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Dr. Dalia El-ShafeiDr. Dalia El-Shafei
Lecturer, Community MedicineLecturer, Community Medicine
Department, Zagazig UniversityDepartment, Zagazig University
Microcytic, hypochromic anemia.
Decreased HG concentration than standards.
The most prevalent single deficiency state on a
Important economically “diminishes the capability of
individuals to perform physical labor, growth and learning
capacity in children”
1. Decreased intake of animal proteins
2. Bad dietary habits (intake of tea after meals)
3. Parasitic infections
4. Inadequate dietary intake especially when
requirements are high “pregnancy, rapid growth”.
5. Impaired iron absorption “low vit C intake, gastric
Hypoacidity, iron Precipitation by oxalates & phosphates”.
6. Chronic blood loss.
1. Pale skin, loss of appetite & apathy.
3. Decreased attention, learning ability, work performance
& immune status.
4. Dry brittle nails which later become flat & spoon shaped.
2- Haemic murmurs.
3- Blood picture:
Low HG>11gm./dL.(different cut-off(s) in different ages)
Small color index 0.5-0.7.
1.Adequate dietary intake.
2.Dietary supplementation “dry milk and bread”
3.Prevention & control of parasitic diseases & pathological
conditions associated with blood loss.
Early detection by lab testing.Early detection by lab testing.
Deficiency of vitamin B12 & Folic acid arrests the
development of erythrocytes in the bone marrow at
the stage of megaloblasts.
o Pregnant & lactating women due to increased demand.
o Vegetarians whose diet lacks vitamin B12.
o Gastrectomy “lacking of intrinsic factor needed for
absorption of B12”.
o Diphyllobothrium latum infestation as it consumes B12.
o Malabsorption syndrome.
o Medications that treat diabetes, acid reflux, and peptic
GIT, NS, and CVS.
Chest pain or heart palpitations,
Confusion, memory loss, Depression or dementia,
Constipation, Pale skin or jaundice, poor appetite, sore
mouth and tongue and weight loss.
Developmental delays and failure to thrive.
Fatigue or weakness,
Numbness or coldness of hands and feet.
Balanced diet with considerable intake of animal food.
Supplementation of pregnant and lactating women and
vegetarians with B12 and folic acid.
Atrophic gastric mucosa or who had gastrectomy should
be given intrinsic factor.
Regulates the nerve cells of the embryonic development.
C/p: If deficiency during pregnancy
Neural tube defect, spina bifida & anencephaly. Low birth
weight, Preterm delivery, Anemia
Prevention: encourage consumption of Liver, Kidney,
Fish, Green leafy vegetables, and Beans.
Folic acid supplementation if needed.
Def. Bone Softening "bone
replaced by soft osteoid
Bone Atrophy "significant reduction of
bone density & mass more than 2.5 SD "
Path. Vit. D or Ca++ & Ph---deficiency
failure to replace bone
demineralized soft osteoid
Bone mass starts to decline after age 40
ys. due to resorption > formation ---too
little bone but with normal mineral
RF Young women with
Indoor living conditions.
Diet deficient in Ca++, Ph---
Malabsorption & chronic
Post menopasual women & Elderly.
Insufficient intake “Ca++, Ph---, vit.D”
Delayed pubeity, hypogonadism
Endocrinal diseases as cushing's
Drugs “corticosteroids, cytotoxic drugs.
Malignancy (lymphoma), CRF
Low body weight.
C/P Bone-ache, tenderness
Uneven gait due to
May be a symptomatic
Persistant backache due to
progressive compression and
collapse of vertebrae
Kyphosis, hip fracture.
TTT Ca++ & vit. D
Early cases: Ca++, vit. D
Late cases: antiresorptive
Most important cause of blindness in developingMost important cause of blindness in developing
Delayed growth, decrease in iron utilization, follicular
keratosis of the skin & increased susceptibility to
respiratory & urinary tract infections (anti-infection vit.).
Night blindness: nyctalopia or day sight.
Conjunctival xerosis due to affection of the lacrimal gland
Bitot spots in the cornea
Xerophthalmia, Corneal ulceration and keratomalacia
mothers after labor (200 000IU)
infants as drops at 9th month (100 000IU) & another dose at
18th month (200 000IU)
Fortification of foods with vitamin A as margarines,
vegetable oils and dried skimmed milk.
Thiamine (vitamin B1)
Common in South East Asia where many
diets consist solely of white rice.
Affects nervous & circulatory system
C/P: muscle wasting & nerve damage.
Prevention: foods such as pork, beef and whole
grain (unrefined) breads and grains.
Niacin or vit B3 (or
Consumption of corn “poorly absorbed”.
C/P: "3 Ds"; diarrhea, dementia and dermatitis.
Prevention: broccoli, eggs, dates, beef, salmon,
seeds and peanuts.
Vitamin C deficiency
In bottle fed infants, pregnant, elderly, workers in desert
who consumed canned food.
C/P: general weakness, muscle & joint pain, swelling
of gums, bleeding, blepharitis, anemia,
Stomatitis, gingivitis & impaired healing of wounds.
Hge under skin & joints provoked by slight trauma.
Anemia occurs because of decreased iron absorption.
Increase intake of fresh vegetables and fruits. (vit C is
heat labile, easily oxidized and destroyed by storage).
Supplying infant during weaning by orange & tomato juice
Dietary supplementation by food rich in vit C for the
high-risk groups in camps or isolated communities.
Most important cause of preventable brain damage and
mental retardation in babies.
Lower IQ by 10-15%.
Deficiency gives hypothyroidosis and goitre.
Stillbirth and miscarriage.
Cretinism: mental retardation, stunted, hypothyroidis,
Prevention: Iodising salt, Sea fish, sea plants
(vegetables grown on iodized soil).
Def in Ca, ph, vitamin D, and fluorine.
Ingestion of carbohydrates, sugars, & soft drinks with
neglecting oral hygiene.
C/P: growth retardation & increased susceptibility to
infections especially skin & eye lesions.
Prevention: consumption of foods as: Whole-grain
cereals, Legumes, Meat, & Chicken and fish.
Definition: it is excess adipose tissue in different parts in the
body due to excess storage of fat.
The ability to store fat is unlimited but if the amount of fat
to be stored exceeds the ability of the fat cells to expand (50
times its size), the body forms new adipose cells. With
weight loss, fat cells decrease in size but not in
number. Once a fat cell formed, it exists for life.
Imbalance between energy intake & energy
expenditure for long periods of time.
A. Biological factors (non-modifiable):
Brown adipose tissue: interscapular adipose tissue and along
the aorta. Thin persons have more brown adipose tissue, so
that fat oxidized more than stored.
Leptin ”satiety factor: It is a hormone secreted from
adipocytes with central control from hypothalamus. suppress
appetite, deplete fat stores and increase energy expenditure.
In obesity there is a state of leptin resistance at cell level with
hyperleptinaemia leading to some complications as
Ghrelin: hormone produced in the stomach. Its secretion
stimulated by adrenaline and nor-adrenaline which are
released in response to hypoglycemia where it promotes
2. Age: Obesity may appear at any age but obesity in
childhood is predictive to obesity later on adulthood.
3. Sex: Both sexes are exposed. Pregnancy causes increase
in mother weight by 4-6 pounds over her pre-pregnancy
weight. Menopause represents a risk period for extra weight
gain and redistribution of fat towards visceral regions.
B. Behavioural factors (modifiable factors):
1. Diet : eat more than need in quality & quantity :
Taking much sweets, fats and snacks.
Nibbling in between meals.
Consuming soft drinks regularly.
2. Physical inactivity : sedentary occupations, preferring
indoor life and with least activity.
3. Psychological & emotional disorders: anxiety,
psychological stress & depressive illness “emotional relieve”.
C. Environmental factors (modifiable factors):
Family lifestyle and feeding pattern, work problems and
unemployment and effect of advanced technology and
foods advertisements on feeding pattern.
fat distribution in the body which is of morbid
Pear-shaped obesity (gynacoid type): in females,
where fat located in hips and thighs.
Apple-shaped obesity (android type): in males, where fat
located around waist and abdomen.
1. BMI is not a sensitive index (BMI > 30)
2. Skin fold thickness.
3. Relative weight :
(RW=body weight "kg"/desirable body weight "kg" x
RW is supposed to be 100%.
Desirable body weight for each height is obtained
from special tables.
RW > 120% is considered obesity.
4. Waist/hip ratio:
if > 85%: android obesity “more health hazards as
If <85% : gynacoid obesity.
5. Arm Fat Area (AFA):
it is a measure of total body fat (fat weight) and calculated
from mid-arm circumference and triceps skin fold thickness
by certain equation as :
AFA = arm area - arm muscle area.
6. Hydrostatic water weighing (densitometry):
It is comparing of body weight on standard
scale with the weight underwater. By assuming
that adipose tissue is less dense than lean tissue
(muscles and bones), so the more adipose
tissue in a body, the less its underwater weight
(the more it tends to float). It is an accurate
method for estimating the total body fat.
Management of obesity:
I) Life style modification:
1. Diet: decreasing caloric intake by about 500 Kcal./day to
achieve a weight loss of 450 gm/week. Because of the
way the body uses fuel from carbohydrates, fats and protein, a
more rapid weight loss will compel the body to use protein
(muscles) instead of fat for energy. This will decrease muscle
mass with each dieting attempt and fat percentage will
Other principles of healthy eating relevant to weight loss:
Eat plenty of food rich in starch and fibres.
Eat plenty of fruits and vegetables.
Avoid eating too much fat and sugars.
Not skip meals “suppress metabolism”.
2. Physical activity:
Generally walking or swimming are safe exercise for all persons.
Those who are bed ridden or are in wheel-chairs can use upper arm
exercises. Aerobic exercises require more air and tend to use the
highest percentage of body fat for fuel.
1. Decrease body fat while helping to preserve muscles tissue tone.
2. Manage mental stress.
3. Increase energy levels.
4. Control of appetite.
5. Improve blood sugar control in diabetes.
6. Reduce blood pressure.
7. ↑amounts of HDL-C.
8. Improve bone density where weight-bearing exercises can
slow down bone loss after menopause or even increase bone density.
3. Behavioural modification:
By focusing on small, gradual behavioural changes, the
individual learns to gain control on eating behaviours
with the goal of permanent changes in eating habits.
Some basic strategies can be useful in promoting
behaviour changes for sustained weight loss include:
Self-monitoring - behavioural contracting – stimulus
control (which precedes eating) - cognitive restructuring
- stress management - social support physical activity
and relapse prevention.
Some drugs are used to control obesity as those used for
appetite suppression or prevention of fat absorption. Other
drugs used for supplementation of vitamins and minerals
or for management of obesity complications.
It is used in cases of morbid obesity (BMI > 40) or in
cases of failure of other methods to control of obesity.
1. Cardiovascular: main cause of death in obese.
A) Coronary heart disease:
Hyperinsulinaemia (insulin resistance).
B) Hypertension: which lead to more renal sodium retention
and catecholamines release.
2. Diabetes mellitus:
Insulin resistance syndrome: due to defect in the insulin
receptors at the cell level leading to inability of the
body cells to utilize blood sugar to give the needed
3. Other complications:
As: musculoskeletal disorders, gout, some types of cancer
(colon, breast), gall stones, hernias and menstrual
To prevent or manage some medical conditions
To maintain or improve health through the use of
appropriate and healthy food choices
To achieve and maintain optimal metabolic and
DASH eating plan:
-It is a dietary approach to stop hypertension (DASH).
-It is a flexible and balanced eating plan which recommends:
1. More servings of vegetables and fruits (3-4 servings/d).
2. Whole grain cereals and bread.
3. Fat-free or low fat dairy products (3 servings/d).
4. Lower saturated fats, cholesterol and total fats.
5. Limiting lean meat intake.
6. Fewer sweets and added sugars.
7. Low sodium (salt) intake (> 2.3 mg /day.).
8. More foods rich in potassium as: milk, banana, orange, and
9. Two or more vegetarian-style or meatless meals each week.
Making heart healthy lifestyle changes while following the
DASH eating plan is the best way to control hypertension
through the following:
1. Maintaining a healthy weight (in overweight or obesity;
reducing daily caloric intake by 500-1000 kcal. to have
a weight loss of 1-2 pounds /week.
2. Be physically active.
3. Making healthy eating choices that less in sodium (by
using of spices, lemon, vinegar or other salt-free seasoning
4. Stop smoking: as smoking harms every organ in the
Reduced intake of cholesterol, trans-fats, saturated fats &
Saturated fats: <7% of total calories
Dietary cholesterol: <200 mg per day
Total fat: 25–30% of total calories
Increase intake of unsaturated fats as: olive oil and omega-
3oil in fish
Carbohydrate: 50–60% of total calories
Fibers: 20–30 grams per day
Protein: Approximately 15-20% of total calories
Total calories (energy): Balanced energy intake and
*Choose more high fiber foods: (more fruits and vegetables)
To help maintain blood glucose levels and cholesterol levels: As:
*Fruits, *Vegetables* Pulses* Oats
To help maintain a healthy gut: Whole grain cereals,* Whole
grain bread,* Whole wheat pasta,* Brown rice,
*Reduce animal or saturated fat intake
Use low fat milk
Use low fat spread instead of butter
Use oil high in unsaturated fat, e.g: olive oil, omega-3 oils in fish
Use less fat in cooking : grill, dry-roast, steam
*Cut down on sugary foods
Cut out sweets, eat starchy foods.
Cut out sugary drinks .Use diet or low calorie, sugar free drinks
Choose low sugar products
*Reduce salt intake
Cut down on added salt
Use alternative seasonings
Look out for reduced/low sodium foods, e.g: bread
Avoid salt substitutes
Eat regular meals
Intended to reduce the amount of excretory work demanded of the kidneys
while helping them maintains fluid, acid-base, and electrolyte balance.
Patients with CRF may have restricted proteins, Na, K, Ph.
Sufficient calories necessary: 25 to 50 kcal per kilogram of body weight.
Diet may limit protein to 40 grams based on glomerular filtration rate and
weight. Protein increases the amount of nitrogen waste the kidneys must handle.
Sodium may be limited if the client tends to retain it.
Fluids are typically restricted for renal patients.
Calcium supplements may be prescribed.
Vitamin D may be added and phosphorus limited, to prevent osteomalcia.
Potassium may be restricted in some patients because hyperkalemia tends
to occur in end stage renal disease (ESRD).Excess potassium can cause
Renal patients often have an increased need for vitamins B, C, and D.
Iron is commonly prescribed.
Diet therapy in liver cirrhosis:
Provides at least 25 to 35 kcal or more.
In advanced cirrhosis, 50 to 60% of the kcal. should be
taken from carbohydrates.
Provides 0.8 to 1.0g of protein per kilogram of weight each day.
Supplements of vitamins and minerals are usually needed.
Sometimes cirrhosis causes ascites: Sodium and fluids may be
If there is bleeding in the esophagus, fibers can be restricted to
prevent irritation of the tissue.
Smaller feedings will be better accepted than larger ones.
Alcohol is prohibited
Diet therapy in Hepatitis:
Diet should provide 35 to 40 kcal/ kgm. body weight:
provided by carbohydrates with restriction of fat
If necrosis is not severe, up to 70 to 80 grams of protein
for cell regeneration.
If necrosis is severe and the proteins cannot be properly
metabolized, they must be limited to prevent the accumulation
of ammonia in the blood.
Diet therapy in Peptic Ulcers:
Sufficient low-fat protein should be provided.
No less than 0.8g of protein per kilogram of body weight
Avoid caffeine, beverages, alcohol, aspirin, and smoking.
Well-balanced diet of three meals a day.
A) Nutritional excess:
1. Increased caloric intake obesity cancer breast, uterus,
2. Increased saturated fatty acids tumour growth.
3. Excess salting cancer stomach and oesophagus.
B) Carcinogens in foods:
1. Microbial toxins: aflatoxins in long stored nuts cancer liver.
2. Chemical toxins: pesticides, herbicides, nitrogenous fertilizers.
3. Packing materials: soldered canned food, lead pipes cancer
kidney, alum in water purification and cadmium in food industry.
4. Chloroform in water and alcohol.
5. Polycyclic aromatic hydrocarbons from food grilling over direct
6. Food additives: colors, flavors, sweeteners, preservatives.
1. Fibres have a protective effect against cancer colon.
2. Fruits and vegetables: rich in antioxidants (vit. A, E, C).
3. Lenolenic fatty acid (polyunsat. FA) has protective role
against cancer breast and colon.
4. Selenium is an antioxidant and calcium has anticancer
5. Coffee and tea have useful role in prevention of cancer
Infection can lead to malnutrition by causing anorexia,
vomiting, diarrhea or bleeding. Increased supply for
nutrients to compensate for the losses is needed.
Malnutrition interferes with body formation of
antibodies (immunoglobulins) lymphocytes and
phagocytes. Vitamins A, C and B2 are responsible for
normal proliferation of phagocytes and lining epithelium of
the respiratory and urinary tracts. These nutrients
deficiency increases body susceptibility to infection.
In the body the oxidation reactions involve highly
reactive molecules called free radicals. When these
free radicals are released from the mitochondria in
sufficient numbers they threaten the protective
biochemical systems of the body and the cell structures
and functions(damage cell proteins, lipoproteins and
DNA)and can lead to diseases, as cancer, coronary
heart diseases, arthritis, diabetes and neurodegenerative
diseases as Alzheimer.
Oxidative stress: impaired balance between free radical
production and antioxidant capacity resulting in excess
Sources of free radicals:
Extrinsic: as radiation, pollution, smoking, pesticides and
Intrinsic: as stress and inflammation.
Antioxidants are chemical compounds which may be
endogenous as superoxid dismutase enzyme in the human
cells or exogenous as vitamins E, C, A, selenium, zinc and
phytochemicals in foods. These antioxidants neutralize the
free radicals preventing them from damaging healthy cells.
Sources of antioxidants (exogenous):
1. Beta-carotene: in apricots, carrots, mangoes.
2. Copper: seafood, milk, nuts and lean meat.
3. Selenium: onion, garlic, wheat germ, mushrooms.
4. Vitamin C: broccoli, cabbage, strawberry.
5. Vitamin E: whole grain cereals, nuts, wheat germ,
6. Phytochemicals: green tea, apple, citrus fruits, onion,
Functions of antioxidants:
1. Against senility, cancer and cardiovascular diseases.
2. Prevent progress of rheumatoid arthritis, diabetes and
3. Decrease muscle damage in athletes.
4. Prevent rancidity in food preservatives and cosmetics
5. Help to reduce menopausal symptoms and
It is a practice of diet that excludes meat, fish and poultry,
egg, milk and honey i.e., excludes any food from animal
Lacto-vegetarianism: consuming milk and excluding
the other animal foods.
Ovo-vegetarianism: consuming eggs and excluding
the other animal foods.
Semi-vegetarianism: excluding meat only.
Causes of choosing vegetarian diet:
Benefits: it is considered a healthy diet if well planned as it can
reduce risk of cancer, ischaemic heart diseases, hypertension and
Hazards: the only deficient nutrient is vit. B12 as it is found
only in animal protein.