Specific learning objective (SLO)
At end of the session the student should be able to …….
o Define Nutritional disorder.
o List and classify protein energy malnutrition
disorders.
o Explain the treatment and sequelae of protein
energy malnutrition.
o Define obesity and describe the various
indices used in assessing obesity
Energy Balance
9/5/2023
Obesity
Obesity is the most
prevalent nutritional
disorder in developed
countries
OBESITY
Obesity are defined as abnormal or excessive
fat accumulation that presents a risk to
health.
Fat below skin is Peripheral and around
abdominal organs is Visceral
APPLE or PEAR ?
OBESITY
TYPES
Central
obesity
Peripheral obesity
OBESITY TYPES
Diseases related to Obesity
o Diabetes mellitus & Hyperinsulinemia
o Hyperlipidemia (increased LDL and decreased HDL)
o Metabolic syndrome
o Increased atherosclerosis
o Elevated blood pressure
o Cardiovascular complications
o Premature death
Treatment of Obesity
• Lifestyle modification is the best suitable remedy.
• The goal is to reduce the intake of calories and fat.
• Frequent small meals with lots of vegetables.
• Controlled exercise is very useful.
• Drugs to decrease appetite
• Drugs to decrease fat absorption
• Bariatric surgery –gastric bypass or gastric banding
Protein Energy Malnutrition (PEM)
It is the most widespread nutritional problem in
developing countries; predominantly affecting
children.
1. Kwashiorkor
2. Marasmus
Protein Energy Malnutrition
Kwashiorkor
• It is a disease caused by an inadequate intake of
protein in the presence of adequate intake of calorie.
• This is seen in children after weaning at about 1 year
of age when their diet is shifted to predominantly
carbohydrate.
Symptoms :
Edema,
Plump belly caused by edema
Anorexia,
Enlarged liver and
Decreased serum Albumin.
Protein Energy Malnutrition
Marasmus
• It is caused by a chronic deficiency of calories and
can occur in the presence of adequate intake of
protein.
• This is usually occurs in children under 1 year of age
when the mothers breast milk is supplemented with
thin watery gruels of cereals.
Symptoms :
Arrested growth,
Extreme muscle wasting
Weakness and anaemia
Absence of edema
Kwashiorkor and Marasmus
Marasmus
Kwashiorkor
Age of onset
< 1 yr
1 – 5 yrs
Deficiency
Calorie
Protein
Early weaning and repeated
infections
Starchy diet after weaning;
precipitated by acute
infection
Marked
Present
Irritable and fretful
Lethargic and apathetic
Shrunken with skin and
bones only; dehydrated
Looks plump due to edema
on face; lower limbs also
show edema
Normal
Anorexia
Cause
Growth retardation
Attitude
Appearance
Appetite
Kwashiorkor and Marasmus
Marasmus
Kwashiorkor
Skin
Dry and atrophic
“Crazy pavement dermatitis”
due to pealing, cracking
Hair
No characteristic change
Sparse, soft and thin hair;
curls may be lost
Other nutritional
deficiencies; watery
diarrhea. Muscles are weak
and atrophic
Angular stomatitis and
cheilosis are common,
watery diarrhea. Muscles
undergo wasting. Crawling
and walking are delayed.
Serum albumin
2 – 3 gm/dl
< 2 gm/dl
Serum cortisol
Increased
Decreased
Associated features
PEM
• Severe malnutrition in early life can lead to
permanent and irreversible physical and
functional deficits.
• Changes in mental function and intellectual
• Severe persistent malnutrition can have
deleterious effects on the intellectual capacity
later in life.
Early Clinical Exposure (ECE)
CASE HISTORY - 1
• A 2- Year old boy was brought to the hospital.
He was eating poorly for the last one month ,
had intermittent diarrhoea, and had become
irritable and apathetic.
• On examination, he was underweight for
height and small for age . He was pale , weak,
skin was flaky, hair was brittle, abdomen was
distended, liver was moderately enlarged and
generalized edema was present.
• Laboratory investigations
•
•
•
•
Hemoglobin – 6.5g/dL
Total protein - 4.0 g/dL
Albumin - 1.8 g/dL
What is your probable diagnosis ?
CASE HISTORY - 2
• An 9-month-old girl was brought to the clinic
in an irritable state. Weight was much lower
than expected, mid-arm circumference and
triceps thickness were very low for age.
• Creatinine- height index was low and serum
albumin was normal. The mother tells that
she had stopped breastfeeding at the age of 6
months and was now giving only formula milk
• What is your probable diagnosis ?
Creatinine Height Index
• CHI= 24-hour urine creatinine excretion (mg)/
expected 24-hour urine creatinine excretion
(mg) × 100.
• if CHI 60-<80%, there is mild protein
depletion,
• if CHI 40- < 60%, there is moderate protein
depletion and
• if CHI < 40 %, there is severe protein depletion
DIETARY FIBER
•
The unavailable or indigestible carbohydrate in the diet is
called Dietary Fiber (non – starch polysaccharides).
•
Requirement is 30g/day.
Types:
(a) Insoluble fiber:
Beneficial in colonic function. E.g. Cellulose and lignin
(b) Soluble fibers:
Lowers blood cholesterol level by binding bile acid and delay
the post prandial rise in blood glucose. E.g. legumes and
fruits
IMPORTANCE
•
Improves bowel motility.
•
Prevents constipation.
•
Decreases reabsorption of bile salts thus lowering
cholesterol level.
•
Improves glucose tolerance.
•
Has hypoglycemic and hypolipidemic effect.
•
Provides a feeling of fullness without consumption of
excess calories.
FIBER
PHYSIOLOGICAL EFFECT
Cellulose (Polymer Retains water in feces, increases
of glucose)
peristalsis and bowel action.
Hemi cellulose
(pentose, hexose
and uronic acid)
Retains water in feces,
increases bile acid excretion.
Lignin
(aromatic alcohol)
Antioxidant, increases bile acid
excretion, hypocholestrolemic.
Pectins
Absorbs water, slows gastric emptying,
increases bile acid excretion.
Mucilage
Binds bile acids and lowers cholesterol
level, improves glucose tolerance.
Prescribing a diet
1. It should be a balanced, well planned diet containing all essential nutrients
2. The diet should be simple, locally available palatable and digestible
3. Adequate protein content with essential amino acids, calcium and iron should be
supplied.
4. Calorie intake should be correct and should balance energy expenditure.
5.
should not differ very much from habitual diet
6.
should provide adequate roughage
• While prescribing the diet of a person; the
following general rules are to be remembered.
• The ideal body weight
• Protein requirement
• Calorie requirement
• Specific dynamic action
Steps
•
•
•
•
•
First Step: Calorie Requirement
Second Step: Proximate Principles
Third Step: General Composition of Food
Fourth Step: Determine the Items of Food
Fifth Step: Three Meals Per Day
Diet for Patients with Diabetes
• a. Giving a diet having low glycemic index, so
that elevation in blood glucose is minimal
• b. Giving the total calories in small divided
doses, so that small quantity of food is taken
at frequent intervals (2 hrs) between 6 AM
and 8 AM.
Total parenteral nutrition
• In patients who cannot (unconscious; removal of large part of gut)
or should not (major trauma or surgery) use their gastrointestinal
tract, total parenteral feeding has to be resorted.
• It contains glucose and amino acids. About 10–30% glucose, 1–1.5
g / kg body weight protein, a fat emulsion containing 1–4 g fat / kg
body weight, along with multivitamins and trace element solution
are commonly used.
• The solution should also contain adequate amounts of sodium,
potassium, calcium and magnesium. The solution may be infused
through one of the large vessels like subclavian vein or superior
vena cava, where the blood flow is sufficient to dilute the
hypertonic solution.
Neutraceuticals
•
•
•
•
•
•
•
•
•
•
•
The nutraceuticals, attempt to accomplish desirable therapeutic
outcomes with reduced side effects, as compared with other therapeutic
agents.
However, nutraceuticals need further extensive scientific study to
prove that they have medicinal effects with reduced side effects.
Some examples of the approved neutraceuticals and the reduced risk of
specific disease given in parenthesis:
Potassium (High blood pressure and
stroke);
Plant sterols (Coronary heart disease);
Soy protein (Coronary
heart disease);
• Calcium (Osteoporosis);
• Fruits and vegetables (Cancer);
• Grain products that contain soluble fiber
(Coronary heart disease);
• Folic acid (Neural tube birth defects);
• Resveratrol from grape (antioxidant);
• flavonoids from citrus (antioxiant);
• Omega-3 fatty acids in fish oil (lowered risk of
cardiovascular disease).
Calorie requirement = BMR+SDA+ work pattern (Exercise)