NUTRITION AND DIETETICS FOR MEDICAL AND ALLIED HEALTHCARE SUBJECTS STUDENTS

1. Nutrition, Dietetics & Energy Metabolism

2. Nutrients
2 types
1. Macronutrients –
Intake larger than that of the other dietary nutrients.
Quantity needed is more
Energy rich - Carbohydrates, Fats, Proteins
2. Micronutrients –
Consumed less & needed less than the above
Vitamins & Minerals

3. Energy is measured as CALORIES
Calorie
It is the amount of energy necessary to raise the temp. of
1kg of water by 10C (from 150C – 160C)
It is the standard unit of heat energy.
In Nutrition & Dietetics kilocalorie (kcal) or (Cal) is used
(with a Capital C )
SI unit is Kilo Joule
1 kcal / Cal = 1000 cal = 4.184 KJ
1KJ = 0.293 Kcal

4. Energy & Nutrient requirements - Dietary
Reference Intake (DRI)
Dietary Reference Inatake (DRI) –
System of nutrition recommendation for various macro & micro
nutrients estimates of the amounts of nutrients required to prevent
deficiencies and maintain optimal health and growth.
Represent upper limit of consumption
DRIs derived from RDA and are slowly replacing RDA
(Recommended Dietary Allowances)
Both the DRI and the RDA refer to long-term average daily nutrient
intake
it is not necessary to consume the full RDA every day.

5. DRIs
Prescribed for energy & all nutrients C,F,P V, M F etc
Established by WHO, FAO, ICMR, NIN (for Indian population)
1. RDA - (Recommended Dietary Allowance) - average daily
nutrient intake estimated to meet the nutrient requirements of
nearly all (97–98%) the individuals of a particular age & gender
group
RDA is more than the minimal requirements and set intentionally
to provide a margin of safety for most individuals to prevent
developing deficiency manifestation
2. EAR – (Estimated Average Requirement) – Average nutrient
intake estimated to meet the requirement of one half of a group of
healthy individuals of a particular age group & gender
- 50 % will require more than EAR 50 % will require less than EAR

6. DRIs
3. AI (Adequate Intake) is a recommended intake value that is used
when not enough data are available to establish an RDA
e.g infants in whom milk is the sole source of nutrients and the
requirement is based on the estimated daily mean nutrients supplied
by human milk for healthy, full-term infants who are exclusively
breast-fed.
4. UL (Tolerable Upper Intake Level) : The UL is the highest
average daily nutrient intake level that is likely to pose no risk of
adverse health effects to almost all individuals in the general
population
The UL is not intended to be a recommended level of intake. Risk
of adverse health effects beyond UL

7. DRIs
5. LRNI - Amount of nutrient that is sufficient for only the few
people in the group with low needs (EAR-2 SD) likely to result in
adverse health effects and over a long period will result in deficiency
manifestations
6. Safe Intake Amount of nutrient enough to almost everyone but
without causing undesirable effects or deficiency states

8. DRIs

9. DRIs

10. Energy Content of food
It is expressed in kilocalories (kcal, or Cal or C - in upper case)
1 Cal or Kcal = 1000 calories = 4.184 joules (J)
The caloric value of food: is amount of heat energy (C) liberated
when 1gm of a certain food is oxidized. It depends on:
type of food.
whether food is oxidized outside the body ( physical caloric value) or
inside the body ( physiological caloric value )
CHO and fats are completely oxidized proteins are not (as N is
not oxidized) also energy to account for TEF (SDA)

11. How to estimate
Energy Content of food ?
Food stuff is burnt in a bomb calorimeter
Ratio of oxygen consumed to the carbon-dioxide evolved is used to
calculate calorie content of food stuff
Energy yield is 20 KJ /L of oxygen consumed irrespective of food
stuff
Based on volume of oxygen consumed caloric value is calculated
If 1 Dosai requires 100 L of oxygen to burn it completely then
caloric value of 1 dosai = 20 KJ or 4.184 x 20 = 84.5 Calories

12. 12
Type of Food physical CV physiological CV
1 gm carbohydrate 4.1 C 4.0 C
1 gm fat 9.45 C 9.0 C
1 gm proteins 5.65 C 4.0 C
1 gm of alcohol 7.0 C 7.0

13. Energy Content of food

14. Why 1 gm of fat yields more calories than 1
gm CHO or Protein ?
Carbohydrates & proteins are more oxidized and require
less oxygen to burn
Fats are more reduced & need more oxygen to be burnt

15. Why 1 gm of fat yields more calories than 1
gm CHO or Protein ?

16. Energy Requirements
Energy from the oxidation of the macronutrients is used
for 3 energy requiring processes
1- Maintenance of Basal or Resting Metabolic Rate
(BMR /RMR )
2- Specific Dynamic Action or Thermogenic Effect
of Food or Diet-Induced Themogenesis (DIT)
3 - Extra energy expenditure for Physical Activity.

17. Basal & Resting Metabolic Rate
(BMR & RMR)
Minimum amount of energy required by an individual
who is awake and resting to carry out the normal body
functions, namely heart contraction, respiration, renal
function of filtration and absorption, circulation, ion
transport and maintenance of cellular integrity.
1. BMR or Basal Metabolic Rate or Basal Energy
Expenditure (BEE)
2. RMR or Resting Metabolic Rate or Resting
Energy Expenditure (BEE)
Vary little in value - RMR is 3% higher than BMR

18. BMR & RMR
BMR or Basal Metabolic Rate is the
energy expended by a person mentally and physically at rest
(after 8 hours of sleep) and awake and fasting (12 hours after
a meal to avoid SDA) in a thermo-neutral environment of 22
- 25 C ( to avoid shivering / sweating)
RMR or Resting Metabolic Rate is the
Metabolic rate at physical and mental rest and awake and 4
hours after a meal (called ‘post absorptive state’ )
In an adult , the RMR is about 1,800 kcal for men (70 kg)
and 1300 kcal for women (50 kg) .
50–70% of the daily energy expenditure in sedentary
individuals is attributable to the RMR

19. Factors affecting BMR / RMR
Physiological Factors affective BMR :
• 1. BMR proportional to lean-body mass (body weight minus body fat
weight)
• 2. Higher for large frame persons compared to small frame persons (
body surface area)
• 3. Lower in women than men of same weight (metabolically inactive
adipose tissue is more)
• 4. Increases with body temperature-12 % increase for every one C rise
• 5. Increases in colder climates as thermogenesis is activated
• 6. More in growing children as metabolically more active organs
compared to their body size
• 7. Declines with aging – for the same reason-metabolically less active
organs and more adipose tissue
• 8. Increases in pregnancy & lactation
• 9. Increases during exercise
• 10.Less during sleep

20. Factors affecting BMR / RMR
Pathological Factors affective BMR :
1. BMR is high in hyperthyroidism and low in hypothyroidism
2. Increases in fever
3. Increases in malignancy

21. Calculation of RMR / BMR
Based on BSA - more accurate
34-37 kcal/sq.m / hour – men
30-35 kcal/ sq.m / hour – women
Based on body weight – less accurate more easy
24 kcal /kg/day – for easy calculation
How is BMR calculated ?
Direct calorimetry – Benedict –Roth apparatus by measuring the
volume of oxygen consumed and volume of CO2 evolved
Open circuit & closed circuit method
Indirect calorimetry
-

22. How BMR is measured ?

23. Thermic Effect of food (aka. Diet Induced
Thermogenesis - DIT)
Increase in metabolic rate and the increased heat production
(energy released) that occurs following intake of food
Formerly called as Specific Dynamic Action – SDA
Energy required to process the nutrients
i.e energy required for the digestion, absorption, storage and
distribution of nutrients in food

24. Thermic Effect of food (aka. Diet Induced
Thermogenesis - DIT)
Gut peristalsis, enzyme and acid secretion, absorption, glycogen
synthesis, AA deamination & urea synthesis, renal excretion etc
Initial energy to be made available to metabolise nutrients which
is obtained from already available energy
Actual or effective or net energy available in the nutrient is
therefore much less than the theoretical energy calculation
or caloric value of food

25. Thermic Effect of food (aka. Diet Induced
Thermogenesis)
Equivalent to TDS
Tax Deducted at Source
Even before monthly salary is given, income tax is
deducted
The pay cheque which you get on 30th of every month is
less than your actual pay

26. Importance of SDA or DIT or TEF
DIT is different for different nutrients
Highest for proteins – 30% of calculated CV (urea synthesis
requires 4 ~ p)
Next for Fats -15%
Least for Carbohydrates - 5%
DIT for a mixed diet -10% of energy available
Hence while calculating energy requirements for a mixed diet,
an extra 10% calories should be provided to account for the
loss of energy as DIT
10% of RMR to be added to calculated calorie requirements

27. Diet Induced Thermogenesis
Total Calories 20 sugar
cubes each weighing 4
gm = 320 C
SDA = 16 C
(5% of 320)
for digestion
absorption,
glycogenesis
etc
Usable Calories =
304 C (320-16)
Minus SDA

28. Physical activity
Responsible for the greatest variation in energy expenditure and
requirements in an individual
3 levels of physical activity
Sedentary - Plus 30 % of BMR or RMR
Moderate - Plus 40% of BMR or RMR
Heavy - Plus 50% of BMR or RMR

29. Physical activity

30. How energy is expended ?

31. Acceptable Macronutrient Distribution Ranges
(AMDR)
Macronutrient Intake adequate enough to provide essential
nutrients without deficiency &
at the same time reducing the risk of chronic diseases
Of the total daily calorie requirements
45 to 65 % of DEE should be obtained from carbohydrates
20-35% - of DEE from fats
10-25 % DEE from proteins

32. AMDR

33. Acceptable Macronutrient Distribution Ranges
(AMDR)

34. Dietary Carbohydrates
• Carbohydrates are not dietary essentials ; can be
synthesised from carbon skeleton of AAs
• But absence of CHO from diet leads to ketosis - Hence
minimum amount of CHO necessary
• RDA for carbohydrate is 130 g/day for adults and
children
• Adults should obtain 45 % to 65 % percent of their
total calories from carbohydrates

35. Carbohydrates are not fattening per se
• CHO are not fattening per se but lead to increased fat
(fatty acid & cholesterol synthesis) when consumed in
excess of 60% of total calories
• Excess sucrose - dental caries esp when fluoride is
deficient

36. Types of Dietary Carbohydrates
• Simple carbohydrates - table sugar, fruits, milk, malt,
honey
• Complex carbohydrates - starch, fibre, meat products
• Simple sugars - rapid rise in blood glucose levels and
hence consumption should be minimized.
• Also lead to excess calorie intake & obesity

37. Dietary Fibres
• The term "fiber" is a misnomer, since they are not actually
fibrous
• Dietary fiber is defined as the indigestible carbohydrates
present in food stuff & NO CALORIC VALUE
• Salivary & pancreatic amylases are specific for α-glycosidic bonds
fibres contain β-glycosidic linkage
• Soluble fibres & Insoluble fibres
• Soluble fiber refers to fibers that form a viscous gel when mixed
with a water. Insoluble fiber passes through the digestive track
largely intact.
• Some of the fibres - Arabinoxylans, Cellulose, Hemi-cellulose,
Lignin (in plants) , Pectin (in apple) , Gums (in vegetables),
Inulin (in vegetables), Raffinose, Chitin, mucilages

38. Beneficial effects of dietary fibres
• First, it adds bulk to the diet, induces sense of fullness or satiety
• Prevents Constipation - Fiber can absorb (10–15 times its own weight
in water), drawing fluid into the lumen of the intestine and increasing
bowel motility.
• Useful in type 2 DM and obesity - Delays gastric emptying and can
result in a sensation of fullness. This delayed emptying also results in
reduced peaks of blood glucose following a meal.
• Lower total cholesterol & LDL-C - interferes with enterohepatic
recirculation of bile acids and thereby increasing fecal bile acid excretion
• Decreases incidence of cardiovascular disease - Diets rich in the
soluble fiber e.g oat bran 25–50 g/day is associated with a significant,
reduction in risk for cardiovascular disease by lowering total and
LDL cholesterol levels.
• Also, fiber-rich diets decrease the risk for constipation, hemorrhoids,
and diverticulosis.

39. Disadvantages of dietary fibres
• Flatulence and distension of abdomen
• Interferes with absorption of minerals like calcium and zinc
– may lead to trace element deficiency
RDA (Average Intake)
25-40 g/day
• 25 g/day for women; & 38 g/day for men

40. Are lipids essential in our diet ?
Cholesterol & Fattyacids - friend or foe ?
Major component of plasma membrane and membrane of
organelles - Confer fluidity to membranes
Absorption of A, D, E & K
Essential fatty acids – Eicosanoids (PGs, TXs, Lipoxins,
Leucotrienes)
Fatty acids - primary source of energy for resting muscle
Cholesterol – Steroid hormones, vit. D and bile acids
Cardiolipin, Surfactant, Myelin

41. Dietary lipids
Major dietary fats – Triacylglycerol (TGL), fatty acids,
cholesterol
Saturated fats –whose fatty acids are saturated without double
bonds – palmitic acid, stearic acid
Increases risk of CHD – increase total plasma cholesterol
& LDL-C
Sources – dairy products, meat, vegetable oils esp. coconut oil,
palm oil
Highest in coconut oil, palm oil, butter, pork, beef
Lowest in sunflower oil, safflower oil, sesame oil, flaxseed oil,
olive oil, sesame oil, corn oil, soya oil

42. Dietary lipids
Monounsaturated fats – fatty acids with one double bond
only palmito-oleic acid, oleic acid
olive oil, safflower oil, sesame oil, rice bran oil fish oils
Lower total cholesterol, LDL-C and increase HDL-C
Lowers risk of CHD

43. Dietary lipids
Polyunsaturated fats – fatty acids with more than 1
double bond
ώ-3 fatty acids – Unsaturated fattyacid with the first
double bond 3 carbons when counted from methyl end(n-3
fatty acid) –
Lower TGL, little effect on cholesterol, decrease
tendency for thrombosis, reduce cardiovascular mortality,
α-linolenic acid (18:3 д 9,12,15) present in
Fish oils containing DHA & EPA , flaxseed oil

44. Dietary lipids
• ώ 6 fatty acids– Unsaturated fattyacid with the first double
bond 6 carbons when counted from methyl end ( n-6 fatty acid)
• Sources: nuts, olive oil, sunflower oil, sesame oil, soyabean
oil, corn oil
• lower LDL cholesterol but also lower HDL cholesterol
• Essential for the synthesis of eicosanoids – prostaglandins,
prostacyclins, thromboxanes, leukoyriens, lipoxins
• Linoleic acid (18:2 д 9,12) & arachidonic acid (20:4 д
5,8,11,14)
• Essential Fatty Acids (EFA) - linoleic acid, arachidonic acid,
α-linolenic acids are called
• Deficiency is associated with dermatitis, poor wound healing,
hair loss -

45. Dietary lipids

46. RDA of lipids
RDA - 20-30% of total daily energy requirement (25-30 g/day)
Not more than 1/3rd of DEE - 10 % from SFA, 10% MUFA
10% PUFA ( 1:1:1 ratio)
ώ-6 to ώ 3 fatty acid – 1:1 to 4:1
ώ 3 – 0.6 to 1.2 % of total calories
α – Linolenic acid (ώ-3 ALA) 0.6 to 1.2 g/day
EPA & DHA 6 g/ day (another ώ-3 from ALA )
ώ 6 - Linoleic acid (ώ 6) 5-10 g/day
Sodium – 2.5 g/day (6 g of NaCl

47. RDA of lipids
Cholesterol - 250 300 mg/day
Sources: present only in animal food
Provide no energy
High cholesterol increases the risk of CHD - esp LDL-C by
accelerating atheroscelrosis
Vegetable oils do not contain cholesterol

48. PUFA
Poly Unsaturated Fatty Acids – more than 1 double bond
Essential for membrane fluidity
Essential fatty acids – Linoleic acid, Linolenic acid
Arachidonic acid DHA, EPA
ω-3 & ω -6 PUFA – based on the position of first double
bond when counting from CH3 end

49. PUFA
ω-6 fatty acids – lower plasma cholesterol LDL-C but also
lower HDL-C
e.g. Linoleic acid & arachidonic acid
Sunflower oil, olive oil, corn oil, soya oil nuts soya
5-10 % of total calories
ω -3 PUFA – linolenic acid 0.6-1.2% of calories

50. Functions of PUFA
1. Major component of plasma membrane and all membranes
of organelles
2. Contributes to membrane fluidity
3. They are precursors of prostaglandins and leukotrienes
4. DHA, EPA in brain
5. PUFAs are required for esterification and excretion of
cholesterol lowering cholesterol
6. They reduce the cholesterol level in blood and are anti
atherogenic - Excess PUFA leads to free radical formation

51. PUFA

52. Trans fatty acids
Trans fatty acids – PUFA with
Trans Double bonds
Lower HDL & Elevate LDL
Formed during hydrogenation of
oils (dalda, vanaspathi margarine)
Present in commercial snacks –
baked products

53. Dietary Proteins
Are essential for synthesis of new body proteins
Food is the only source of 8 essential amino acids
All EAA need to be supplied in adequate quantities in diet
10-15 % of daily total calorie requirement must be met
from dietary proteins

54. ‘High’ & ‘Low’ Quality Dietary Proteins
Animal proteins – High quality proteins
(meat, poultry, milk, and fish) are called ‘high quality
proteins’ because they contain all the essential amino acids in
proportions similar to those required for the synthesis of
human tissue proteins
Plant proteins - Low quality proteins
(wheat, corn, rice, and legumes beans) have a lower quality
than animal proteins as they are deficient in 1 or more of the
essential amino acids

55. Limiting amino acid &
Mutual supplementation of proteins
Certain proteins may be lacking in 1 or more of the 8
essential amino acids which limits the growth of the
organism
This AA is called ‘limiting amino acid’
Limiting amino acid is that which limits the weight gain
when the protein is supplied to an animal
If a second protein containing this limiting amino acid is
supplemented in the diet it overcomes the deficiency of the
AA in the first protein and growth occurs in the animal
This is called ‘mutual supplementation of proteins’

56. Limiting amino acid &
Mutual supplementation of proteins
Wheat is lysine-deficient but methionine-rich
Beans is methionine-poor but lysine-rich
If the two taken in diet combined during the same meal
or during the same day to produce a complete protein of
improved biologic value.
Similarly Rice & Pulses supplement each other
Eating foods with different limiting amino acids at the
same meal or during the same day can result in a dietary
supply of proteins with a higher biologic value than either
of the component proteins alone
Animal proteins can mutually supplement plant proteins

57. Limiting amino acid &
Mutual supplementation of proteins

58. Recommended Dietary Protein Allowances
(RDA)
Adult Men & Women 0.75-0.8 g/kg /day
Pregnancy 2.0 g/kg/day
Lactation 2.5 g/kg/day
Infants 2.4 g/kg /day
Upto 10 years 1.75 g /kg/day
Adolescents 1.6 g/kg/day

59. How to know a protein food is of high quality ?
Nutrional Indices or Values
1. By weight gain in animals
2. Serum albumin level restoration in animals following
plasmaphereiss

60. How to know a protein food is of high quality ?
Protein Digestibility Corrected Amino Acid Score (PDCAAS)
"Best'" method of evaluating protein quality based on both the
amino acid requirements of humans and their ability to digest it
Adopted by the US Food and Drug Administration (FDA) and the
Food and Agricultural Organization of the United Nations/Word
Health Organisation (FAO/WHO) in 1993 as "the preferred“
method of assessing protein food quality
Other methods for evaluating the quality of protein are inferior
A PDCAAS value of 1 is the highest, and 0 the lowest

61. How to know a protein food is of high quality ?
PDCAAS of different food stuffs
1.00 - caesin milk protein, egg white, soya protein, whey milk
0.92 beef
0.91 soya bean
0.78 chickpeas
0.76 fruits
0.73 vegetables
0.70 Other legumes
0.59 cereals and derivatives
0.52 peanuts 0.42 whole wheat

62. Other methods of assessing protein food quality
1. Biological Value (BV)
Ratio of nitrogen retained to the N absorbed
2.Chemical Score
mg of EAA /gm of protein compared against egg protein
which is the reference protein - CS 1
3. Net Protein Utilisation (NPU)
Ratio of Nitrogen retained to N intake better than BV
4.Protein Efficiency Ratio (PER)
Weight gain / gm of protein taken
5. Net Protein Dietary Value (NPDV)

63. Nitrogen Balance

64. Nitrogen Balance
Only proteins contain Nitrogen
Measuring bodily nitrogen levels can be the most accurate
way to determine whether the body is receiving adequate,
inadequate, or excess protein.
Nitrogen is excreted in urine, faeces, sweat
Nitrogen Equilibrium, Positive Nitrogen Balance &
Negative Nitrogen Balance
A healthy human adult is said to be in N balance or
Equilibrium, when the daily dietary N intake equals N loss
thro’ urine, faeces and sweat
Nitrogen Intake = Nitrogen Loss in U+F+S

65. Positive Nitrogen Balance
When the Nitrogen Intake exceeds N output the body is said to be in
“Positive Nitrogen Balance”
It means that person is consuming more protein than his body needs.
Ideal state for growing children and adolescents, athletes and body
builders, because the extra protein will contribute to muscle growth.
Excess protein can also help athletes and body builders recover faster
from workouts.
1. During periods of active growth – children, adolescents, atheletes,
body builders,
2. Hormones –Insulin, GH, Androgens
3. During Convalescence – during recovery from an illness, after
surgery
4. Pregnancy – Growth of foetus

66. Negative Nitrogen Balance
When the Nitrogen Output or Loss from the body exceeds N Intake
the body is said to be in “Negative Nitrogen Balance” manifested as
weight loss (body protein is destroyed)
It means that person is consuming less protein than his body needs.
1. Protein deficiency, deficiency of even one of the 8 essential amino
acids as in PEM,
2. Any acute illness, burns, major trauma
3. Any chronic illnesses – malignancy, uncontrolled DM
4. Prolonged starvation
5. Cortisol Excess – ‘stress hormone’
To maintain N balance a minimum amount of protein is required to
be taken in diet daily which is 0.75-0.80 g/ kg/day

67. Alarming statistics
99 million children malnourished in the world
One in every three malnourished children in the
world lives in India (33 million i.e 3.3 crore )
50 per cent of all childhood deaths are attributed
to malnutrition.
In India, around 46 per cent of all children below
the age of three are too small for their age, 47
per cent are underweight and at least 16 per cent
are wasted
15th in Global Hunger Index out of 100 nations

68. Protein –Energy (Calorie)Malnutrition
(PEM/PCM)
Two extreme forms of malnutrition – Marasmus
& Kwashiorkor
Seen among in infants and under-five pre-school
children
Common developing countries due to poor
nutrition
In developed world occurs only in chronically ill,
hospitalized patients and in patients with major
trauma

69. Kwashirokar
Kwashiorkar – Translated as "the sickness the
deposed child gets when the new baby comes”
The word ‘Kwashiorkar’ describes the
malnourished child, which develops when an
infant is weaned from breast-feeding and
substituted on nutrionally deficient milk
substitutes
Sometimes translated as ‘red-haired boy’ in Ga
language of Ghana

70. • OEDEMA
• DERMATOSES
• APATHY
• GROWTH
FAILURE

71. Kwashirokar
Cause
A state of acute form of PEM
Seen 1-5 years of age
that results from a deficiency of dietary
protein in the
presence of a normal calorie or carbohydrate
intake
Major cause is ‘weaning’ - when breast milk is
replaced by an inadequate and often unbalanced
diet when 2nd child is born

72. Classification of Protein – Energy
(Calorie)Malnutrition (PEM/PCM)

73. KWASHIROKAR
Hypoalbuminemia – inadequate supply of AAs
derived from proteins
Impaired synthesis of plasma proteins & other
proteins
Oedema – low Oncotic Pressure of plasma
resulting from hypoalbuminemia and water of
plasma exudes out of the intravascular
compartment in Inter Cellular Space
Fatty liver – decreased incorporation of fatty
TGL into VLDL Hence TGL accumulates in liver
Skin changes (different types of dermatoses),
Hair changes

74. KWASHIROKAR
Growth failure, Apathy, oedema cardinal
features
Mineral and vitamin deficiencies – Vitamin A, B-
complex group, Iron Deficiency anemia
High Insulin levels and Low Cortisol, Epinephrine
levels
Catabolism of muscle – leading to muscle wasting
Decreased synthesis of proteins – plasma
proteins, transferrin, Hb, Apolipoproteins
Accumulation of Fattyacids and TGL as
sufficient precursors are available for fattyacid
synthesis from carbohydrates

75. • OEDEMA
• DERMATOSES
• APATHY
• GROWTH
FAILURE

76. MARASMUS
‘Marasmos’ - Greek word meaning ‘ to decay’ or
‘to waste’
Chronic form of PEM
Deficiency of calories & protein
Prolonged restriction of food - both Calorie
and Protein Deficiency
Wasted and Emaciated
Usually occurs before 1 year of age

77. MARASMUS
No oedema
Mild hypoalbuminemia
Absence of fatty liver
Severe muscle wasting ( less than in kwashirokar)
Body fat absent ( decreased in Kwashiorkar)
Insulin levels low Cortisol levels High
Prognosis better – more easily treatable

78. MARASMUS
Precipitating factors
Parasitic infections, TB, viral infections like
measles, bacterial infections like UTI
Common during times of famine, low SE groups,
among migrant population
Seen in 1 -5 year age group

80. What is the glycemic index?
Glycemic Index (GI)
A scale that ranks carbohydrate
containing food stuffs by how much
they raise blood glucose levels
compared to a reference food.
Reference food is glucose
Ranked from 0 to 100

81. Glycemic Index (GI)
Foodstuff 1 (50 gm CHO) - a
rapid rise in blood glucose
concn. followed by a steep fall
(1 h 15 min)
Food stuff 1
Food stuff 2
These differences in the time
course of postprandial glucose
concentrations are quantitated
by a score called “The
glycemic Index”
Foodstuff 2 (50 gm CHO) – a
gradual rise followed by a slow
decline. (1h 45 min)

82. Glycemic Index (GI) Ranking of food stuffs
GI of food stuffs is ranked from 0 to 100
GI of glucose is considered 100
Low GI 0 – 55
Moderate GI 56 – 69
High GI 70 & above
Lower the glycemic index slower is the ability of
the food stuff to raise blood glucose level
compared to glucose
GI of 41 means ability to raise the blood glucose
is only 41% of that of glucose

83. Glycemic Index (GI): How is it estimated ?
Protocol
1. 25 or 50 grams carbohydrate of test food.
2. Blood samples taken:
1st hour: every 15 minutes
2nd hour: every 30 minutes
3rd hour: every 30 minutes*
3. Values plotted; AUC calculated.
4. Test food response compared to reference food
(glucose) response.
5. Average GI of 8-10 volunteers = GI of test food.
* DM volunteers only.

84. Glycemic Index (GI): Sample Graphs
Adapted from Good Carbs Bad Carbs Reprinted courtesy of Marlowe & Company.

85. Factors Influencing GI Ranking
• Type of starch - Amylopectin greater GI than Amylose
• Physical entrapment – Bran of rice lowers GI
• Viscosity of fiber Foodstuffs with Viscous, Food stuffs
with visocous soluble fibers transform lower GI
• Sugar content - Sucrose less GI (GI 60)compared to
glucose GI (100) or maltose (GI 105)
• Acid content – of food stuffs slows gastric emptying &
lowers GI
• Fat and protein content Fat & protein slow down gastric
emptying, and slows down digestion of starch & thus lower
GI
Ice creams lower GI (35-40) compared to bananas (60-65)
• Food processing - Highly processed foods - high GI
• Cooking – cooking increases GI

86. How does all this affect our glycemic levels?
How does all this make us feel after eating
carbohydrate-containing foods?
Type of starch
Physical entrapment
Viscosity of fiber
Sugar content
Fat content
Protein content
Acid content
Food processing
Cooking
Factors Influencing GI Ranking

87. Glycemic Index Curve – Area Under Curve (AUC)

88. Glycemic Index Curve – Area Under Curve (AUC)

89. Is there any clinical importance & benefit of low GI diet?
Food with a low glycemic index tends to give a
sense of satiety or fullness over a longer period of
time, and may be helpful in limiting caloric intake.
YES!
Blood Glucose
levels
Lipid levels
Weight – Obesity
Heart Disease Risk
Type 2 DM risk

90. Obesity
Obesity is a type of malnutrition
At one end of the spectrum of malnutrition is overweight & obesity
At the other end is undernutrition, marasmus, kwashiorkor
Overweight and obesity are defined as abnormal or excessive fat accumulation
that presents a risk to health.
Due energy or calorie imbalance - energy intake greater than energy
expenditure
Assessment of obesity
Body Mass Index – Weight in Kg
(Height in meters)2
Waist-Hip Ratio – Hip at the most prominent
Waist circumference – is measured 1 inch above umbilicus at a level midway
between the lowest rib and the highest point of iliac crest
High risk of morbidity & developing diseases & indicates metabolically
inert abdominal fat
Men > 102 cm ( > 40 in)
Women > 88 cm ( > 35 inches)

91. Obesity is a type of malnutrition
Overweight & Obesity Undernutrition,
Marasmus,
Kwashiorkar
Normal
Weight

92. Prevalance of Obesity
Prevalence of overweight & obesity
As of 2005 (current world population 7.164 billion)
1.6 billion are overweight
400 million are obese
By 2015 2.3 billion will be overweight
700 million will be obese
Indian Scenario
According to a study in Coimbatore & Chennai & Jaipur
36% of population studied in Coimbatore is obese
24.5 % of males, 30.2 % of females are obese in Jaipur
In Chennai 38 % of males & 33% of females are overweight
Among children 4-6% are obese

93. Cause of Obesity
Energy
Expenditure
Energy
Intake
nutritional, activity levels, endocrine,
genetic, drugs
ENERGY IMBALANCE –
INTAKE GREATER THAN EXPENDITURE

94. Body Mass Index (BMI)
for assessing obesity
Originally devised by Adolphe Quetelet (Hence Quetelet’s Index)
Index of body fat for a particular weight & height (Weight
adjusted for height)
Considered appropriate for population studies only when BMI
was adopted in 1972 as a measure of body fat in & not for
individual diagnosis. But still widely used
BMI = Weight ( Kg)
(Height in Meters)

95. Waist –Hip ratio (WHR)
for assessing obesity
Waist Hip Ratio (WHR)
According to WHO Obesity is if
WHR > 0.90 in males
> 0.85 in females
people with "apple-shaped" bodies with more weight around the
waist face more health risks than those with "pear-shaped" bodies
who carry more weight around the hips.

96. Waist circumference
for assessing obesity
Measured just above umbilicus
Midway between highest point of iliac crest & lower margin of last
palpable rib ( WHO)
Better predictor of mortality than BMI
Your waist measurement compares closely with your body mass index
(BMI), and is often seen as a better way of checking your risk of
developing a chronic disease.
Measuring your waist circumference is a simple check to tell how much
body fat you have and where it is placed around your body. Where your
fat is located can be an important sign of your risk of developing an
ongoing health problem.
Regardless of your height or build, for most adults a waist measurement
of greater than 94cm for men and 80cm for women is an indicator of
the level of internal fat deposits which coat the heart, kidneys, liver and
pancreas, and increase the risk of chronic disease.
Risk High risk
Men > 94 cm (37.0 in) > 102 cm (40 in)
Women > 80 cm (31.5 in) > 88 cm (34.5 in)

97. Effects of obesity - Metabolic changes observed in
obesity
Insulin Resistance
Dyslipaedemia
Glucose Intolerance
Metabolic Syndrome
All are more common with abdominal obesity
Increased risk of Diseases in obesity
Increased incidence of Death
Increased risk of Hypercholesterolemia, hypertriglyceridemia
Coronary Artery disease, cerebro-vascular disease, some cancers, gallstones,
osteoarthritis, and gout
The relationship between obesity and associated morbidities is stronger among
individuals younger than 55 years.

98. Physical Effects of Obesity
Cardiovascula
r
Respiratory disease
Gall bladder disease
Hormonal abnormalities
gout
Stroke
Diabetes
Osteoarthritis
Cancer

99. Body Mass Index (BMI)
for assessing obesity
Category BMI
Normal 18.5 – 24.9
Overweight 25 – 29.9
Grade I Obesity 30 -34.9
Grade II Obesity 35 – 39.9
Grade III Obesity 40 -& Above
Category BMI
Normal 16 - 18.5
Underweight 25 – 29.9
Severely Underweight 15 - 16
Very Severely
Underweight
Less than 15