FOT 339

PRINCIPLES OF FOOD SCIENCE

AND NUTRITION
 LAST LECTURE
DISCUSSION

• MODIFICATION IN DIET
MALNUTRITION
PROTEIN-ENERGY
MALNUTRITION
 MALNUTRITION
WHO defines Malnutrition as "the cellular
imbalance between the supply of nutrients and
energy and the body's demand for them to
ensure growth,
maintenance, and specific functions.“
Malnutrition is the condition that develops when the
body does not get the right amount of the vitamins,
minerals, and other nutrients it needs to maintain
healthy tissues and organ function.
  PROTEIN ENERGY MALNUTRITION
It is a group of body depletion disorders which
include kwashiorkor, marasmus and the
intermediate stages
 MARASMUS
Represents simple starvation . The body adapts
to a chronic state of insufficient caloric intake
 KWASHIORKOR
It is the body’s response to insufficient protein
intake but usually sufficient calories for energy
DESCRIPTION

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 Protein-Energy
Malnutrition

 PEM is also referred to as
protein-calorie
It is considered as the
malnutrition.
primary nutritional
problem in India.
Also called the 1st National
Nutritional Disorder.
 The term protein-
energy malnutrition (PEM)
applies to a group of
related disorders that
include marasmus,
kwashiork or, and
intermediate states of
marasmus-kwashiorkor.
 PEM is due to “food gap”
between the intakeSt.Ann's
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requirement. Women
AETIOLOGY
 AETIOLOGY:
Different combinations of many
aetiological factors can lead to PEM in
Social andchildren.
EconomicThey are:
Factors
Biological factors
Environmental factors
Role of Free Radicals &
Aflatoxin
Age of the Host

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  Amongst the Social, Economic,
Biological and
Environmental Factors
Lack of breast feeding andthe common
giving diluted
formula causes are:
 Improper complementary feeding
 Over crowding in family
 Ignorance
 Illiteracy
 Lack of health education
 Poverty
 Infection
 Familial disharmony

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  Role of Free Radicals & Aflatoxin: Two new
theories have been postulated recently to
explain the pathogenesis of kwashiorkor.
These include Free Radical Damage &
Aflatoxin Poisoning . These may damage liver
cells :giving rise to kwashiorkor.
 Age Of Host
Frequent in Infants & young children whose
rapid growth increases nutritional requirement.
PEM in pregnant and lactating women can
affect the growth, nutritional status & survival
rates of their fetuses, new born and infants.
Elderly can also suffer from PEM due to
alteration of GI System
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CLINICAL FEATURES
The clinical presentation depends upon the
type
, severity and duration of the dietary
deficiencies. The five forms of PEM are :
1. Kwashiorkor
2. Marasmic-
kwashiorkor
3. Marasmus
4. Nutritional dwarfing
5. Underweight child
 Classification of
PEM
(FAO/WHO)
Body weight
 Oedema Deficit in
as percentage weight for
of standard height
Kwashiorkor 60 – 80 + +

Marasmic < 60 + ++
kwashiorkor
Marasmus < 60 0 ++

Nutritional < 60 0 Minimal

dwarfing
Underweight 60 – 80 0 +
child
Source: FAO / WHO 1971
Expert Committee on
Nutrition 8th Report. WHO
Technical Report Series 477
 The term kwashiorkor is taken from the Ga
language of
Ghana and means "the sickness of the weaning”.
 Williams first used the term in 1933, and it
refers to an inadequate protein intake with
reasonable caloric (energy) intake.
 Kwashiorkor, also called wet protein-energy
malnutrition, is a form of PEM characterized primarily
by protein deficiency.
 This condition usually appears at the age of about
12 months when breastfeeding is discontinued, but
it can develop at any time during a child's formative
years.
 It causes fluid retention (edema); dry,
peeling skin; and hair discoloration.
 Kwashiorkor was thought to be caused
by insufficient protein consumption
but with sufficient calorie intake,
distinguishing it from marasmus.
 More recently, micronutrient and
antioxidant deficiencies have come to be
recognized as contributory.
 Victims of kwashiorkor fail to produce
Antibodies following vaccination against
diseases, including diphtheria and typhoid.
 Generally, the disease can be treated by adding
food energy and protein to the diet; however, it
can have a long-term impact on a child's
physical and mental development, and in
severe cases may lead to death.
 SYMPTOMS
 Changes in skin pigment.
 Decreased muscle mass
 Diarrhea
 Failure to gain weight and

grow
 Fatigue
 Hair changes (change in
color or texture)
 Increased and more severe
infections due to damaged
immune system
 Irritability
 Large belly that sticks out
(protrudes)
 Lethargy or apathy
 Loss of muscle mass
 Rash (dermatitis)
 Shock (late stage)
 Swelling
(edema)
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 The term marasmus is derived from the Greek word
marasmos, which means withering or wasting.
 Marasmus is a form of severe protein-energy
malnutrition characterized by energy deficiency and
emaciation.
 Primarily caused by energy deficiency, marasmus is
characterized by stunted growth and wasting of
muscle and tissue.
 Marasmus usually develops between the ages
of six months and one year in children who have
been weaned from breast milk or who suffer from
weakening conditions like chronic diarrhea.
SYMPTOMS

abse
nt
DIFFERENCE IN CLINICAL FEATURES
BETWEEN MARASMUS AND
KWASHIORKOR
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DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

CLINICAL MARASMUS KWASHIORKOR

FEATURES
-MUSCLE
WASTING Obvious Sometimes
hidden by edema
and fat
-FAT WASTING Severe loss of Fat often retained
subcutaneous fat but not firm

-EDEMA None Present in lower

legs, and usually
in face and lower
arms
May be masked
-WEIGHT FOR Very low by edema
HEIGHT
Irritable,
-MENTAL Sometimes quite moaning,
CHANGES and apathetic apathetic
DIFFERENCE IN CLINICAL FEATURES BETWEEN MARASMUS AND KWASHIORKOR

CLINICAL MARASMUS KWASHIORKOR

FEATURES

-APPETITE Usually good Poor

-DIARRHOEA Often Often

-SKIN CHANGES Usually none Diffuse

pigmentation,
sometimes „flaky
paint dermatitis‟
-HAIR CHANGES Seldom Sparse, silky,
easily pulled out

-HEPATIC None Sometimes due to

ENLARGEMENT accumulation of fat
MARASMIC-KWASHIORKOR
A severely malnourished
child with features of both
marasmus and
Kwashiorkor.
 The features of
Kwashiorkor are severe
oedema of feet and legs
and also hands, lower
arms, abdomen and face.
Also there is pale skin and
hair, and the child is
unhappy.
 There are also
signs of marasmus,
wasting of the muscles of
the upper arms, shoulders
and chest so that you can
see the ribs.
 NUTRITIONAL
DWARFING
OR STUNTING

 Some children adapt to prolonged insufficiency

of food-energy and protein by a marked
retardation of growth.
 Weight and height are both reduced and
in the same proportion, so they appear
superficially normal.
 UNDERWEIGHT
CHILD
 Children with sub-
clinical PEM can be
detected by their
weight for age or
weight for height,
which are
significantly below
normal. They may
have reduced plasma
albumin. They are at
risk for respiratory
and gastric infections
BIOCHEMICAL &
METABOLIC
CHANGES
 BIOCHEMICAL & METABOLIC
CHANGES
 Significant findings in kwashiorkor include
hypoalbuminemia (10-25 g/L), hypoproteinemia
(transferrin, essential amino acids, lipoprotein), and
hypoglycemia.
 Plasma cortisol and growth hormone levels are
high, but insulin secretion and insulinlike growth factor
levels are decreased.
 The percentage of body water and extracellular water is
increased.
 Electrolytes, especially potassium and magnesium, are
depleted.
 Levels of some enzymes (including lactase) are
decreased, and
circulating lipid levels (especially cholesterol) are low.
 Ketonuria occurs, and protein-energy
malnutrition may cause a decrease in the urinary
excretion of urea because of decreased protein intake.
 In both kwashiorkor and marasmus, iron deficiency
anemia and
metabolic acidosis are present.
 Urinary excretion of hydroxyproline is diminished,
reflecting impaired growth and wound healing.
TREATMEN
T
 TREATMEN
T
Treatment strategy can be divided into three
stages.
 Resolving life threatening
 Restoring nutritional
conditions
Ensuring nutritional rehabilitation.
status

There are three stages of treatment.

1.Hospital Treatment
The following conditions should be corrected.
Hypothermia, hypoglycemia, infection, dehydration, electrolyte
imbalance, anaemia and other vitamin and mineral deficiencies.
2.Dietary Management
The diet should be from locally available staple foods - inexpensive,
easily digestible, evenly distributed throughout the day and increased
number of feedings to increase the quantity of food.
3.Rehabilitation
The concept of nutritional rehabilitation is based on practical
nutritional training for mothers in which they learn by feeding their
children back to health under supervision and using local foods.
PREVENTION
 PREVENTION

 Promotion of breast feeding

 Development of low cost weaning
 Nutrition education and promotion of
correct feeding practices
 Family planning and spacing of births
 Immunization
 Food fortification
 Early diagnosis and treatment
OBESITY
 OBESITY
• Excessive amount of body fat

–Women with > 20% body fat

–Men with > 20% body fat
• Increased risk for health problems
• Are usually overweight, but can have healthy BMI and high % fat
• Measurements using calipers
 Body Fat Distribution: Gynecoid

• Lower-body obesity--Pear shape

• Encouraged by estrogen and progesterone
• Less health risk than upper-body obesity
• After menopause, upper-body obesity appears
 Body Fat Distribution: Android

Upper-body obesity--apple shape

Associated with more heart disease, HTN,
Type II Diabetes
Abdominal fat is released right into the liver
Encouraged by testosterone and excessive
alcohol intake
Defined as waist measurement of > 40” for
men and >35” for women
Body Fat Distribution
Facilitators Barriers
Change in eating behaviour No self control
Increase in physical activity Special occasions
Attitude and motivation Not exercising enough
Monitoring food records, weighing Attitude and motivation
oneself
Social support Stress, eating habits
Awareness of the calorie content of the Eat everything on plate attitude, eat
food balanced diet fast foods, eating quickly, having lot of
food around, liking for fatty food, liking
for sweets
Causes of Excessive Energy Intake

• Active: large portion sizes, frequent meals and snacks

• Passive: excessive intake of energy-dense foods
containing hidden calories
• Variety of options: the greater the variety of foods
offered, the greater the intake
–Sensory-specific satiety: as foods are consumed they
become less appealing
Assessment of obesity
 Body weight

• In adults, weight of 10% or more is said to be overweight

while 20% and above is said to be obese.

% body fat in excess Degree of obesity

25 Mild
50 Moderate
75 Severe
100 Very severe
 BMI
• Is accepted as a better estimate of body fatness and
health risk other than weight. It is also known as quetlet
index.
BMI= weight/height 2 (m)
Grades Status
>35 Grade III
30-34.9 Grade II
25-29.9 Grade I
<25 Obese
Proposed reclassification of overweight for asian adults is >23 kg/m 2
and for obesity is >25 kg/m2
•It does not distinguish between overweight due to obesity and muscular hypertrophy
and it happens in athletes.
•No information about distribution of fat in the body
 Waist circumference
• For children
• Measures abdominal fat
level male Female
I > 94 cm > 80 cm
II > 102 cm > 88 cm

•Level I is the maximum acceptable waist circumference irrespective of the adult age
and their should be no further weight gain
•Level II denoted obesity and requires weight management to reduce the risk of type II
diabetes and cardiovascular complications
 Measurement of body fat
• Males - >25%
• Females- >30%
• Sub-cutaneous fat is less likely to cause insulin resistance
• Sumo wrestlers have more sub-cutaneous fat and less
visceral fat
category males females
Normal 12-20 20-30
Borderline 21-25 31-33
obesity >25 >33
 Ponderal Index
• Ratio of height in inches to cube root of weight
• Less than 13 is associated with obesity

Broka’s Index

• Height (cm)-100=ideal weight (kg)

Waist/Hip ratio
Waist circumference is measured at the level of the
umbilicus to the nearest 0.5 cm
The subject stands erect with relaxed abdominal muscles,
arms at the side, and feet together
The measurement should be taken at the end of a normal
expiration
 Discussion of
Today’s lecture