter of 1846, There is a general consensus that about 2100 Kcal per head
and hardly any money to buy warm clothing, typhus and should be catered for planning the energy requirements for a
relapsing fever (“Famine fever”), compounded the problems. disaster situation. Proteins must contribute to 10-12% of the
Starvation followed and millions died. They tried to migrate energy (about 52g of proteins per day). Fats must provide 17-
to the New World - America, but many died enroute in the 20% of energy (46g of fat); half from invisible sources and half
ships, some overloaded ships sank killing scores of people from visible fats (23g each). Critical micronutrients like iron,
on board. Those who reached were too rickety and miserable iodine, vitamin A and other vitamins (thiamine, niacin, vitamin
to work even in America… C) must also be provisioned for, systematically. Ensuring the
provision of locally available foods and maintaining their
Any disaster as such, leads to scarcity of food but other inevitable continuous supply would go a long way in disaster relief. At
consequences of disaster lead to disease prone conditions like times, fortified foods and pharmaceutical supplements are also
overcrowding, poor sanitation, natural vagaries, lack of water, called for. A typical food survival ration is outlined in Table-2.
and lack of health care. These multiple factors in turn, worsen
Meeting Nutritional Requirements in a Disaster
the scarcity of food and malnutrition. Starvation and epidemics
Situation
force people out of the town displacing them. There is panic
and social disruption. People become helpless and may die in Nutritional requirements in a disaster situation can be
large numbers. They might have to be moved to relief camps, effectively met through being prepared all the time for a disaster
which too are not problem free. and instituting sound interventions in the event of disaster.
1. Be Prepared … Disaster may Strike
Importance of Nutrition in Disaster
The community has to be taught to be always prepared for
Nutrition assumes extreme importance in a disaster situation
a disaster. Such preparations not only keeps the community
as food is a primary requirement for sustenance of life. Nothing
confident that they can meet the ‘unknown challenge
depletes human morale more than the non availability of food.
effectively’ but such a preparation can make the difference
Micronutrient deficiency is a reality in the absence of food,

• 798 •
 Table - 2 : Typical food survival ration (3) 2. Interventions in the event of disaster
Rapid initial assessment will have to be undertaken to ascertain
(Quantity in g based on 2100 Kcal/person/day)
the origin of nutritional problem (failure of crops, war, drought,
Ration Option Ration Option etc.), demographic profile of the affected population, baseline
Item
1 (g) 2 (g) health data, factors affecting interventions like security, water,
Rice/Wheat flour 415 430 food and potential logistics constraints e.g. transport, roads,
food supply, etc. Based on the above data the strategy for a
Pulses 45 0
particular feeding programme is chalked out. Many types of
Vegetable oil 25 25 feeding programmes are available, depending on the situation.
Groundnuts 35 35 These are outlined in Fig. - 1. Various feeding programme
strategies are described here in brief.
Canned fish 0 30
Sugar 15 15 Fig. - 1 : Feeding programme strategy (4)
Salt 5 5
Feeding programmes
Total 540 540
General food distribution Selective feeding prog
between life and death. Simple steps of storing food and water
at vantage points and regularly replenishing them are some
basic ‘preparation’ measures. The basic tips for storing water Supplementary feeding prog Therapeutic feeding prog
and food are summarised in Box - 2.
Targeted SFP
Box - 2 : Be Prepared … Disaster may Strike
Store Water Blanket SFP
●● For drinking - @ 2 lit / person / day
●● For cooking - @ 2 lit /person /day
●● At least for 3 days (2 weeks) General Food Distribution (GFD) :The aim of the general food
●● If supplies run low, don’t ration water distribution strategy is to provide food to all for a basic level
●● Don’t risk dehydration of survival. The limitations in this strategy are that the food
●● Store in a cool, dark place at home, office, vehicle might be insufficient to meet needs of all the people and the
●● Preferably in store-bought, factory-sealed water most vulnerable groups might be ignored. In any case it is a
container useful strategy esp. in the beginning of the disaster aid. It is
●● Or in washed, rinsed food-grade containers done either through supplying cooked meal as an emergency
●● Change every six months measure or distributing dry ration when the situation has
Store Food stabilized and people can cook in makeshift camps/shelters.
●● That is eaten regularly The third option could be mass feeding the population with
●● Requires no refrigeration, preparation, cooking cooked meal. The principle is to provide energy dense foods on
●● Include vitamin, mineral, protein supplements an immediate and urgent basis. 1 metric ton cereals can cater
●● Store two weeks supply for the energy requirement of 1850 males for 1 day (5).
●● Canned food can be stocked Presuming the individual consumption at a rate of 540g/
●● Stock for infants – formula feed, pacifiers, medicines
person/day, the planning figures to determine food needs
●● Wrap perishables and keep sealed
●● Empty opened packages into screw-top / airtight jars (in metric tons) has been worked out in Table - 3.
●● Avoid fatty, high protein, salty foods
Table - 3 : Planning figures to determine food needs (3)
Don’t forget
●● Can opener, disposable cups, plates, knife, sugar, salt, (Food quantity in metric tons @ 540g/person/day)
plastic bags
●● To replace water/foods at regular intervals Popu- 1 1 3 6
1 year
lation day month months months
Replace at six monthly intervals
●● Dry fruits, biscuits, infant formula 1,000 0.54 16.20 48.60 97.2 197.10

Replace at yearly intervals 5,000 2.70 81.00 243.00 486.0 985.0

●● Canned meat 10,000 5.40 162.00 486.00 972.0 1971.0
●● Vegetable soups, fruit juices
●● Jelly, butter, instant cereals, vitamins 50,000 27.0 810.00 2430.00 4860.0 9855.0
Store indefinitely 1 lakh 54.0 1620.0 4860.00 9720.0 19710.0
●● Some foods like dried corn, dry noodles instant coffee,
(Basis of calculation: Requirement in metric tons = No. of persons per day x
tea, soft drinks, vegetable oils, salt, soybean, wheat and 0.540/1000 Kg)
rice can be stored almost indefinitely.

• 799 •
It must be remembered that any food that is offered should also the prime focus of therapeutic feeding. Mothers of infants
be culturally acceptable, as close to routine food, available for with lactational failure are also given such care.
consumption in a digestible form, suitable to vulnerable groups Conclusion : It can be well appreciated that nutrition during a
and must contain adequate quantity of micronutrients. disaster situation is not merely providing a ‘feed’. But it involves
Organizing Mass Feeding : Mass feeding can be undertaken anticipating, preparing and training for disaster beforehand;
in institutions and refugee camps. Local foods should be used assessing the disaster situation in terms of impact, demography
as far as possible. The calculations for mass feeding are similar and resources; making an immaculate plan; implementing the
to the one shown above. Mass feeding must be undertaken in plan and learn from the mistakes. Infant feeding, nutrition for
enclosed areas. Public kitchens have to be established under the elderly and nutrition for pregnant and lactating women
supervision of administrators. Timings must be fixed for meals. remain special situations and need expert attention.
Distribution of cooked food can also be done through families.
Some special feeding regimes have to be thought of, for the Fairs and Festivals
elderly, infants and pregnant women (6). India is a country of fairs and festivals. There is no month that
Selective Feeding Programme : Selective feeding programme doesn’t have a festival or two. People tend to enjoy themselves
have to be undertaken for vulnerable groups. It could be a during various festivals. Fairs and community feeding are
supplementary feeding programme or therapeutic feeding integral to festivals. Fairs and festivals pose threat to public
programme. The aim of the supplementary feeding programme health as well, as people tend to congregate in large numbers
is to provide necessary nutrient supplements to the vulnerable in restricted spaces. The community is put to numerous risks;
groups like under fives children with malnutrition, pregnant these could be as diverse as stampede, heat exhaustion, heat
and lactating women. This helps prevent deterioration stroke, dehydration, infections, outbreaks, violence, terrorist
of nutritional situation through correction of moderate threats, building collapse, fire, etc. The public health aspects
malnutrition, prevention of severe malnourishment, infections pertaining to food in fairs and festivals are dealt with in brief,
like measles, pertusis, ARI, diarrhoea and chances of epidemics in the subsequent paragraphs. Mass feeding (during a festival)
and mortality (7) The planning figures for supplementary whether at the level of household or a community, poses threat
feeding for typical daily rations (with monthly totals) providing to the people. The factors that make the community more
350 Kcal, 15 g protein/person/day) are given in Table - 4. vulnerable to food borne disease during mass feeding are:
●● Large congregation of people
Table - 4 : Planning figures: Supplementary Feeding (3) ●● Compromised food hygiene
●● Scarcity of water
(Typical daily rations (with monthly totals) ●● Business interest of people that compromises basic
providing 350 Kcal, 15 g protein/person/day) hygiene
Monthly ●● Flies and other pests
Item Amount Energy Protein
Fat (g) (metric ●● Indiscriminate littering of waste and poor waste disposal
(daily) (g) (Kcal) (g)
ton) Facilities
Cereal 50 180 - 4 1.50 ●● Inadequate (hand, raw foods, utensils) washing facilities
●● Inadequate toilets and wash rooms
Veg oil 10 89 10 0 0.30 ●● Participation of unspecified food handlers
Wheat- Responsibilities of Local Health Authority
55 204 3 11 1.65
soya
It must be appreciated that the local health authority has a
Salt 5 0 0 0 0.15 major role to play in managing health during fares and festivals
Total 120 473 13 15 3.60 and ensuring proper measures to prevent disease. The local
health authority is responsible for:
Therapeutic Feeding : The aim of a therapeutic feeding a) Selecting the correct site for establishing the ‘food centre’
programme is to help in medical and nutritional treatment b) Selecting right agents/contactors providing food material
of severely malnourished children (8) This is aimed to reduce (raw and cooked)
infant and child deaths esp. because of severe PEM. Therapeutic c) Ensuring appropriate source of food
feeding provides an intensively managed, carefully balanced d) Provision of safe drinking water
medical regimen. It helps in the rehabilitation of severely e) Licensing the food shops and eateries
malnourished children. It can be undertaken at a residential f) Food hygiene and inspections
level wherein the mothers (along with the sick malnourished g) Attending to complaints
children) are admitted and treated with special focus on h) Food sampling as per the PFA act and follow up action
nutrition. An alternative approach is to take care of the i) Food and workplace safety
children in the day care centres established for this purpose. j) Control of infectious disease and prevention of food
The mothers visit such centres for day long period, get medical poisoning
attention and learn the basic skills in child nutrition, care and k) Fly and pest control
disease prevention. Besides the severely malnourished young l) Educating the community on various aspects of food
vulnerable children and adolescents, the low-birth-weight hygiene
babies, orphan infants who lack inadequate traditional care are The most common issues that must be ensured by the

• 800 •
administrators are : served
●● Adequate contingency planning and consistent procedures ●● Uncooked food apart from fruits and vegetables that can
●● Communication between management and food handlers be peeled must be avoided
●● Adequate training, information, instruction and supervision ●● Foods exposed to flies and pests must be shunned
for all Taking Care of Cleaning and Waste Management
●● Hazard analysis pertaining to feeding Clean premises will reduce the risk of contamination, avoid
●● Recognition of potentially hazardous procedures. pest infestations, provide a safe and pleasant environment to
Responsibilities of the Community work. These simple guidelines must be observed:
The local health authority might make rules and try to ●● Always keep the premises clean
enforce them, but it is the community that has to ensure ●● A cleaning schedule must be followed. Staff must be
their implementation in the right earnest, for its own benefit. nominated to clean a particular equipment or area, on a
The community must take the responsibility of adhering to given day
the rules laid down by the health authority. The community ●● Keep all chemicals locked away from food
must be aware of various aspects of food hygiene, food safety, ●● Provide suitable dustbins with lids. Ensure their regular
foods to be consumed and foods to be avoided during mass evacuation.
gatherings. The importance of flies and pests, safe drinking ●● Regularly clean refuse areas
water and basic procedures like hand washing and proper Taking Care of Drinking Water, Ice and Beverages
garbage disposal must be appreciated by the community.
It must be ensured that only clean and safe drinking water
Unhygienic and unlicensed food vendors must be shunned and
is used. The source of water must be ascertained and safety
reported against. The community must co-operate in the efforts
ensured. If in doubt do not drink that water. Bottled or
of the authorities in maintaining food hygiene.
carbonated water might be safer! Water used for recreational
Role of Food Handlers purposes (such as swimming) is often contaminated and must
The responsibility of food handlers becomes even more not be consumed.
important in the situation of fairs and festivals as they can Commercial ice must be avoided unless one is sure that it is
transmit infection to numerous people. Their responsibilities made from safe water and has not been contaminated by dirty
have been discussed in detail in the chapter on food borne hands, pests, or equipment. Ice-cream from unreliable sources
infections. Only the most salient points are repeated here. may be contaminated and cause illness. If in doubt avoid it.
To prevent food borne infections hand-washing is of utmost Beverages such as hot tea, coffee, beer, carbonated soft drinks
importance. Hands must be washed with soap and water after or fruit juices are usually safe to drink. Expiry dates and seals
visiting the toilet, handling rubbish, handling raw foods, must be checked. Avoid unpasteurised milk, cheese, paneer and
putting hand over your nose or mouth and before starting other products.
work or after taking a break. Hands must be dried with clean
towels. The nails must be clipped short; food handlers must Specific Foods
be vaccinated against common diseases esp. typhoid. If the Some food stuff must be viewed with suspicion and consumed
food handler is sick or has diarrhoea, it is best to refrain from only if one is sure of their safety, as there is a higher potential
kitchen duties. of food poisoning with them. Some of these are enumerated in
Taking Care of Food the Box - 3.
Whenever a communal feeding is planned either at home or To keep these foods safe ensure strict temperature control
at a community centre the following simple points must be during the entire course of food processing: delivery, correct
ensured: freezing, thawing, refrigeration, cooking and serving. They
must be protected from contamination (bacterial and chemical).
●● Once procured, the food must be cooked at the earliest but
The entire supply line of the food product must be traced for
closest to the time of consumption
hygiene.
●● Prepare and store raw and cooked food separately
●● Expiry date must be checked for all packed foods
Box - 3 : Suspicious foods - Consume with care!
●● Keep pets and pests away from food and food preparation
surfaces Cooked meats and poultry
●● Wash hands thoroughly before preparing food, and after Milk, cream, artificial cream, cottage cheese (paneer) custards
going to the toilet and dairy produce
●● Wash worktops and utensils
●● Avoid food containing uncooked eggs Cooked eggs and products made with fresh shelled eggs
●● Ensure food is piping hot (mayonnaise)
●● Keep hot food hot and cold food cold Fish and sea foods
●● Food handlers with diarrhoea / vomiting must be excluded Cooked rice
●● Food freshly cooked is usually safe. Eating stale food (more
than couple of hours old) constitutes greater risks of food Ice
borne disease Salads, vegetables and fruit eaten raw
●● Food has to be thoroughly cooked and must be hot when Sandwiches and filled rolls

• 801 •
Duties of Health Officers Preparing food for infants and children
Health officers have the responsibility to ensure implementation Some precautions that must be taken for preparing foods for
of laid down health policies. They inspect premises for ensuring infants and children are enumerated in Box - 4.
hygiene, correct cooking practices, storage and distribution of
food, etc. They undertake surveillance to keep an eye on the Summary
cases reported as diarrhoea, vomiting and dysentery and rule Nutrition assumes extreme importance in a disaster situation
out if they were food poisoning. They would also ensure taking as food is a primary requirement for sustenance of life. At
samples from suspicious locations. Health officers can arrange an average energy requirement is 2100Kcal/person/day. It
to collect samples and have them examined at the Public Health is best to be prepared for a disaster. Food and water must
Laboratory. be stored at vantage points. After a disaster various feeding
If a restaurant or food shop is implicated, the officer will carry programmes namely a) General food distribution b) Selective
out an inspection of the premises and take food samples for food distribution can be resorted to. The latter can be applied
examination (if required). Mainly the officer looks for the either as a supplementary or a therapeutic feeding programme
bacterial risks arising from the type of food handled in the depending on the situation and the distribution of beneficiaries.
business and how food is stored, prepared, cooked and served. Organizing a mass feeding programme for the disaster struck
They investigate incidences of outbreaks of food poisoning in and refugees might pose a challenge to the authorities, so,
detail; recommend and take appropriate prevention and control sound administrative acumen is needed to make it a success,
measures. besides merely providing the relief material.
Mass feeding during fares and festivals is a common and
Community Feeding of Children frequent feature in India. Large scale food preparation and
There are many instances when the community feeding of distribution poses a serious public health threat if the same
children has to be resorted to. It is commonly seen as part of is not organized as per basic principles of hygiene. The local
certain national nutritional programmes. The Mid Day Meal health authorities have to ensure implementation of relevant
Programme, Balwadi Programme and under the ICDS programme rules. Close monitoring and effective surveillance of health and
(Anganwadi), children are fed in groups ranging from a few hygiene during the feeding is indispensable. The community
dozens to thousands. While running such a programme is has a major role to play in marinating health through following
essential for the up-liftment of the nutritional status of children, the rules laid down. Community must make effort to be aware
such a mass feeding entails tremendous risk as well, given the of the basics of food hygiene and the dos and don’ts of eating
large numbers involved. There have been occasional reports in a large communal gathering. Cooks and food handlers must
indicating food poisoning episodes in such congregations of also realize their responsibilities to stop spread of infection.
children. This not only puts the lives of children at risk but also Community feeding of children is often resorted to through
puts the very programme at stake of disrepute and rejection various feeding programmes organized by the government,
by the community. It is therefore imperative to take adequate under the national programmes (Mid Day Meal, ICDS, etc).
measures to prevent such situations. Special care in procurement, processing and distribution
Infants and children are more vulnerable to infections owing of food must be taken to prevent instances related to food
to a poorly developed immune system and higher vulnerability poisoning. This can be achieved through immaculate kitchen
to infections. For this reason it is important to take extra care hygiene, healthy food handlers and an aware community. We
when preparing food for infants and young children. must strive to achieve these.

Box - 4 : Guidelines for Preparing Food for Infants and Children

Raw food must be procured from authentic sources
Immaculate personal hygiene of cooks must be ensured
Dining area, tables, chairs, bibs must be thoroughly cleaned before and after every meal
Kitchen surfaces, floors, platforms, etc. must be immaculately clean
Avoid foods that are more likely to cause food poisoning e.g. cream, raw eggs, paneer, meat dishes, salad, etc.
Kitchen towels and cloths must be changed daily or more often
‘Cook fresh and consume fresh’ should be the rule
Avoid storing cooked food for another day
Discard left-overs
Children must wash their hands after visiting the toilet or touching pets.

• 802 •
Study Exercises Match the following
Long Question : Discuss the nutritional interventions that
could be undertaken in the event of an earthquake. Act Responsibility of

Short Notes : (1) Storing food for disaster (2) Therapeutic 6. Take food samples (a) Community
feeding programme (3) Community feeding of children (4) Post 7. Lay down policy (b) Local health authority
exercise feeding of athletes (5) Precautions with drinking water 8. Report diarrhoea cases (c) Food handler
during fairs
9. Report own illness (d) Local doctors
MCQs
1. At an average ____________ Kcal/person should be catered 10. Maintain food hygiene (e) Health officers
for planning food aid during disaster: (a) 2100 (b) 1850 (c)
2400 (d) 2800 Answers : (1) a; (2) b; (3) b; (4) d (5) d; (6) e (7) b; (8) d;
2. Water must be stored @ ________lit for drinking and ____ (9) c; (10) a.
lit for cooking (per day): (a) 1,1(b) 2,2 (c) 2,3 (d) 3,2
3. One metric tonne grains are sufficient to feed_______________
References
1. ICMR, Nutrient Requirements & RDA for Indians: A report of the expert
males/day in a disaster situation : (a) 2100 (b) 1850 (c) group. National Institute of Nutrition, Hyderabad, 2005.
1000 (d) 1500 2. WHO, The Management of nutrition in major emergencies. Geneva, 2000.
4. In a disaster situation the aims of therapeutic feeding 3. USAID, Field operations guide for disaster assessment and response, 2005
includes all except (a) Medical treatment of severely 4. UNHCR/WFP Guidelines for selective feeding programmes in emergency
situations. Geneva, United Nations High Commissioner for Refugees, 1999
malnourished (b) Nutritional treatment of severely
5. Passmore R, Eastwood MA. Human Nutrition and Dietetics. ELBS. Churchill
malnourished (c) Reduce infant/child deaths (d) Treat Livingstone, Edinburgh, 1986.
cases of infections 6. Pasricha S, Thimmayamma BVS, Dietary Tips for the elderly. National
5. Community feeding of children is undertaken in all Institute of Nutrition, Hyderabad, 2005.
except (a) ICDS programme (b) Mid day meal programme 7. WHO, Communicable disease control in emergencies : A field manual,
Geneva, 2005.
(c) Balwadi programme (d) School health programme 8. WHO, Management of severe malnutrition: A manual for physicians and
other senior health workers. Geneva, 1999.
9. McArdle WD, Katch FI, Katch VI. Exercise Physiology: Energy, nutrition and
human performance. 4th ed. 1996. Williams and Wilkins, Baltimore, USA

• 803 •
 139 Nutrition Tables

Rajul K Gupta

Table - 1 : Nutritive Value of Commonly Used Foods (per 100g) (1)

Food stuff Proteins (g) Fat (g) Fibre (g) Carbohydrates Energy (Kcal) Iron (mg)
(g)
Wheat flour 12.1 1.7 1.9 69.4 341 4.9
Rice polished 6.8 0.5 0.2 78.2 345 0.7
Rice parboiled 6.4 0.4 0.2 79 346 1
Bajra 11.6 5 1.2 67.5 361 8
Maize dry 11.1 3.6 2.7 66.2 342 2.3
Bengal gram 17.1 3 3.9 60.9 360 4.6
Soya bean 43.2 19.5 3.7 20.9 432 10.4
Rajmah 22.9 1.3 4.8 60.6 346 5.1
Redgram 22.3 1.7 1.5 57.6 335 2.7
Beans 1.7 0.1 1.8 4.5 26 0.61
Spinach 2 0.7 0.6 2.9 26 1.14
Tomato 0.9 0.2 0.8 3.6 20 0.64
Carrot 0.9 0.2 1.2 10.6 48 1.03
Onion 1.2 0.1 0.6 11.1 50 0.6
Potato 1.6 0.1 0.4 22.6 97 0.48
Groundnut 25.3 40.1 3.1 26.1 567 2.5
Guava 0.9 0.3 5.2 11.2 51 0.27
Amla 0.5 0.1 3.4 13.7 58 1.2
Mango 0.6 0.4 0.7 16.9 74 1.3
Orange 0.7 0.2 0.3 10.9 48 0.32
Banana 1.2 0.3 0.4 27.2 116 0.36
Lime 1.5 1 1.3 10.9 59 0.3
Grape green 0.5 0.3 2.9 16.5 71 0.52
Grape blue 0.6 0.4 2.8 13.1 58 0.5
Papaya 0.6 0.1 0.8 7.2 32 0.5
Egg 13.3 13.3 - - 173 2.1
Fish (Hilsa) 21.8 19.4 - 2.9 273 2.1
Chicken 25.9 0.6 - - 109 -
Milk, cow 3.2 4.1 - 4.4 67 0.2
Milk, buffalo 4.3 6.5 - 5 117 0.2
Ghee - 100 - - 900 -
Butter - 81 - - 729 -
Veg oils - 100 - - 900 -
Cheese 24.1 25.1 - 6.3 348 2.1
Curd 3.1 4 - 3 60 0.2
Jaggery 0.4 0.1 - 95 383 2.64

• 804 •
 Table - 2 : Recommended Dietary Allowances for Indians (Infants, Children, Adults, Pregnant and Lactating women) (1)
Body Vitamin Ribo- Nicoti- Pyri- Folic
Group Particulars Energy Protein Fat Ca Fe Thiamin Vit C Vit B12
wt A flavin nic acid doxin acid
Retinol β carotene
Kg Kcal/d g/d g/d mg/d mg/d µg/ d µg/ d mg/d mg/d mg/d mg/d mg/d µg/d µg/d
Man Sedentary
2425 1.2 1.4 16
work
Moderate
60 2875 60 20 400 28 600 2400 1.4 1.6 18 2.0 40 100 1
work
Heavy work 3800 1.6 1.9 21
Woman Sedentary
1875 0.9 l.l 12
work
Moderate
50 2225 50 20 400 30 600 2400 l.l 1.3 14 2.0 40 100 1
work
Heavy work 2925 1.2 1.5 16
Pregnant
50 +300 +15 30 1000 . 38 600 2400 +0.2 +0.2 +2 2.5 40 400 1
woman
Lactation
0-6 months 50 +550 +25 45 1000 30 950 3800 +0.3 +0.3 +4 2.5 80 150 1.5
6-12
+400 +18 +0.2 +0.2 +3
months

• 805 •
65pgl
2.05/ 55µl Kg
Infants 0-6 months 5.4 108/ Kg 500 0.1 25 25 0.2
Kg Kg 710µgl
Kg
6-12 60µg/Kg
1.65/ 50µl
months 8.6 98/Kg 350 1200 650pgl 0.4
Kg Kg
Kg
Children 1-3 years 12.2 1240 22 12 400 1600 0.6 0.7 8 0.9 30
4-6 years 19.0 1690 30 25 400 18 400 0.9 1.0 11 40 40 0.2-1.0
7-9 years 26.9 1950 41 26 600 2400 1.0 1.2 13 1.6 60
Boys 10-12 years 35.4 2190 54 22 600 34 600 2400 l.l 1.3 15 1.6 40 70 0.2-1.0
Girls 10-12 years 31.5 1970 57 19 1.0 1.2 13
Boys 13·15 years 47.8 2450 70 22 600 41 600 2400 1.2 1.5 16 ~.O 40 100 0.2-1.0
Girls 13·15 years 46.7 2060 65 28 1.0 1.2 14
Boys 16-18 years 57.1 2640 78 22 500 50 600 2400 1.3 1.6 17 2.0 40 100 0.2 1.0
Girls 16-18 years 49.9 2060 63 30 1.0 1.2 14
Table - 3 : Major Contributors of Energy to Our Diet (Some raw foods and their energy content per 100g) (1)
Food stuff Energy (Kcal) Food stuff Energy (Kcal)
Cereals & Millets Non vegetarian foods
Wheat flour 341 Egg (hen) 173
Rice polished 345 Fish (Hilsa) 273
Bajra 361 Chicken 109
Maize dry 342 Mutton (lean) 118
Ragi 328 Pork (muscle) 114
Pulses & Legumes Milk & milk products
Bengal gram 360 Milk, cow 67
Soya bean 432 Milk, buffalo 117
Rajmah 346 Milk, human 65
Redgram (Arhar) 335 Butter 729
Greengram (Moong) 334 Ghee 900
Lentil (Masoor) 343 Cheese 348
Pea dry 315 Curd 60
Fruits & Vegetables Nuts
Banana 116 Groundnut 567
Apple 59 Cashew nut 596
Grapes, pale green 71 Coconut, fresh 444
Custard apple 104 Miscellaneous
Jack fruit 88 Jaggery 383
Raisins 308 Sugar 398
Potato 97 Veg oils 900

Table - 4: Calorie Content of Selected Cooked Food Items (per serving) (2)
Food item Kcal Food item Kcal
Samosa (1no.) 256 Dalia (1 plate) 80
Masala dosa (1no.) 360 Khichri (1 plate) 160
Kachori (2 no.) 500 Biscuits (4 no.) 150
Omelette (1egg) 236 Poha (1 plate) 120
Puri (4 no x 25g each) 320 Bread (2 slices) 125
Chapati with ghee (4 no.) 360 Chapati (2no x 35g each) 160
Cake (1small piece) 250 Kheer (1 katori) 120
Butter chicken (1 katori) 400 Cornflakes (1bowl) 190
Chicken biryani (200g) 400 Veg salad 50
Malai paneer (1 katori) 270 Butter milk (1 glass) 90
Paratha (2no x 50g each) 360 Jam (2tsp) 40
Ice cream (100ml) 250 Dhokla (2 pcs) 100
Pastry (1 no.) 290 Green leafy veg (1katori) 130
Milk cake (1 piece) 300 Idli (2no x 55g each) 155
Butter (2 tsp) 180 Dosa (2no x 45g each) 250
Fried Cashew (50g) 375 Tinned cheese (2tbsp) 105

• 806 •
Table - 5 : Signs ‘Strongly Suggestive’ of Dietary Deficiency or Excess (3)
Sign of Deficiency Suggested nutrient abnormality
Pale conjunctiva Iron
Bitot’s spots Vitamin A
Angular stomatitis Riboflavin
Spongy, bleeding gums Vitamin C
Bilateral edema (young children) Protein and Energy
Thyroid enlargement Iodine
Bilateral epiphyseal enlargement of wrists Vitamin D
Sign of Excess Suggested nutrient abnormality
Mottled enamel Fluoride
Dental caries Sugar

Table - 6 : Normal Range of Some Biochemical Tests (4)

Normal Low (Medium Deficient
Nutrient Test
(Acceptable) risk) (high risk)
Albumin (g/100ml)
Serum levels >3.5 2.8-3.4 <2.8
for age 6-17 yrs
Vitamin A (μg/dl) Serum levels >30 20-30 <20
Serum levels of 25-Hydroxy
Vitamin D (ng/ml) >10 5-10 <5
cholecalciferol
Vitamin E Ratio of serum vitamin/total lipids >0.8
If PIVKAS
Vitamin K *PIVKAS accumulation
accumulates
Prothrombin time Delayed **
100μg/24 hrs or
Thiamin Urinary thiamin
65μg/g creatinine
Riboflavin Urinary Riboflavin 80μg/g creatinine
2-Pyridone to NI-methyl
Niacin 1 to 4 <1
nicotinamide ratio
<20μg/g
Vitamin B6 Vitamin B6 urinary excretion
creatinine
Pyridoxic acid excretion <0.5mg/day
Folic Acid Serum Folate (ng/ml) >6.0 3.0-5.9 <3
RBC Folate (ng/ml) >160 140-159 <140
Vitamin B12 Serum B12 (pg/ml) <80
Ascorbic acid Plasma (mg/dl) >15 8-15 <8
* PIVKAS: Protein Induced by Vitamin K Absence
** Prothrombin time is a functional test

• 807 •
 Table - 7 : Approximate Fatty Acid Composition of Common Fats and Oils (g/100g) (5)
Oil/Fat Saturated MUFA Linoleic acid α-linolenic acid Predominant FA
Coconut 90 7 2 <0.5 SFA
Palm kernel 82 15 2 <0.5 SFA
Ghee 65 32 2 < 1.0 SFA
Vanaspati 24 19 3 <0.5 SFA (t-FA)
Red palm oil 50 40 9 <0.5 SFA + MUFA
Palm oil 45 44 10 <0.5 SFA + MUFA
Olive 13 76 10 <0.5 MUFA
Groundnut 24 50 25 <0.5 MUFA
Rape/Mustard 8 70 12 10 MUFA
Sesame 15 42 42 1.0 MUFA + PUFA
Rice bran 22 41 35 1.5 MUFA + PUFA
Cotton seed 22 25 52 1.0 PUFA
Corn 12 32 55 1.0 PUFA
Sunflower 13 27 60 <0.5 PUFA
Safflower 13 17 70 <0.5 PUFA
Soyabean 15 27 53 5.0 PUFA

References
1. Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian
foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.
2. Pasricha S, Count what you eat. National Institute of Nutrition (ICMR),
Hyderabad. 1989.
3. Jelliffe DB, Jelliffe EFP. Community Nutritional Assessment. Oxford University
Press. 1989.
4. Bamji MS, Rao NP, Reddy V. Textbook of Human Nutrition. 2nd ed. Oxford &
IBH Publishing Co Pvt Ltd, New Delhi. 2003.
5. Ghafoorunissa, Krishnaswamy K. Diet and Heart Disease. 2000 National
Institute of Nutrition, Hyderabad – 500007.

• 808 •