NUTRITION AND HEALTH

J. C. C. Maina
(PhD no-going, MPH – Epidemiology & disease Control,
BSc.N)
KMTC- Nakuru Campus
Department of nursing
 Course outline
• Introduction
• Basic nutrition
• Energy requirements
• Classification of Nutrients
• Clinical importance
• Community Nutrition
• Child feeding and nutrition
• Nutrition in special groups
• Abnormal nutrition and clinical malnutrition
• Assessing the nutritional status of an individual
• Assessing the nutritional status of a community
• Nutritional interventions by health workers
 Introduction

•Def: Nutrition is the process by which food consumed by an

organism is utilised through digestion, absorption, transport,
storage, metabolism and elimination.
– Nutrition is the intake of food, considered in relation to the body’s
dietary needs.
•Good nutrition is an adequate, well balanced diet combined with
regular physical activity.
•According to medical dictionary-It is the process of taking in
food and using it for growth, metabolism, and repair.
•Nutritional stages are ingestion, digestion, absorption, transport,
assimilation, and excretion. It can also be defined as a nourishing
substance, such as nutritional solutions delivered to hospitalized
patients via an IV or IG tube.
 GOOD NUTRITION IS BASIC TO GOOD
HEALTH
• The purpose is to maintain life, growth, normal functioning of organs and
the production of energy.
•It is a cornerstone of good health.
•Poor nutrition can lead to reduced immunity, increased susceptibility to
disease, impaired physical and mental development, and reduced productivity.
• Good Nutrition:
• The physical and mental development of children and adolescents
• Healthy pregnancies and deliveries
• Resistance to infectious diseases
• The ability of adults to work well
• The prevention of deficiency diseases e.g. protein energy malnutrition (PEM), iron
deficiency anaemia, night blindness and goitre.
 MALNUTRITION
• Def: “Bad” nutrition.
•Malnutrition is an abnormal physiological condition that results
from deficiencies, excesses or imbalances in the consumption of
macro and or micronutrients.
• It can be due to under-nutrition or over-nutrition.
• Under-nutrition is common in developing countries.
– Means eating too little food or not enough healthy foods.
– Under-nutrition affects mostly children and pregnant women or
lactating women.
– Under-nutrition is particularly bad for children because it affects their
mental and physical growth and development.
– It is also a major cause of death in children.
• Over-nutrition or eating too much of certain
foods (fats, sugars and refined carbohydrates)
causes obesity and some degenerative
diseases.
 Basic Nutrition
• Foods can be classified into three main groups
based on their nutritional function in the body:
– Energy foods (Carbohydrates)
– Body building foods (Proteins)
– Protective foods (Vitamins)
Each group (except water) contains a large number
of different nutrients with a similar but not
identical, chemical structure.
 Constituents of a diet
Group Function
Carbohydrates As fuel energy for body heat and work
Fats As fuel energy and essential fatty acids
Proteins For growth and repair
Minerals For developing body tissues and for
metabolic processes
Vitamins For metabolic processes
Water To provide body fluid and help regulate
body temperature
Spices and flavourings To add enjoyment to eating
Roughage (fibre), indigestible and To transport other nutrients, add bulk to
unobservable particles the diet, provide a habitat for bacterial
flora and assist in proper elimination.
 BALANCED DIET
• The term “balanced diet” refers to a diet that
has all nutrients required by the body in the
right amounts i.e. carbohydrates, proteins,
vitamins, minerals, fats, and water.

• Figure illustrating
 Energy requirement
•Energy is defined as the capacity to do work. In nutrition, this refers to
the way the body makes use of energy within the food. The ultimate
source of energy in living organisms is the sun through the processes of
photosynthesis. Energy for the body comes from the food we eat. In the
absence of food, energy is produced from the breakdown of body tissues.
• Energy is required by the body for movement and to do work. Energy is
also required continuously by the body even when we are asleep for
metabolism and to keep the heart and other organs functioning. Foods
that provide energy are carbohydrates, lipids (fats and oils). When energy
foods are eaten, they are burned or broken down providing energy and
releasing carbon dioxide. Our body requires energy to make body cells.
• Energy is needed for vital functions like heart beat and respiration, growth, repair
and maintenance of body tissues, and for maintenance of body temperature.
• Energy needs above the normal requirements are needed for:
• Pregnant women need energy to give to the growing baby
• Lactating mother needs energy to produce milk
• Children require energy to grow, run, play, and walk
• Adults need energy to work. Everybody needs energy for metabolism.
• Energy is measured in joules and previously it was measured in calories. There are
4.184 joules equivalent to one calorie.
• Large people, growing children, pregnant and lactating women, sick people, those
doing heavy work and those living in cold places need more energy than smaller,
less active people.
• The burning of food to supply energy is called metabolism.
• Energy is measured in units called Calories (Ca) or Joules.
– 1 Ca = 4.12kilojoules
• Some approximate energy requirements are:
– The average male office worker needs 2500Cal/24 hours
– The average non-pregnant woman needs 2000Cal/24 hours
– A lactating woman needs an extra 500 or 600 Cal/24 hours
– A man or woman doing heavy work all day needs an extra 1000
Cal/24 hours
– A woman who is pregnant and is also breastfeeding needs about
3000 Cal/24 hours.
 Purpose of Energy in the Human Body

Energy is needed in the human body for the following purposes:

1. Required for normal body functions such as the brains, nervous
system and breathing
2. Maintenance of body temperature
3. Continuous action of the heart, lungs and other organs
4. Breakdown, repair and building of tissues (metabolic processes)
Factors that influence energy requirements

The energy requirements of the body are affected by:

 Body size: the larger the body size, the higher the energy needs
 Basal metabolic rate: The higher the metabolic rate the higher the energy
needs
 Activity: for heavy work and play or activity more energy is required than a
sedentary lifestyle
 Pregnancy: Extra energy is needed to develop and to carry additional
weight of the foetus
 Lactation: Energy is needed to produce energy containing milk for the body
 Age: Infants and children need more energy for growth and activity than
older persons. In older persons, there is a decline in activity and BMR
 Climate: In cold climates, more energy is needed to keep the body at its
normal temperature than in hot climates
 Sex: Males use more energy than women for the same body size
 Sources of Energy

•The main energy foods are carbohydrates mainly obtained from

cereals or staples and foods containing lipids (fat/oils) such as
groundnuts, simsim, cashew nuts and also pulses.
•Most energy foods are mixtures of nutrients.
•We call them energy foods because they contain more carbohydrates
or fats/oils than other nutrients.
•Therefore they have more joules of energy than other foods.
• Carbohydrates and fats provide energy but no amino acids therefore
they do not build the body. In a normal diet, it is recommended that
carbohydrates provide ½ or above of the energy needs.
Energy balance and energy deficiency
•There is a relationship between the amount of food eaten, the
energy spent and body weight.
•If a person eats more food than he or she uses, the extra energy is
converted and stored as fat in the body and the person gains weight.
•If one eats less food than he or she needs for energy, the fat
reserves will be used up and the person will lose weight.
•The energy needed for the essential basic metabolic processes (e.g.
heart beat, respiration, maintenance of temperature) is called the
basal metabolic rate (BMR)
•BMR varies with age. Sex, body size, presence of disease (e.g.
goitre) and other factors.
•Basal metabolic rate (BMR) Basal
is theMetabolic Rate
rate at which the body functions are carried
out while the body is at rest.
•These processes include respiration and circulation, synthesizes of organic
compounds, pumping of ions across membranes and to maintain body
temperature.
•The hormones thyroxin and nor-epinephrine are the principle regulators of the
metabolic rate.
•Metabolic rate is highest during periods of rapid growth.
•BMR varies with body surface area, age, sex, body size, diseases such as
goitre and other body functions.
•Fevers increase the metabolic rate.
•Environmental temperatures such as in the tropics result in higher energy
needs than in temperate climates.
•Resting energy expenditure in adult females fluctuates with the menstrual
cycle.
•During pregnancy the metabolic rate is higher due to the processes of the
uterine, placenta development, foetal growth and development and the
mother’s increased cardiac work.
 Table 1: Energy in commonly Consumed Foods in
Kenya

Food Energy in joules in 100gm of food

Lipids
Oils and fats 38kJ
Butter, margarine, animal fat 30-35kJ
Carbohydrates
Sugar 16.2kJ
Wheat flour 15.2kJ
Maize and rice 15kJ
Cassava flour 14.1kJ
Honey 12.1kJ
Cassava (fresh) 4.6
Sweet potatoes 4.1kJ
Bananas 3.1kJ
Irish potatoes 2.9kJ
 Recommended Dietary Allowances

The recommendations for the average daily energy allowance based on

the Food and Nutrition Board, National Research Council and National
Academy of Sciences Washington DC are:
• 2,900 kcalories for a reference man weighing 79 kg
• 2,200 kcalories for a reference woman weighing 63 kg
It is recommended that one gets about 25-30% of energy kilocalories
from lipids, 60% from carbohydrates and 15% from proteins.
 NUTRIENTS: Carbohydrates
Definition of Terms
•Amylase: The enzyme that acts on the starch amylose
•Amylose: a form of starch with long straight chains of glucose units
•Cellulose: a structural carbohydrate in plants that resists hydrolysis in the human digestive
system.
•Deoxyribonucleic acid (DNA): Is found in the nucleus of cells and determines the hereditary
makeup of an individual.
•Dextrin: An intermediate product of starch hydrolysis.
•Disaccharide: A sugar capable of being hydrolyzed to two monosaccharide molecules.
•Fibre: Compounds of plant origin not capable of hydrolysis by enzymes in the human digestive
system.
•Fructose: A monosaccharide occurring in fruits, honey and some vegetables. It is the sweetest
monosaccharide.
•Galactose: A monosaccharide produced by the hydrolysis of lactose by digestive enzymes.
•Gluconeogenesis: The formation of glucose from non-carbohydrate molecules, such as glycerol
and the carbon skeletons of amino acids.
•Glucose: The main monosaccharide in blood and an important source of energy for living
organisms. It is found in large amounts in fruits and honey.
•Glycogen: The storage form of carbohydrate in man (animals).
•Glycogenolysis: The hydrolysis of glycogen to yield glucose.
•Hemicellulose: A group of polysaccharides that resemble cellulose but contain fewer glucose
units, are more soluble, and decompose more easily.
•Insulin: a Hormone secreted by the pancreas that is necessary for metabolism of blood sugar.
•Lactase: The enzyme that acts on the starch lactose.
•Lactose: a disaccharide composed of glucose and galactose. Lactose is the principal sugar found
in milk of mammals such as cow’s milk.
•Lactose intolerance: A condition in which the body is deficient in lactase, the enzyme needed to
digest lactose (the sugar in milk). This generally leads to abdominal bloating, gas and diarrhoea
especially in children.
•Maltose: A disaccharide composed of two glucose molecules.
•Marasmic kwashiorkor: a form of protein energy malnutrition characterized by oedema and
reflects deficiency of both proteins and energy
•Marasmus- A chronic form of protein energy malnutrition in which the deficiency is primarily
energy.
•Monosaccharide: A sugar incapable of being hydrolyzed to a simpler form.
•Pectin: A noncellular polysaccharide made of units of galactose derivative found in fruit.
•Polysaccharide: A carbohydrate that upon hydrolysis yields more than 10 monosaccharide units.
•Ribonucleic acid (RNA): Is found mainly outside the nucleus of the cell. It controls manufacture
of body proteins including enzymes.
•Sucrose: Ordinary table sugar, a disaccharide composed of glucose and fructose found in cane
sugar, sugar beets, molasses, some fruits, vegetables and honey.
 Definition, Composition and Classification of Carbohydrates

Def: Carbohydrates are organic compounds that consist of carbon, hydrogen

and oxygen.
Composition: The general formula of carbohydrates is CnH2nOn.
•They range from simple sugars of three to seven carbons to complex
polymers. In nutrition, the six carbon sugars (hexoses) and the five carbon
sugars (pentoses) and their polymers are the ones that play important roles.
Classification
•Carbohydrates consist of monosaccharide, disaccharides and
polysaccharides.
•Monosaccharides are either aldoses or ketoses.
– Glucose is a monosaccharide that is the most important dietary energy
source.
•Disaccharides of nutritional value/importance are sucrose, lactose and
maltose.
•The primary structure of all carbohydrates is a monosaccharide sugar.
Sources
•Glucose: Sources are fruits, honey and traces in most plants especially
vegetables.
• Fructose: Occurs naturally in fruits such as bananas, oranges, tomatoes,
honey, and traces in most plants.
• Galactose: Comes from the digestion of lactose that is the sugar in milk. It
is not found free in nature except from digested milk
• Carbohydrates are the main source of energy in African diets.
• Carbohydrates are considered the major nutrient because they avert
starvation.
• Carbohydrates form the main staples used in times of food shortage.
• Carbohydrates together with lipids and proteins are referred to as
macronutrients because they are required in large amounts by the body.
Disaccharides
•These consist of two monosaccharide molecules one of which is glucose.
These include the sugars sucrose, lactose and maltose. During digestion
they are broken down in to monosaccharide components.
• Sucrose = Glucose and fructose.
•Lactose = Glucose and galactose.
•Maltose = Glucose and glucose.
Sources
•Sucrose is found in table sugar. It is also found in sugar cane, sugar
beets, molasses and fruits. Sucrose in certain foods causes tooth decay.
• Lactose (milk sugar) is found in milk and some dairy products. It is not
found in plant foods.,.
• Maltose (malt sugar) is found in sprouted seeds and produced in the
digestion of starch otherwise it does not occur naturally in nature
Polysaccharides
•Polysaccharides are complex carbohydrates.
•They are formed from monosaccharides and disaccharides.
•They include starch, glycogen, dextrin, cellulose, hemicellulose and
pectin..
•Starch
– Starch is found only in plants.
• Dextrin
– Dextrin is formed when heat (toasting) or enzymes (during digestion)
act on starch.
• Glycogen
– This is the storage form of carbohydrates in humans and the primary
and most readily available source of glucose and energy. It is stored
mainly in the liver.
Normal Digestion of Carbohydrates
•Mouth
– The enzyme salivary amylase breaks down starch into dextrin and
maltose in the mouth.
•Stomach
– Salivary amylase is inactivated by strong acid medium in the stomach.
•Small intestines
– Enzymes from the pancrease (amylase) and intestine break down starch
and dextrin in to maltose. Enzymes from the walls of the intestine,
sucrase, lactase and maltase break disaccharides sucrose, lactose and
maltose respectively into glucose, fructose and galactose.
Summary of Carbohydrate Digestion
Starch enzyme amylase Dextrin Maltose
Sucrose enzyme sucrase glucose and fructose
Lactose enzyme lactase glucose and galactose
Maltose enzyme maltase glucose and Glucose
Lactase deficiency is when lactose cannot be digested due to deficiency of the
enzyme lactase.
• This leads to nausea, vomiting and diarrhoea. This condition is referred to
as lactase intolerance.
Large intestines
• If fibre intake in the diet is too low, this leads to constipation because water
is absorbed from the faeces.
• Too high fibre content may lead to diarrhoea.
• Therefore in cases of diarrhoea reduce high fibre diets. Fibre is excreted in
the faeces.
 Carbohydrate Metabolism
Monosaccharides
•As soon as glucose is in the bloodstream, it is carried to the individual
cells. In the cells, it is used in three ways:
1. It is metabolised or oxidised immediately as a source of energy.
2. When available glucose exceeds the amount needed for energy, it is
converted to glycogen and stored in either the liver or muscle tissues.
3. When the liver and muscle can no longer store glycogen because they
have saturated their storage capacity, glucose is converted into fat and
stored in regular cells or in special fat storage cells known as adipose
cells.
• Latter when the energy intake is less than required, the body will use the
glycogen stored in the liver and muscle. When glycogen is almost used
up, the body will switch to use fat reserves.
 Functions of Carbohydrates
•Carbohydrates are a source of energy, a dietary essential and a source of palatability in the diet among
others.
•Carbohydrates are the least expensive source of energy in the body. I gram of carbohydrates yields 4
kcalories of energy regardless of the source.
•The specific functions of carbohydrates are:
1. The primary function of carbohydrates is to provide energy. It is recommended that about 60% of the
energy requirement should be provided from carbohydrates in the diet. Glucose is the major source of
energy for the brains, nerve tissue and the lungs.
2. Carbohydrate is a dietary essential. Although carbohydrates can be replaced as a source of energy by
fat and proteins, a series of undesirable symptoms appear when there is no carbohydrate in the diet.
This leads symptoms of weakness.
3. Carbohydrates contribute to protein sparing. The body uses energy from carbohydrates first as a source
of energy. When energy from carbohydrates is insufficient, then the body utilizes energy from proteins.
4. Fat metabolism is possible only with presence of carbohydrates. Inadequate carbohydrates in the diet
results in larger amounts of fat being used for energy than the body can handle.
5. Provides bulk in the diet. Fibre/roughage is obtained from carbohydrates.
6. Lactose remains in the small intestines for a longer time than other disaccharides and encourages
growth of beneficial bacteria. This results in a laxative effect. These bacteria synthesis vitamin K in the
large intestines.
7. Carbohydrates maintain body temperature
8. Carbohydrates are essential in the utilisation of other nutrients in the body.
9. It is a source of sweetness or palatability in the food consumed.
 Sources
•The main carbohydrate sources are:
1. Sugar. This is found in honey, sugar in fruits and other sweet foods.
2. Cereals. This includes cereals such as maize, millet, sorghum, rice
and wheat.
3. Roots and tubers. These are cassava, sweet potatoes, irish potatoes,
yams and arrowroots.
4. Fruits. These include, bananas, pumpkins, pineapples, avocadoes and
many others.
5. Lactose in milk. All other sources of carbohydrates are from plants
foods.
•Although the above foods are often referred to as carbohydrates or
energy foods, it is important to note that these foods also contain protein,
vitamins and minerals to some degree. In the diet, carbohydrates are
mainly provided as starches and sugars.
 Fibre
•Although fibre does not add nutrient value to the body, it acts as a broom
and enables the food to move through the gastro-intestinal tract through the
process of peristalsis and food wastes to be eliminated from the body. On
the other hand, fat clogs up the intestines. Fibre is obtained from plant
sources only.
Sources
•Dietary fibre is found only in plant foods. These include fruits, vegetables,
nuts, whole grain cereals and legumes and whole grain products.
Deficiency
•Inadequate intake of proteins and carbohydrates leads to protein energy
malnutrition (PEM). This condition is due to starvation and not enough
proteins and energy foods. PEM can be kwashiorkor, marasmus or marasmic
kwashiorkor which are severe forms of PEM. Mild PEM may not show
specific signs but generally the child is underweight for his/her age and not
as active as their age-mates.
•Marasmic kwashiorkor
•This is mainly due to consumption of inadequate protein and energy foods.
•In children this condition is evident through symptoms indicated below.
•Common symptoms of a marasmic kwashiorkor child are:
 Child is underweight for his/her age
 The child is very thin
 Legs and hands are like sticks
 The ribs are visible
 Very thin muscles
 Big head
 Thin face like that of an old person
 There is loss of appetite.
 Marasmus occurs at an age. The child takes long to heal. This condition is
due to a starvation.

Marasmus
•This is due to deficiency of carbohydrates in the diet. It is rare that a child
suffers from marasmus alone because a child who is deficient in carbohydrates
is most likely to be deficient in also proteins and other nutrients.

Recommended Dietary Allowance

•There is no recommended dietary allowance for carbohydrates.
 FATS AND OILS

•Fat is a lipid that is solid at room temperature while oil is a lipid that is liquid at
room temperature.
•Like carbohydrates, fat is composed of carbon, hydrogen and oxygen.
•However, the ratio of oxygen to carbon and hydrogen is much lower than in simple
carbohydrates.
•Dietary fat is composed of two major components.
•These are a three carbon molecule (glycerol) with one to three compounds called
fatty acids (FA) attached to it. Lipids are a group of compounds that include ordinary
fats and oils, waxes, and related compounds found in foods and the human body.
– Fat- Solid
– Oils- Liquid

Fats are:
 Insoluble in water
 Soluble in organic solvents and
 Capable of being used by living organisms.
Composition of Dietary Fat
– Fat is a lipid that is solid at room temperature while
– Oil is a lipid that is liquid at room temperature.
•Like carbohydrates, fat is composed of carbon, hydrogen and oxygen.
However, the ratio of oxygen to carbon and hydrogen is much lower than in
simple carbohydrates. Dietary fat is composed of two major components.
•These are a three carbon molecule (glycerol) with one to three compounds
called fatty acids (FA) attached to it.
Fats when digested in the intestine, release glycerol and fatty acids.
 Types of Fatty Acids
Saturated fatty acids
•In fatty acid chains, each carbon atom between the methyl end and the carboxyl end
has the capacity of holding or having two hydrogen atoms attached to it.
•When every carbon atom has two hydrogen atoms attached, the maximum number
possible, the fatty acid is called a saturated fatty acid.
•A saturated fatty acid has two hydrogen atoms (the maximum possible) attached to
each carbon in the chain.
O H H H
HO----C-------C-------C--------C------------------------C---H
H H H H H

Long chains above 12 carbons are the ones that common in food.
The longer the carbon chain and the more saturated, the harder the fat at room
temperature.
The exception is coconut oil which is highly saturated and liquid at room
temperature because of the many short-chain fatty acids.
 Unsaturated fatty acids

•These are fatty acids that have fewer than the maximum number of hydrogen atoms attached to
the carbon chain.
•These have double bonds in their structure.
•
•Monounsaturated fatty acids (MUFA)
•Monounsaturated fatty acids (MUFA) are fatty acids in which one hydrogen atom is missing
from each of the two adjacent carbons, resulting in a double bond between the two carbons.
These have only one double bond in the structure.
O H H H H H H H
HO-----C------C--------C-------C-------C====C-------C------C--------C-------C---H
H H H H H H H H H

•For example olive oil has a predominance of oleic acid (77%) a monounsaturated fatty acid.
•
•Polyunsaturated fatty acids (PUFA)
• Polyunsaturated fatty acids (PUFA) are fatty acids in which double bonds between carbon
atoms appear in two or more places. For example corn oil has predominance (59%) of
linoleic acid, a polyunsaturated acid.
 Essential Fatty Acid (EFA)

•This is a fatty acid that must be provided in the diet for good health.
•There are three EFAs, linoleic, linolenic and arachidonic acids.
•These three cannot be produced by the body.
•These fatty acids are known to cure dermatitis or inflammation of the
skin and to restore the growth of young animals that have fed a diet low
in fat.
Omega 3 Fatty Acids
•Omega 3 fatty acids are found in salad cooking oils and margarines
and shortening made from canola or soybean. Fish oils and shellfish are
also rich in omega 3 fatty acids.
 Characteristics of fats and oils

Lipids are:
1. Insoluble in water therefore floats. Because they are insoluble in water,
they may cause problems in digestion. Fat soluble substances are not
excreted after they are absorbed in the body.
2. Provide satiety as it floats therefore other foods are digested before it.
• Fats are invisible in foods such as nuts, beans, meats, germ of grains,
eggs and diary products.
 Functions of fats and oils in the diet

1. Provide energy in a more concentrated form than carbohydrates. 1gm

of fat gives 9kcalories of energy. Therefore it provides 2¼ times more
concentrated in energy than carbohydrates or proteins.
2. Acts as a carrier of fat soluble vitamins A, D, E and K.
3. Are a source of essential fatty acids (EFA) needed by the body.
4. Provides palatability in the food. It gives taste, flavour and juiciness
that enhance food. Most times, nutritious food is not the most palatable.
5. Provides satiety value of foods. Therefore it has negative effects
immediately before sports or athletic events.
 Functions of fats and oils in the body

They act as:

1. Energy reserve in the body
2. Insulates the body and keeps it warm. Maintains body temperature as
the cell membranes combine with phosphorus to form layers.
3. Protects important body organs like liver, kidney and heart.

•The levels of carbohydrates and fats in the diet should be enough to

provide needed energy so that the protein in the diet is spared for other
functions.
Sources
•The main sources of lipids in Kenya diets are:
1. Found in foods such as avocado, simsim, milk, coconuts,
groundnuts and all other nuts and fatty meats.
2. Foods high in cholesterol are of animal origin such as eggs and liver.
Foods high in fats are not necessarily high in cholesterol.
• Fats and oils used in food preparation are also a source of fat in the
diet.
 Deficiency and Excess

•Deficiencies of lipids in general in the diet are rare however there are
deficiencies of the essential fatty acids.
Deficiency of Essential Fatty Acids (EFAs)
•This leads to a condition known as dermatitis.
•This is a condition characterized by inflammation of the skin. Occurs mainly in
infants fed on non-fat milk formula.
•Breast milk provides enough of the (EFA).
•In adults deficiency is rare although it leads to cases of reproductive failure;
impaired foetal development and lactation failure have been reported. Linolenic
and linoleic are found in the same foods.
Excess
•Excess of fat in the body leads to obesity. Problems of lipids are connected to
heart diseases especially cardiovascular diseases and cancers.
Recommended Dietary Allowances
•It is recommended that one gets 25-30% of energy kilocalories from fats and
oils.
• Fats from animals (meat fat and butter) contain more saturated fatty
acids than fats of vegetable origin.
• Vegetable fats (except for coconut oil) and fish fats are rich in
polyunsaturated fatty acids.
• Saturated fatty acids in the diet causes degenerative disease of the
heart and blood vessels
• Fat makes food more tasty and yields up to 9 Cal/g
• Fat is also useful as a vehicle for the fat soluble vitamins
• Fats from the diet and fats converted in the body from excess
carbohydrates are stores in the body – under the skin, around the
organs, as an energy reserve. This reserve is used when the energy in
the diet is insufficient.
 PROTEINS

•Proteins are complex combinations of amino acids that are essential parts of
all living cells.
•Proteins are synthesised from basic units called amino acids.
•It is nitrogen that distinguishes proteins from carbohydrates and lipids.
•Amino acids are the units from which protein is synthesised and from which
it is broken down during digestion.
•Therefore proteins are many amino acids linked together.
• Protein is an essential part of all living cells and is needed for growth and
repair of tissues.
• Extra protein is needed for pregnancy, lactation, growing children and
during sickness.
• There are thousands of different proteins in both animal and plant foods.
These proteins are made of about 26 different amino acids.
• The body can convert some acids, but there are eight that it cannot make;
these are called the essential amino acids and we must get from the protein
in our diet.
• Proteins are made from carbon, hydrogen and oxygen.
• They also contain nitrogen and sometimes sulphur.
• Nitrogen is important for growth and repair of the body.
• Protein is broken down into amino acids.
• All extra amino acids from the diet are broken down and the
nitrogen component of the compound is separated and eliminated
from the body as urea.
• The rest of the structure is converted into fat or glycogen.
 Types of Amino Acids
• There are two types of amino acids, essential amino acids and non-
essential amino acids.

Essential amino acids

•These are the amino acids that cannot be synthesized by the body. They
therefore must be provided in the diet. There are eight known essential
amino acids. These are: Lysine, methionine, phenylalanine, leucine,
isoleucine, valine, tryptophan, threonine and histidine and possibly
arginine.
Non-essential amino acid
•These are the amino acid that can be manufactured or synthesized in the
body as long as enough nitrogen is available. These are: glycine, tyrosine,
aspartic acid, glutamic acid, alanine, serine, arginine, glutamine,
asparagines, proline, and glutamine.
 Protein Quality
•The quality of protein is determined by the kind of amino acid a food
contains.
Biological value
•Proteins that contain all essential amino acids in proportions capable of
promoting growth when they are the sole source of protein in the diet are
described as complete proteins or good quality proteins or proteins of high
biological value. All animal proteins except gelatine are complete proteins.
• Incomplete proteins also known as poor quality proteins or proteins of
low biological value are those that lack or have limited amounts of one or
more essential amino acids. These are proteins from plant sources.
 Functions of Proteins
Proteins are involved in:
•Growth and maintenance of body tissue, regulation of many of the normal
workings of the cell, maintenance of body neutrality, antibody formation and
transport of nutrients.
•Additionally, proteins are used in the production of energy when there is not
enough energy available from carbohydrates and lipids.
Growth and maintenance of tissue of body tissue
•Growth or increase muscle mass is possible only when there is an appropriate
mixture of amino acids over and above those needed for maintenance and repair
of tissue. Protein of the body is in a dynamic state. It is constantly broken down
and re-synthesized.
Formation of essential body compounds
•Proteins are used to form hormones, enzymes, pigments.
•Hormones are produced by various glands in the body.
•This includes the hormones insulin, gastrin, growth hormones all of which
are proteins.
•Every body cell contains many different enzymes all of which are proteins.
•The enzymes facilitate digestive changes in food.
•Haemoglobin, the pigment found in the blood is responsible for the red
colour and the blood’s capacity to carry both oxygen and carbon-dioxide is a
protein substance.
•Almost all the substances involved in blood clotting are proteins.

Regulation of water balance

•Water in the body is contained in two different compartments in the tissues.
Little proteins in the body results in an accumulation of fluid in the tissues
that makes them soft and spongy and gives a somewhat bloated appearance.
•This condition is known as oedema.
Oedema
•Condition caused by protein deficiency in which fluid collects in body
tissues.
•Oedema has several causes but it is recognised as an early sign of protein
deficiency.
Antibody formation
•Antibodies are produced by the body to fight off foreign substances such as
bacteria.
•The body’s ability to fight infection depends on its ability to produce
antibodies.
•These are proteins that react with particular infective organisms or foreign
substances that may enter the body.
•The body must produce an antibody specific to each organism or foreign
substance.
•The need for protein for this purpose may be very extensive.
Transport of nutrients
•Proteins play an essential role in the transport of nutrients from the
intestines across the intestinal wall to the blood, from the blood to the
tissues, and across the cell membranes.
•Most substances necessary to transport specific nutrients are proteins.
Proteins in excess of the above functions is used as a source of energy or
stored as fat.
 Digestion and Absorption of Proteins
Digestion
•Dietary proteins consist of complex units of amino acids joined together and
these are too large to pass through the intestinal wall. In order to be absorbed,
they must be broken down in the digestive tract to simple units of one, two or
three amino acids. Digestion of proteins is accomplished by action of the
enzymes proteases that are available in the stomach, small intestines, and
intestinal wall.
Absorption
•The amino acids, formed in the process of digestion are in a simple enough
form chemically to pass from the wall of the intestinal tract directly into the
bloodstream.
 Metabolism of Proteins

1. Proteins are not stored in the body.

2. When energy intake is adequate, the amino acids derived from dietary
protein are used first to make body proteins.
•The end products of protein metabolism are the same as those that result
from metabolism of carbohydrates and fats.
•These are carbon-dioxide, water and energy.
•However, the body must get rid of leftover nitrogen as urea.
•This strains the body in the case of excessive protein intake in the diet.
 Deficiency of Proteins

•Deficiency of proteins and energy foods leads to kwashiorkor.

•This is Ghanaian name that means a displaced person/child.

Symptoms:
 Round swollen cheeks
 Oedema in the legs and hands. Too fat as swollen with water.When press
a finger, it leaves a hole/dent.
 Big stomach
 Weak lose muscle
 Pale thin hair that is easily pulled out.
 Pale skin that peels off easily.
 Sad looking and inactive
 May stop walking and growing
•Kwashiorkor is got quite easily. Children may die early or get well
quickly if attended to.
Marasmic kwashiorkor: This is a state where a child is very thin like
marasmic child but also has oedema like a kwashiorkor child. The child is
inactive and has no appetite.
N/B: Most under nutrition is not seen.
It is therefore important to take a child for growth monitoring so
that loss of weight can be identified early and corrective feeding done.
Excess of Protein Intake: Leads to deamination and elimination of
proteins through the urine.
• Excess intake also heavily stresses the kidneys and the liver as these
organs struggle to eliminate the excess nitrogen from the amino acids.
• Since excess proteins can be converted into fat, excess intake also leads
to obesity.
Recommended Dietary Allowances
•Daily protein requirements are: women 60 grams, men 65 grams,
lactating and pregnant women 65 grams per day. Proteins are not stored in
the body therefore they need daily intake.
• Protein deficiency results in energy protein deficiency diseases.
• Deficiency of protein causes a disease called kwashiokor which mainly
affects children during the weaning period.
Marasmus Kwashiorkor

• Severe weight loss and wasting • Bi-lateral oedema and fluid accumulation
• Ribs prominent • Loss of appetite
• Limbs emaciated • Brittle thinning hair
• Muscle wasting • Hair colour change
• May have good appetite • Apathetic and irritable
• With correct treatment, good prognosis • Face may seem swollen
• High risk of death
 Minerals
•Together with vitamins, minerals are referred to as micronutrients.
• The body needs minerals for various functions:
• Sodium, potassium and chlorine are found in the body fluids
• Some minerals form part of body tissue (e.g. calcium and phosphorus in bones), some
form part of certain hormones
• Minerals found in the human body include:
– Calcium
– phosphorus,
– Potassium
– Sodium
– Sulphur
– Copper
– Magnesium
– Manganese
– Iron
– Chloride
– Chlorine
– Iodine
– Flourine
 Minerals:
Iron
•Iron is important for transport of oxygen in the body.

Functions
•Iron is a carrier of oxygen and carbon dioxide.
•It is used in blood formation to make haemoglobin, the red pigment in blood that is
responsible to carry oxygen from lungs to the cells.
•Iron plays a vital role in the body’s immune system.
– It is used in antibody production and detoxification of drugs in the liver. It eliminates old red
blood cells and builds new cells.
•It makes haemoglobin. Iron builds blood. Iron is found in haemoglobin of the red blood
cells.
• It is found in the muscle of pigment myoglobin
• Is also an important constituent of many enzyme system
• Iron-deficiency anaemia is the most common nutritional deficiency disease worldwide.
• Foods rich in iron include meats, seafood, beans, greens, including kale and spinach
and nuts
 Factors Affecting Absorption of Iron in the Body

•The body’s need for iron, the higher the need the more the absorption.
The form of iron, the hem iron is more easily absorbed. The composition
of the meal influences the amount of iron absorbed. When the meal has
iron from plant sources, the inclusion of vitamin C rich foods in the meal
enhances iron absorption. Iron absorption is inhibited by pyhtic acid.
Inhibitors
•The practice of taking tea (especially when tea leaves are boiled), coffee,
and chocolates with or immediately after meals is not recommended
because they contain tannins which bind iron and inhibit its absorption.
Enhancers of Bioavailability of Iron
•Bioavailability of iron is enhanced by consumption of foods with
vitamin C rich foods; Serve plant and animal sources of iron in the same
meal; fermentation, sprouting, malting and germination of pulses and
other grains increases iron absorption.
Food Sources
•Animal sources such as liver, egg yolk and other meats.
•Plant sources include: pulses, nuts, dried fruits, molasses, dark green
vegetables such as spinach, black night shade, amaranthus, kale, stinging
nettle.
•Plant sources of iron are best consumed with vitamin C rich foods, to make
iron more availability.
•Milk, milk products and sugar have no iron
Deficiency
•Nutritional anaemia is caused by dietary deficiencies of one or more of the
following: iron, vitamin B6, protein, vitamin C and copper.
•In Kenya and most developing countries deficiency may also be due to
hookworms or bilharzias and malaria that destroy the red blood cells.
Symptoms of Anaemia
•Common symptoms of iron include tiredness, parlour of the mucous
membranes, palpitations and breathlessness.
 Recommended Dietary Intakes (RDI) for different age-groups

Age Group/Sex Amount in (mg)

Diet *
H M L
Children both sexes
0-6 months - - -
6-12 months 7 11 27
1-5 years 6 11 14
5-7 years 7 10 10
7-10 years 8 12 23
Boys
10-12 years 8 12 23
12-16 years 12 18 36
16-18 years 8 11 23
Girls
10-12 years 8 12 23
12-16 years 13 20 40
16-18 years 16 24 48
If pregnant 26 38+ 76+
Men Active
18>60 years 8 11 23
Women Active
Child bearing 16 24 48
Pregnant 26 38 76
Lactating 9 13 26
>60 years 6 9 19
•Source: WHO, 1985, (Savage and Burgess, 1998)
• Note: + supplements needed to provide enough iron
• # No available data. Assume breast milk is adequate
• * H a high iron bioavailability diet (about 15% iron absorbed)
• M a medium iron bioavailability diet (about 10% iron absorbed)
• L a low iron availability diet (about 15% iron absorbed)
 Potassium
•Potassium occurs in the cells where it balances sodium in the intracellular
fluids.
•Humans contain twice as much potassium as sodium.
Functions
• Healthy functioning of cells depends on potassium.
• Is an electrolyte that is necessary for muscle building, organ and tissue
repair, carbohydrate metabolism and protein synthesis
•Together with sodium it regulates the water balance and acid base
equilibrium.
Deficiency
•Primary deficiency is unlikely because all cells have potassium.
•Secondary deficiency is possible in the case of diarrhoea as the potassium is
excreted in the faeces.
• Lack of potassium will cause fatigue or muscle cramps, but a severe
potassium deficiency or hypokalemia can cause serious problem such as
irregular heart function, nervous system impairment and even death
Sources
•Bananas
• Food source include:
– Legumes, whole grain,
– leafy vegetables,
– meats and
– fruits such as ripe bananas.
 Chlorine

•Makes up about 0.15% of the body weight.

Functions
•Chlorine as part of hydrochloric acid is necessary to maintain the
normal acidity of the stomach contents required for action of gastric
enzymes.
Sources
•Table salt, sometimes water, and human milk.
Deficiency
• No deficiency is found in breastfed infants. In none breastfed infants
those on formula deficiency may lead to death
 Phosphorus
• About 85% of phosphorus is found in the teeth, and bones and 15% has
various functions in the body.
• Is a component of bone, teeth and a number of enzymes in the body.
• It helps build strong bones and teeth
• It is involved in the energy release from fat, protein, and carbohydrates
during metabolism and is involved in the formation of cell membranes and
many enzymes
Functions
•Formation of nucleic acids DNA, and RNA.
•Part of the adenosine triphosphate necessary for energy release.
•It is part of the cell membranes.
•It is required for the B vitamins to perform their coenzyme functions.
Sources
Milk and dairy products, cereals, dried beans, peas, fish, meat, poultry, eggs
and nuts.
•Deficiency: Primary deficiency is not possible as it is found in the cells.
•Deficiency of phosphorus is rare, but can result in the:
– weak, fragile bones,
– fatigue,
– loss of appetite,
– less energy and
– susceptibility to infections
 Magnesium

•About 70% of magnesium is found in the bones and teeth together with
calcium and phosphorus.
•The remaining 30% is found in the red blood cells and cells of various
tissues especially muscle tissues.
•Like calcium it is poorly soluble, absorbable and it is easily soluble in
acidic state.
Functions
•Magnesium is a component of the skeleton. It is used in the metabolism of
carbohydrates, proteins and fats. It stimulates the cells; it is responsible for
relaxation of muscles.
Sources
•Groundnuts, beans, soy beans, and cereals.
•Milk contains enough to cover dietary requirements of infants but not
adults.
Deficiency
•Usually occurs as a complication of diseases or stress.
Calcium
•An average adult contains 1250grams of calcium in the bones and teeth,
blood and extra cellular fluids and soft tissues.
Functions
•Calcium is essential for skeleton development and clotting of blood.
•It works together with vitamin D to build strong bones and teeth.
• It is important for the functioning of the heart and muscle functions, blood
pressure and immune defences.
• Bones and teeth are made mainly from protein and calcium
• Calcium is involved in bone formation, tooth formation and general
metabolic functions including blood coagulation, nerve transmission and
muscle contraction and relaxation.
Sources
•Milk and cheese are the richest, bony fish (omena), green vegetables (cowpea
leaves), oil seeds and pulses (dried legumes) and cereals such as millet, dairy
products, eggs and nuts.
 Recommended Dietary Allowance (RDA)

•Adults 400-500mg/day
•Children 500-800 mg/day
• Pregnant and lactating mothers 1000-14000mg/day
• Pregnant and lactating women as well as growing children need
extra calcium
Deficiency
•Deficiency of calcium leads to rickets in children.
•Rickets may also be due to vitamin D deficiency resulting in calcium
deficiency.
•In adults, deficiency of calcium leads to osteomalacia and tetany.
•In this case, calcium is taken from the bones. The bone is normally formed
but becomes decalcified.
•Osteoporosis is due to aging due to lack of absorption of calcium.
– The bone becomes more and more porous.
•Proteins promote calcium absorption.
•Risks of osteoporosis that are unavoidable are:
– sex, females are more prone than males; early menopause, small frame
and family history.
•Risk factors that are avoidable include:
– a life long low calcium intake,
– inactivity,
– smoking high alcohol intake and
– underweight.
 Iodine
•Iodine is an essential trace element that is a constituent of the thyroid
hormones.
•It is found concentrated in the thyroid gland but also found in salivary,
mammary and gastric glands and in the kidneys.
•Iodine found in ocean waters but it is unevenly distributed in the soils.
•Soils in mountainous regions and in areas with frequent flooding have
relatively low iodine levels.
Functions
•Iodine ensures the development and proper functioning of the brain and
the nervous system.
•As part of the thyroid hormone, thyroxin, iodine plays a major role in
regulating growth and development.
•It is used in energy metabolism.
•It is essential for reproduction.
 Sources
•Sea foods such as seaweed, shellfish, sardines, iodised salt and plants
depending on the levels of iodine in the soils where grown.
•Levels of iodine in tropical countries will have losses due to:
 Long term exposure to air, moisture, light and heat
 Contaminants in salt may also enhance losses
 Deficiency
•Deficiency of iodine leads to goitre, a swelling in the neck.
•This is due to enlargement of the thyroid gland as it attempts to
compensate for lack of iodine essential for the synthesis of thyroxin.
•Deficiency is common in areas of flooding, tropical rains, highlands that
have iodine leached from the soils.
• Cretinism: This occurs among children born of mothers who have had
a limited supply of iodine intake during adolescence and pregnancy
and who live in goitre endemic areas.
• Children become physically dwarf (small) and mentally retarded,
have thick, pasty skin and enlarged protruding abdomen.
 Recommended Dietary Intakes (RDI) for Various Groups

Age/group/sex Amounts micro grams

0-6 months 40
6-12 months 50
1-3 years 70
3-7 years 90
7-10 years 120
10 years-adults 150
Pregnant women 175
Lactating women 200
Source: WHO/UNICEF/ICCIDD,
1993
 Zinc
•Zinc occurs in all living tissues.
•It is a component of many enzymes and is part of the hormone insulin molecule.
Functions
• It is a component of many enzyme systems that function in:
– tissue growth, maintenance and healing;
– metabolism of carbohydrates, proteins and lipids and synthesis and
degradation of nucleic acids (DNA and RNA) and therefore important in cell
division.
– Other functions include:
• sexual maturation and reproduction,
• development of immune reactions,
• contributes to wound healing as concentrated in wound tissue,
• plays a role in growth as it has a role in protein synthesis.
• It enhances the sense of taste therefore it is required for restoring taste and
Deficiency
•Zinc deficiency leads to delayed sexual development, growth failure, loss
of sense of taste, mental lethargy, skin changes, delayed wound healing,
reduced resistance to diseases and low birth weight babies.
•Zinc supplementation has been found to reduce the severity and duration
of diarrhoea, pneumonia, malaria and HIV/AIDS.
Dietary Sources
• The richest sources of zinc are fish, poultry and meats.
• Eggs and dairy products are free of phytates but their zinc content is
not known.
• Nuts and seeds such as pumpkin seeds, melon seeds, simsim, almonds,
and cooked beans are high in zinc.
• Fermentation of staples (porridge from fermented cereals) increases the
amount of phytase which breaks down the pyhtates.
 Sodium
Function
•Sodium functions are osmotic pressure in the fluids in the body.
•Sodium is also essential for the transport of glucose and other nutrients
across membranes especially in the intestine.
Deficiency
•Signs of deficiency of sodium are lethargy, nausea and vomiting, irritable,
confused, weak and sometimes hostile.
Excess
•Excess in adults may even be lethal.
•For infants, due to immature kidneys that have limited ability to excrete
sodium, too much is harmful.
Dietary Sources
•Iodised cooking salt is the main source.
•Vegetables such as carrots and spinach, milk and meat contain some
sodium. Most foods contain sodium.
Recommended Dietary Allowance
•1050 milligrams per day
 Vitamins
• Vitamins are needed in small quantities, to act as catalyst for metabolism.
• They are classified into:
– water soluble (Vitamins B and C) and
– fat soluble (A, D, E and K)
• The Vitamin of most public health interest in Africa is Vit. A
• Vit. A was discovered in 1913
• Is fat soluble
• Is also called retinal is found only in foods of animal origin.
• The main sources of Active vit. A are butter, liver, eggs, milk and some kind of
fish.
• In Africa most people get vit. A from beta carotene which is found in abundance
in dark green leafy vegetables (Sukuma wiki -Kales, mchicha, spinach and the
leaves of beans, sweet potato, cassava and of many wild plants traditionally used
as vegetables), Maize (the only cereal with beta caritene) and palm oil.
• Vit. A is stored in the liver
 Vitamins
•Vitamins and minerals are referred to as micro-nutrients because they are
required in very small amounts in relation to the other nutrients but they
are essential for good health
•Vitamins are organic substances that we take in foods but are unrelated
chemically.
•They are required or essential or vital for normal functioning of the body
and must be supplied in the diet.
•They are essential to health and life because without them, the body
cannot use other nutrients.
•They are therefore required for specific functions.
•Vitamins are special molecules made mostly by plants and are needed in
very small amounts.
 General Functions
•They are essential for the digestion and utilisation of the energy producing
elements (proteins, fats and carbohydrates) and minerals present in the diet.
•They are required for specific metabolic functions, growth and physical
well being.
•They are also referred to as micronutrients. High intake of some vitamins
in the synthetic form may damage health and may cause death.
•Most vitamins are not made in the body so they must be obtained from the
diet. Vitamins differ in their RDAs, different units of measure, stability and
interactions.
 Classification
•Vitamins are classified into two groups.
1. Fat soluble: Vitamins A, D, E and K and unutilised supplies can
be stored in the body.
2. water soluble vitamins: vitamins B complex and C and cannot be
stored in the body therefore they must supplied daily in the diet
 Functions
Eye function
•Vitamin A is responsible for vision in dim light.
•If there is no adequate supply of vitamin A, this can be noted when one
moves from a lighted room to a dark room, they ca’t see well.
Making and maintenance healthy epithelium
•Vitamin A maintains the health of cells and is responsible for the
formation of epithelial cells.
•Essential for keeping the body lining moist and protecting the skin
Essential for an effective immune system
•Vitamin A is essential for proper immune function.
•The vitamin protects the skin and the body against infections. It also plays
a role in the effectiveness of the senses of taste, smell, vision and hearing.
 Sources

•Liver, egg yolk and dairy products are rich

sources. Precursors are found in deep yellow and
dark green leafy vegetables and fruits such as
pumpkins, sweet potatoes, paw paws, sukuma
wiki, cowpea leaves, spinach, amaranthus, kales,
spider weed (saga) managu and carrots.
 Deficiency
•Deficiency of vitamin A leads to the immune system being compromised and
impairment of the visual system which progresses to xerophthalmia.
• Inability to see in deem light especially in the evenings which is referred to
as night blindness (nyctalopia) and dryness of the eye (exophthalmia and
kerotomalasia).
•This condition can be corrected by taking vitamin A supplementation.
Reduced immune system
• A continual low intake of vitamin A leads to dry, scaly skin and increases
skin and other infections (follicular keratosis). Early treatment with vit. A
pills will reverse these conditions.
•This leads to slow healing of wounds; the skin hardens and does not secrete
sufficient mucus.
•Lowered resistance to bacterial and viral infections occurs, therefore increased
vulnerability to infection.
• Vitamin A deficiency may also lead to spontaneous fracture of bones
•Deficiency of vitamin A in Kenya is associated with low fat intake in
addition to low dietary intake in some communities.
•Isolated pockets of blindness occur especially in arid and semi-arid
parts of Kenya and in communities who have low lipid intake in their
diets.
• Prevention depends on giving the right nutrition advice.
• In cases where vit. A is a major public health problem, mass
medication of children and mothers with vit. A is encouraged.
 Excess
•Excessive accumulation of vitamin in the body stores leading to toxic
symptoms occurs with excessive intake of vitamin A in the supplement
form, daily for several months.
•It is therefore advised that consumption of vitamin A supplements be
taken based on the advice of the doctor or health personnel to avoid
toxicity.
•However, no toxicity is observed due to consumption of vitamin A from
food sources.
 Recommended Dietary Allowances
(RDA) for retinol

RE (Retinol equivalent) IU (International units)

Children 14years + 400-700 2,000-3,300

Male 1,000 5,000

Female 800 4,000

Pregnant 1,000 5,000

Lactating 1,200 6,000

• The daily requirement of vit. A for adults is about 750 mcg.
• Lactating mothers need up to 50% more
• Children need less than adults
• High doses of vit. A should not be given to pregnant mothers as this can
cause harm to the foetus.
• Supplementation of vit. A has been incorporated in the immunization,
growth and monitoring services. The schedule for this is 100, 000 IU
at 6 months, then 200, 000 IU every 6 months till the baby is five years.
 Vitamin D (Cholecalciferol; Calciferol)
•Vitamin D is also referred to us the sunshine vitamin.
Characteristics
•Vitamin D is very stable as it is not sensitive to heat or oxidation. It is
fat soluble and it requires fat to transport and bile salts for absorption.
Unlike other vitamins, vitamin D is synthesized by the action of
sunlight on the skin. It is stored in the liver.
Functions
•Vitamin D helps the body absorb calcium and phosphorus from the
intestines into the blood. Assists in increased calcium absorption from
the gastro-intestinal track.
 Sources
•There are only a few sources of food that contain vitamin D. These include
oily fish, cod liver oils. Other foods are fortified with vitamin D such as
margarine. Vitamin D is got when the skin is exposed to light.
Recommended Dietary Allowances (RDA)
• An adult should take 200-400 IU or 5-10 micrograms per day

Deficiency
•A deficiency of vitamin D in infants and children can lead to rickets
whereas in adults it leads to osteomalacia. Rickets is defective bone
formation such as knock-knees and deformities in the ribs of children.
 Vitamin E (Tocopherol)
Characteristics
•Vitamin E is not destroyed by heating, however, it is destroyed by
rancidity.
•It is fat soluble.
Functions
•Vitamin E requires bile and fat for transportation and absorption.
•It acts as an anti-oxidant especially of unsaturated fatty acids and vitamin
A.
•This is because it protects the double bond by being oxidized first.
•Vitamin E protects membranes of the nerves, muscles including blood
against destruction.
•Vitamin E contributes to a healthy immune system.
 Deficiency
•There is no clear indication of vitamin E deficiency in humans.
However it has been observed in adults who have difficulty absorbing
fats and in some premature infants who suffer from haemolytic
anaemia.
•That is problems may be seen in those who have difficulty absorbing
fat and in new born babies.

Food Sources
•Good sources of vitamin E are vegetable oils (corn oil, sunflower oil
cottonseed oil) and cereal oils, margarine, most nuts such as
groundnuts, milk, liver, egg yolk, soy products, and dark leafy
vegetables.
 Vitamin K
Function
•Vitamin K promotes coagulation of blood, that is, it is responsible for
normal blood clotting.
Food Sources
•Good dietary sources are green leafy vegetables such as spinach, sukuma
wiki and cowpea leaves, fruits, cereals, carrots, egg yolk, liver and
cabbage. It is synthesised in large amounts by bacteria in the intestinal tract
then absorbed in the blood.
•Note in the treatment with antibiotics, the bacteria flora is destroyed
thereby requiring vitamin K intake.
•There is no recommended dietary allowance for vitamin K.
Deficiency
•Shortages are rare but individuals suffering from liver disease or who are
unable to absorb fat are at risk.
Water Soluble Vitamins (Vitamins C and B Complex)
• These vitamins are less stable than the fat soluble vitamins.
• Vitamins C, B1, folacin, B12 have no direct role in energy metabolism and
all are involved directly or indirectly in blood formation.
Vitamin C (Ascorbic Acid)
• Characteristics
• It is sweet to taste. It is water soluble. It is sensitive to heat and easily
destroyed at 100ºC (boiling point of water).
• Therefore it is destroyed by boiling.
Functions
• Vitamin C is important for growth and repair of body cells, helping the
immune system to function, absorption of iron and long term health.
• It helps the body to absorb iron.
• Therefore the importance of consuming plant sources of iron such as beans
together with vitamin C rich foods such as oranges, guavas and tomatoes.
• Vitamin C is important for the body’s immune system to function as it
helps the white blood cells to fight infection.
 Food Sources

• Vitamin C is found in many fresh fruits and vegetables in Kenya.

These include citrus fruits, guavas, amaranthus, spinach, and
tomatoes.
• However, the amounts present depend on the part and type of the
plant, stage of maturity, exposure to air processing and method of
preparation. Since the vitamin is sensitive to heat, boiling destroys
it.
• This means the amount present in the food will depend on the
amount of heat the food is subjected to.
Recommended Dietary Allowances
• 60 micro grams per day. Vitamin C requires daily intake because it
is not stored in the body.
 Deficiency
•Deficiency of vitamin C leads to one being more susceptible to infections,
make wounds heal slowly, leads to bleeding gums, irritability and muscle
wasting. A severe deficiency leads to scurvy.
•This is because failure to produce collagen leads to weak blood vessels,
muscle tissue breakdown, inability to produce scar tissue and therefore soft
bleeding gums.
Symptoms of scurvy are:
•Listlessness, weakness, fatigue, shortness of breath and muscle crumbs.
•Aching bones and muscles, loss of appetite, dry feverish rough skin and
bleeding and swollen gums. Slow wound healing, more susceptible to
infections.
•A major problem in drier parts of Kenya.
•People groups prone to deficiency include:
 The elderly, who may find it difficult to prepare and eat fruits and
vegetables
 Those who eat junk food and miss eating fresh fruits and vegetables.
 Heavy drinkers and smokers.
 Vitamin B Complex
•The B vitamins are a group of vitamins that each has their own roles in the
body.
•They work together as a team and are generally found together in foods.
•They help break down foods to provide us with energy and the building
blocks for growth.
•They help the brain; nerves and muscles function properly and aid the
production of red blood cells. Vitamins are sensitive to heat and are soluble
in water.
•They are therefore destroyed by cooking above 100ºC and when vegetables
are cut then washed, the vitamin get washed in the water.
•It is therefore recommended to cut vegetables before washing and not to
cook vegetables at high temperatures.
Vitamin B1 (Thiamine, Aneurine, Anti-Beriberi)
Characteristics
•It is very unstable. It is sensitive to oxidation, light and ultraviolet light. It is
very sensitive to temperature at 100ºC.
•There is no reserve of the vitamin. Excess is excreted in the urine therefore
 Vitamin B2 (Riboflavin)

Characteristics
•Vitamin B2 is resistant to acid, heat and oxidation. Unstable to alkali and
light therefore store food such as milk in dark bottles away from bright
sunlight. It is not stored in the body therefore we need daily intake. It is
water soluble.
Functions
•It is important in cell respiration. It is essential in the formation of the red
blood cells in the bone marrow.
•It is also used in the synthesis of glycogen and fatty acids breakdown.
Recommended Dietary Allowance (RDA)
•0.6 micrograms per 1,000 Kcal about 0.8-1.8 micrograms per day.
Sources
•Widely distributed in both animal and plant foods. Milk and milk products
are major sources.
 Deficiency

• Insufficient intake causes cracked lips, sore tongue and skin rashes.
Riboflavin deficiency seldom occurs in isolation but rather it occurs
together with other water soluble vitamin
 Niacin

•It is vital for energy release in tissues and cells. Working with riboflavin
and thiamine, it helps to maintain healthy nervous and digestive systems.
It is relatively stable although when food is blanched, losses occur.
Sources
•Dietary sources include meat and wholemeal bread or whole grain
cereals and whole meal cereal flour products.
Deficiency
•Deficiency leads to the disease pellagra which causes diarrhoea, skin
rashes and dementia. Deficiency is still wide spread in poor communities
in Kenya who consume mainly maize.
 Folic Acid

•Characteristics
•Easily destroyed during prolonged storage and up to 50% can be lost during
cooking.
•Functions
•The biologically active form of folate is involved in DNA and RNA synthesis
and therefore important for cell division. Folic acid is vital for healthy blood
cells, the formation of new body cells and for healthy growth.
•Food Sources
•Found primarily in leafy green vegetables, oranges, fortified cereals, whole meal
bread, brewer’s yeast, spinach, fish, groundnuts and liver. Deficiency of iron and
vitamin C impairs folate utilization.
•Deficiency
•Shortages can cause a form of anaemia.
 Vitamin B12
Characteristics
•This vitamin is unusual in that it can be stored in the liver and tissue
reserves last for as long as three to five years.
Function
•Vitamin B12 is vital for growth, a healthy nervous system and for the
formation of red blood cells. The metabolic functions of this vitamin are
closely associated with folic acid and a deficiency causes the same type of
anaemia.
Deficiency
•Shortages can cause pernicious anaemia normally among people who are
unable to absorb the vitamin.
Sources
•Meats, chicken, fish, liver, cheese, milk, fermented products and yeast
extracts. Found in foods of animal origin only unless fortified foods.
Functions
•Vitamin B1 is essential for carbohydrate metabolism. Supports appetite and
nervous system functions.

Recommended Dietary Allowance (RDA)

•0.7-1.6 micro grams per day. Daily needs depend on how much carbohydrate we
eat, and how active we are.

Sources
•Whole grain cereals, legumes, peas, chicken, eggs and milk.
•Deficiency
•Loss of appetite accompanied by vomiting, nausea and constipation. Problem is
common among alcoholics. This is because the deficiency affects the nervous
system.
 WATER
•Water is an essential component of all body tissues.
Functions
•Water is essential to the processes of digestion and absorption of food and
elimination of food wastes.
•Water maintains the physical and chemical consistency of the intracellular and
extra-cellular fluids.
•It maintains body temperature.
•It gives the lungs the moisture needed to breathe.
•Water also provides the form and functioning of our body’s 100 trillion cells.
– If cells do not have enough water, they become dry and more vulnerable to attack by viruses.
•Water holds our body’s nutrients in solution, transports and eliminates them from
the body.
•Water plays a key role in the structure and function of the circulatory system. It
acts as a transport medium for all nutrients and all body substances.
•Loss of 20% of body water may cause death and loss of 10% of body water results
into a severe disorders.

Recommended Allowance
• Water is ingested in form of water, as fluids and also as part of ingested
food.
• Water requirement is controlled by thirst.
• The body has no provision for water storage therefore the amount lost
must be replaced every 24 hours to maintain health and body efficiency.
• Under normal conditions, the recommended allowance is 1ml/kcal for
adults and 1.5ml/kcal for infants.
• Recommended to take 8 classes of water per day for adults.
 Community Nutrition
• An approach that provides a long-term
solutions, promotes stability and supplies
communities with methods to reduce
malnutrition-often referred to food security.
• A successful fight against global and local
hunger must involve a community-centred
approach to malnutrition.
 Causes of Malnutrition
Figure1.1: UNICEF Conceptual Framework: Causes of Malnutrition

Malnutrition

Inadequate Food Intake Disease

Imediate Causes

Access to Health
Household Food Social and Care
Care & the Health Underlying Causes
Security Environment
Environment

National Policies
Basic Causes
Formal and Informal Structure
Context and Potential Resources
• They are divided into direct and underlying causes
• Direct /Immediate causes of malnutrition:
– Deficient intake of a particular nutrient e.g. deficiency of protein leads to
kwashiorkor, deficiency of iron leads to anaenmia, deficiency of vit. A leads to
xerophthalmia, deficiency of iodine leads to goitre etc

• Underlying causes:
– Infection and disease – Poor nutrition lowers the resistance of the whole body to
infections.
– Under-nourished children are more prone to infection, recover from illness more
slowly and frequently die from infection.
– Malnutrition tends to be underreported in disease and mortality statistics because
a sick child with malnutrition is likely to develop complications such as
gastroenteritis which leads to death; the deaths are then reported as being due to
these diseases rather than malnutrition.
– Under nutrition and malnutrition are themselves serious problems, even when
they are mild or moderate, as they influence the onset and outcome of infection.
– A malnourished child is more likely to get infections more often and more
seriously than a well nourished child.
• Infection causes fever, loss of appetite, diarrhoea and
vomiting, all of which interfere with the intake and
absorption of food, and malnutrition follows.
• Fever and the repair of damaged cells also increase the need
for food.
• Therefore, with less intake and greater need, the infected
child with poor reserves tipped into a state of malnutrition.
• Off all infectious diseases, diarrhoea is the most important
cause of malnutrition.
• Diarrhoea is common during the weaning period-weaning
doarrhoea.
 Low resistance

UNDERNUTRITION INFECTIONS

Malnutrition
Frequently
severe
Increased need Low food intake
Low resistance

Diarrhoea and vomiting

Death
Death

The nutrition-infection cycle

• Ignorance about nutrition:
– Lack of knowledge about nutrition: Some parents
sell nutritious food like eggs and chicken for
money so as to buy things like sugar to prepare
porradge for children.
– Parents’ lack of understand about the need for
frequenct meals in the course of the day. To meet
their nutritional requirements, children must feed
four or more times a day.
• Seasonal changes and lack of food production
• It happens in arid areas
• Where wars and civil strife disrupt food
production
• During particular seasons
• The worst seasonal food shortages usually occur a
few weeks before the next crop is ready.
• Under nutrition and malnutrition become common
and children may suffer from malaria as well.
• Unequal distribution of food
• Food may be unequally distributed within the family, within
the region and within the country.
• Within the family, the distribution of food usually favours the
head of the family (the man when present),and the nutritional
risk groups (children and women) are at a disadvantage.
• Unequal food distribution in a country result from low
production of certain foods in some areas, poor infrastructure,
lack of storage and preservation facilities and poverty.
• These factors lead to a high incidence of malnutrition in some
parts of the country.
 Factors promoting good nutrition
• Good agriculture:
– Clearing land at the right time
– Planting sufficient food crops
– Use irrigation and fertiliser, if necessary, and advice
from agricultural instructor
– Harvesting at the right time, and safe storage of the
food to avoid loss through pests or through having to
sell at a bad time
– A good transport and distribution system to ensure
delivery of enough food to all regions
• Good economy
– Sufficient money and resources, wisely allocated,
for priorities like agricultural improvement, food
and fuel, education and health
– Enough cultivatable land to grow sufficient food
crops for income.
– Communal production and fair distribution,
marketing and pricing (e.g. through co-operative
societies)
• Healthy environment
– Sufficient safe water located reasonably close to
houses
– Adequate fuel for cooking
– Use of latrines and a good general standard of
sanitation
– Vector and disease control important for nutrition
and general health
• Good education
– Teaching about good nutrition and child health in
schools, families and communities
– Showing ways of improving present attitudes and
practices. Special emphasis should be placed on
good nutrition for the most vulnerable groups
including poor mothers and children.
• Healthy size. All the children in the family are likely to receive
enough good food and attention if the family is small.
– The younger children usually need more care. Encourage family planning
– If either or both parent are from the home, it is important to ensure that the
children are looked after properly and that they have enough food.
– Problems with alcohol and drugs are common in disrupted families.
– Appropriate distribution of money, work and food within the community
and the family. Support for mothers is important in keeping children healthy
– Priorities within the family include seeing that children get their share of
high quality energy and protein food. Children need smaller portions of
food given several times during the day.
– Care for the children from broken or one-parent families. Social integration
and communal care for these and for underprivileged families, is an
children and good maternal care are important factors.
• Prevention and control of disease
– Most children illnesses are preventable by
immunization.
– Comprehensive vaccination of children and good
maternal care are important factors in good
nutrition.
• Early detection and effective treatment of
acute diseases such as diarrhoeal diseases and
respiratory tract infections.
Poverty and disease go together

PRODUCTIVITY

NUTRITION

HEALTH EDUCATION

Major factors influencing nutrition

• Customs and beliefs affecting nutrition
– Most people have fixed customs and beliefs about different
foods and cooking practices.
– In some places insects like termites and grasshoppers are
eaten. Such insects are rich in proteins and other nutrients.
Such practices should be encouraged by the health workers
– Some traditional food habits should not be promoted such as
where women and children are not allowed to eat chicken
and eggs, preventing children with measles from eating meat
or taking salt. These traditions should be carefully
discouraged in order to prevent resistance and confrontation.
• To achieve the goal of good nutrition, poor productivity
has to be converted into high productivity; diseases have
to be prevented or treated efficiently; and poor education
must be replaced by awareness and knowledge.
• Improvement of nutritional status by these means will in
turn improve people’s health, productivity and ability to
develop further.
• Solving the malnutrition problem must also take into
account socio-economic, political and cultural factors
that are not illustrated in the diagram.
 Children feeding and nutrition
• Breast feeding
• Human breast milk is by far the best food for babies and all mothers must be
encouraged to breast feed their babies exclusively for six months and to continue
breast feeding for as long as possible after that.
• Breast milk is:
– Always fresh,
– safe from diarrhoea and other infections since it contains the mother’s antibodies; and it
is also
– easily available, clean and ready for the child at all times.
– It is easy to digest, has the right temperature, protects and brings the mother and baby
close together.
– Breast feeding is cheap and is always ready.
– Sucking at the breast helps the postpartum uterus to contract and breast feeding gives the
mother the opportunity to care for and love her baby.
– The mother’s breast milk is usually sufficient for a baby for the six months of life.
– By the sixth month, supplementary foods (weaning) should be introduced gradually.
 Advantages of breastfeeding using the
breastfeeding acronym
• B-Best for baby
• R-Reduced allergies e.g. Asthma, aczema
• E-Economical – no waste or cost
• A-Antibodies thus higher immunity
• S-Satisfies infants nutritional needs
• T-Temperature constant, correct
• F-Fresh milk-never spoiled
• E-Emotional bonding
• E-Easy once established
• D-Digested easily 3-4 hours
• I-Inhibit ovulation, reduces interval between births
• N-No mixing required
• G-Gastroenteritis greatly reduced
 Breast feeding and HIV/AIDS
• A child born to a HIV positive mother may be HIV negative
• A child may acquire the virus from the mother through breast milk
• The most likely way that this may happen is when a child’s gut lining
is bruised.
• Bruising of the child’s gut happens when it is given solid foods at an
early age since the foods erode some of the protective membranes
along the GI Tract.
• HIV positive mother should be counseled during ANC visit to choose
between either feeding the baby on breast milk exclusively for four
months then stop the breast milk and substitute it with animal milk
and solid foods, or to feed the baby on formula feeds or milk from
animals sources without any one time giving the baby her breast milk
• HIV positive mother should never mix-feed the baby i.e. give breast
milk and solid foods at the same time.
 Expressed breast milk
• Expressed breast feeding should be encouraged among mother who have to work
and are only allowed a month or two for maternity leave. After this period they
have to learn to express breast milk for the sake of the baby.
• The same is important for a mother who is HIV positive and chooses to breast
feed exclusively but has to leave the baby for more than six hours.
• It is important to maintain hygiene for mother, baby, expressed milk and utensils
should be emphasized to prevent contamination that may lead to diarrhoea.
• Expressed breast milk should be stored in a closed container, in a cool place in
the house away from direct sunlight.
• The child should be fed the expressed breast milk using cup and spoon and not a
bottle.
• The health care work should take time to the mother on these practices as they
go a long way in minimising childhood illness, related complications and deaths
arising from malnutrition, infections and other diseases.
 Weaning and under-nutrition
• Def:-
• Weaning is the time during which a child’s diet changes from breast milk
(or formula) alone to family food.
• Weaning has three stages:
– Stage 1: The baby gets almost all nutrients from breast milk but starts other. These
first foods must be easy to eat and digest and are called weaning foods.
– Stage 2: The child continues to get the same amount of breast milk but eats
increasing amounts of other foods. The type of food gradually changes from
weaning foods to regular family foods.
– Stage 3: The child takes less breast milk and eats more and more of the family
foods. Breast milk is mainly a snack and for comfort.

• Under-nutrition in Sub- Sahara Africa occurs most frequently in children of

weaning age (6months to three years)
• To prevent under-nutrition the most important measure to be taken is to
improve weaning foods.
 Weaning foods
Three factors must be borne in mind when preparing good weaning foods
for young children.
1. To provide enough energy within the small amounts that a young child
can eat at one time. Ensuring an adequate intake of energy foods by:
– Feeding young children frequently (4 or 5 times).
– Mixing foods with a high energy concentration into the basic staple foods. E.g.
one teaspoon (5g) of oil gives 45 Cal; 2 teaspoons (10g) of sugar give 40 Cal.
– NB: Feed young children at least 4 times every day.
2. To add protein to the staple food i.e. porridge given to the child
– Most cereals have a protein concentration of about 7% or 8%, but this protein
is of low biological value. To improve the quality of the protein, small amounts
of other animal or plant foods containing protein must be added. Suitable
protein foods are cowpeas, beans, groundnuts, fish powder, dried milk powder,
flaked fish, minced meat or eggs.
NB: Continue breast feeding during weaning.
3. To provide food in a form which is easily
swallowed and digested
• This is done by mashing the food or grinding it
into fine particles and adding liquid until it is
soft.
• It is important to cook it well.
• Teach mothers how to enrich weaning foods.
NB: Use weaning mixtures
 Weaning recipes
• Weaning recipes give different ways of mixing protein foods
with thin porridge to give young children protein-enriched
foods.
• E.g.
– Boil cowpeas and then mash
– Roast groundnuts and then grind to powder
– Soak red beans overnight, remove skin then cook and mash
– Cook fish, remove bones and mash
– Scrape meat with a knife to obtain small pieces
– Mix powdered milk to a paste with water and cook with the
porridge.
– If the porridge is made from maize or millet flour, only small
amounts of other foods need be added.
• A demonstration garden:
– To encourage mothers to grow a wide variety of foods for their
children, a demonstration garden at the health centre is useful.

• Day care centres:

– Where young children are looked after while the mothers go to work.
– Health workers can advice the community about suitable foods for
children at these centres which will supplement the home diet.
– Foods such as fruits grown in the community, may be added to the
main meal.
– If the community has cows, they are advised to set aside some milk
for the children.
 Nutrition in special groups
• Nutrition during pregnancy and lactation
– During pregnancy and lactation, a woman’s nutritional needs are greater than at any
other time in her life.
– All the food the foetus needs to grow and the food needed for production of milk must
come from the mother.
– A child borne to a poorly nourished mother is likely to have a low birth weight (below
2.5 kg).
– Such babies are more likely to die in the first few months of life.
– During pregnancy there is increase in weight of the woman and the BMR also increases.
– These increases require extra food to provide extra energy, proteins and other nutrients.
– Anaemia is a common problem in Africa, especially among pregnant women.
– A child borne to an anaemic mother may have a very low reserve of body iron and is
likely to develop anaemia in the few weeks of life.
– It is advisable to give iron supplements routinely to pregnant women in areas where
iron-deficiency anaemia is common.
• This is given in the form of ferrous sulphate tablets to be taken three times a day
• Folate, one of the vit. B complex, is also required for making red blood cells and
should be given, together with iron, to pregnant women.
• Vit. A deficiency is also bad for the baby, so multivitamin tablets should be given
during pregnancy in areas where xerophthalmia is prevalent. Encourage pregnant
women to eat foods rich in vit. A.
• Lactating mother/mothers who have just delivered need to eat more than usual
and include foods that are rich in iron and vit. A.
• Women must feed well during their reproductive years.
• They should be in a good nutritional health before and during pregnancy and
lactation.
• A woman who becomes pregnant while poorly nourished has a greater risk of
complications during pregnancy and is likely to give birth to a low birth weight
baby.
 Nutrition and HIV/AIDS
• Malnutrition is one of the complications of HIV/AIDS.
• HIV/AIDS is associated with conditions that result in
reduced food intake.
• Decreased food intake may result from:
– an inability to swallow due to sores in the mouth and throat,
– loss of appetite as result of fatigue or depression,
– side effects from the medication or
– reduced quantity and quality of food in the household as a
result of inability to work or reduced income due to illness.
• HIV interferes with the body’s ability to absorb nutrients.
• Poor absorption may be caused by infection of the
intestinal cells or increased incidence of opportunistic
infections such as diarrhoea.
• To deal with this problem effectively there should be:
– Good nutrition,
– Hygiene,
– Food safety.
Good nutrition strengthens the immune system to fight OIs and
delays progression of the disease.
Good nutrition contributes to weight gain and stops wastage
 Nutrition for the elderly
• The number of elderly persons in Africa is increasing owing to improved
health care and quality of life.
• Care of the elderly has changed with many of them being left on their
own while their children emigrate in search of jobs.
• The elderly have an increased nutrition challenges due to:
– Various growth and developmental challenges
– Illnesses
– Poor appetite
– Lack of teeth making it difficulty to eat any type of food
– Lack of support and carers who would provide food and cook for them.

These are a few of the challenges that HWs should be concerned about.
The elderly should not be left to become malnourished or die from malnutrition
due to neglect.
Nutrition in people with diabetes
• Diabetes is on the increase among many
communities in Africa.
• This can be attributed to factors such as sedentary
lifestyles and changed feeding and dietary habits
that favour junk food.
• The effects of the disease can be minimized with
appropriate diet, exercise and family diet.
• The patient should be encouraged to eat a diet rich
in proteins including fish, poultry, nuts, fruits,
vegetables and whole grain.
 Abnormal nutrition and clinical
malnutrition
• Main types of abnormal (mal) nutrition
include:
– Undernutrition,
– Micronutrient deficiencies
– Overnutrition
 ABNORMAL NUTRITION

Under-nutrition Over-nutrition

Underweight Micronutrient Overweight

deficiencies

Low birth Protein Vitamin Mineral Obesity Nutrient

weight energy deficiencies deficiencies Excess
deficiency syndroms

Marasmus Xerophthalm Iron deficiency Flourosis

Marasmus ia Anaemia Hypertention
kwashiokor Pellagra Iodine Diabetes
Kwashiorkor deficiency
goitre
• Underweight is the first stage of protein energy deficiency
(a mild or moderate form of protein energy malnutrition-
PEM).
• PEM affects up to 30% of children between 1 and 5 years
old.
• PEM is about 10 times more than all other forms of
malnutrition except anaemia.
• It is only detected as a growth failure when weight for age
or upper arm circumference is measured.
• Early diagnosis and treatment of underweight prevents
progression to clinical malnutrition.
• Effects of underweight:
– Slow growth
– Risk of infections as they have weak body defences and
do not develop antibodies easily
– Death if exposed to serious infections such as measles,
gastroenteritis, whooping cough or tuberculosis.
– Underweight children develop clinical form of protein
energy malnutrition very rapidly during episodes of
infectious diseases.

NB: Low weight = High risk

• Diagnosis:
– Early underweight cannot be recognised in the early stages by
clinical examination.
– It is only diagnosed by regular weight measurements
• Underweight is uncommon in breast fed babies under nine
months
• To detect the “at risk” underweight child between the ages of
one and five years is one of the main functions of children’s
clinics. To do this:
– Follow the growth curve on a weight chart at regular interval
– Where the birth date is not known, use a local calendar of event to
estimate the age of the child.
– High risk underweight children are those whose
weights are between 60% and 80% of normal;
those whose weights are not rising but are steady;
or those whose weights are falling.
– When the age is unknown, measure the mid upper
arm circumference to assess children under one
year old.
• Management:
– Increase calories in the diet by augmenting the amount of energy foods. If this is not done, the
limited amount of protein in the body will be used to provide the body with energy and therefore
be wasted. The best way to increase the calorie intake of a young child is to increase the frequency
of meals. Children under 2 years should eat at least 3 and preferably 4 to 5 times a day.
– Protect the child from infection by immunization, prophylaxis against malaria, treatment of
intestinal parasites and advice to the mother on hygienic food preparation.
– Weigh the child regularly and encourage the mother by showing her the child’s growth curve
moving upwards along the normal weight for age path on the growth chart.
– Recommend a mixed diet. Find out which additional foods the mother can easily obtain, and
encourage her to mix any of these with the main staple.
• Do not tell the mother to use proteins that she cannot afford.
• The important thing is to increase the amount of staple or energy foods by adding a small amount of oil or
margarine and some powdered groundnuts (or groundnut butter) or soya bean flour, cowpeas, red beans or
any local legume.
• Children’s meals should also include some dark green leafy vegetables and some fruit every day.

NB: Give energy foods for underweight

• Prevention
– Treatment of underweight children prevents:
– The development of clinical malnutrition
(marasmus and kwashiorkor)
– High mortality from infectious diseases, especially
measles, tuberculosis
– This means a reduction in morbidity, mortality and
hospital admissions.
 Protein energy malnutrition (PEM)
• Types of PEM:
– There are three syndromes of protein energy deficiency
with a similar underlying causes.
– These are:
• Marasmus
• Kwashiorkor
• Marasmic kwashiorkor
The syndromes are also referred to as:
Protein Calorie Malnutrition (PCM),
Protein Joule Malnutrition (PJM), and
Protein Energy Deficiency (PED)
• They are rarely seen in more than 5% of
children less than 5 years old.
• They are the clinical manifestation of the
under-nutrition problem in the community.
• The difference between underweight and
Marasmus, Kwashiorkor and Marasmic
kwashiorkor is seen in the degree of severity
of the PEM and the presence or absence of
peripheral oedema.
 The difference between underweight and
Marasmus, Kwashiorkor and Marasmic
kwashiorkor.

Weight for age (as percentage of normal)

60-79% Below 60%

No oedema Underweight Marasmus

Oedema present Kwashiorkor Marasmic kwashiorkor

 Micronutrient deficiency diseases
• Iron deficiency anaemia
• Results from lack of iron in the diet, or by blood loss from hookworm, excess
menstruation, abortion, postpartum haemorrhage of injuries
• To manufacture red blood cells, the bone marrow needs iron, protein, folic
acid and a few other minerals.
• The body stores iron in the liver, spleen and bone marrow.
• People with good iron stores recover rapidly from losses of blood and the
stores are replenished when we eat iron-containing foods.
• Depending on severity, acute iron deficiency anaemia can be treated with iron
tablets (ferrous sulphate) Inferon injection or if absolutely necessary, blood
transfusions.
• Educate patients so that they eat iron-containing foods to replenish the iron
stores in the body after treatment is complete.
• Iron and folic acid deficiency anaemia are common in pregnancy. It is
therefore important to give pregnant women supplementary iron/folate tablets
routinely.
• NB: Treat anaemia with iron tablets
• Iron-containing foods e.g. pumpkin seeds, spinach and other dark green leaky
vegetables such as leaves cassava and cowpeas, are plentiful and cheap.
When these leaves are dried and preserved the iron content is very high.
• The main sources of iron are:
– Red meat
– Liver
– Millet
– Legumes such as red beans and chickpeas
• Not all iron from food or tablets is absorbed. Animal products (haem iron)
are better absorbed than iron from plant origin. Vit.C in the diet helps the
absorption of iron.
• A daily mixed diet which contains either legumes or dark green leaves will
maintain sufficient iron reserves in the body.
• Occasionally supplement this with liver and red meat.
• NB: Prevent anaemia with iron rich foods
 Iodine deficiency disorders
• We need iodine so that the thyroid in the neck can make
thyroid hormones.
• Thyroid hormones are essential for many body processes
including:
– The development and working of the brain and nervous system
– The way we use energy and control our temperature
– The growth of young children

The thyroid gland cannot make enough hormones if the amounts

of iodine in the blood or stored in the thyroid gland are too low.
If this happens, iodine deficiency disorders (IDDs) develop.
 How iodine deficiency disorders
develop
The diet contains little iodine

Low iodine level in the blood and thyroid gland

The thyroid gland makes less thyroid hormones

Low levels of thyroid hormones, stimulates the thyroid gland to get bigger so it can
collect more iodine from the blood. The enlarged gland is called goitre

The enlarged gland either:

Does produce enough thyroid hormones, so apart from goitre , the person is normal, or
Does not produce enough thyroid hormones. This disorder is called hypothyroidism

Iodine deficiency in women can result in babies being cretins

• IDDs are serious because:
– Iodine deficiency delays development in an area
because:
• There are more handicapped people who require care
• Cattle, goats, chickens and other animals are iodine
deficient. They grow slower and reproduce less.
• Those affected are mentally slower, less energetic and
harder to motivate than healthy people
– Some people with cretinism die very young
– Large goitres are uncomfortable and unattractive and
may affect a person’s self esteem
• Sources of iodine:
– The amount in plant foods depends on the iodine
content of the soil on which they grow.
– Soils in mountainous areas or places where there
are frequent floods are often low in iodine.
– Important sources are fish and other foods from
the sea (sea water is rich in iodine) and salt
containing added iodine (iodized salt)
• Ways to control IDDs:
– Giving extra iodine to at-risk group.
– This prevents IDD in unborn babies, corrects some
of the effects of hypothyroidism and sometimes
makes goitre smaller.
– The most important control programmes are:
• Adding iodine to salt
• Giving high dose of iodine by mouth or injection.
• Xerophthalmia and keratomalacia
• Xerophthalmia is the name used for all eye conditions due to
vitamin A deficiency.
• In the earlier stages it causes difficulty with seeing in the dark-
night blindness. The conjunctiva becomes dry and a whitish
spot may form on the outer corner of the eye- a Bitot’s spot.
• If not treated early, the cornea may soften and go on to
ulceration, secondary infection, scar formation and blindness.
In this severe form it is called keratomalacia and should be
treated as an emergency with intramuscular injection of
vitamin A with antibiotics for infection.
• Prevention involves:
– General social measures to reduce poverty and
malnutrition.
– Health and agricultural extension workers should
co-operate during food production and nutrition
education to increase the availability and intake of
vitamin A containing foods.
– In places where xerophthalmia is endemic, mass
dosing of oral vitamin A is advisable. This will
give protection for 4-6 months.
 Fluorosis
• Is not a deficiency disease but a condition due to an
excess of fluorine.
• We need fluorine to build strong bones and teeth.
• Most people get enough fluorine from drinking
water.
• In some areas there is too much fluorine. When
children get too much fluorine, it replaces some of
the calcium in their bones and teeth and causes weak
chalky patches called fluorosis.
• The patches on the teeth may become brown.
 Assessing the nutritional status of an
individual
• There many methods of assessing a person’s
nutritional status among them:
– Physical measurements of the body
– Clinical examination
– Laboratory tests
Physical measurements of the body
• These methods are useful in the case of growing
children, particularly the under fives, and are used
to detect growth failure.
• Physical growth is one of the best indicators of the
nutritional status.
• The common methods of measuring are divided into
two groups depending on whether the age of the
child is known or not.
– Age known: Weight for age and height for age.
– Age unknown: Weight for height and arm circumference
 Weight
• This is the most important measurement. When the child’s month of
birth is known, the weight can be recorded on a road to health chart.
• If the exact age of a child is not known, it is possible to make a good
estimate of by using a calendar of local event.
• Knowing child’s weight without having a fairly accurate idea of the age
is of little use.
– Weight between 80% and 100% of the standard are normal
– Weights between 60% and 79% are regarded as underweight (mild moderate
PEM) and the child is at risk for malnutrition
– Weight below 60% of the standard usually means clinical malnutrition (Severe
PEM) and such children need hospital admission.

The best information is obtained from a series of weights that will show whether
the child is gaining, not gaining or actually losing weight over a period of time.
 Height
• Height remains stationary when a child
becomes malnourished, so growth failure may
not be detected for several months.
• Height for age can be used as a measure for
detecting chronic malnutrition (stunting) in
children.
• All children under the age of five grow at
nearly the same rate except for sex differences.
 Weight for height
• When a child’s age is not known, the weight
for height measurement will help in detecting
acute malnutrition (wasting and thinning).
• It’s a practical method in emergency nutrition
survey, using Wall Thinness Chart (Nabarro’s
Chart).
Mid upper arm circumference (MUAC)

• Is a very simple and quick measurement.

• Is used:
– When the child’s age is over one and under five years.
– When weighing scale are not available.
– As a screening method in outpatient work
– In community nutrition survey
– When the weight graphs (Road to Health Charts) are
out of stock
– When visiting homes
• Method:
– The circumference of the upper arm is measured half way
between the point of the shoulder and elbow.
– The measurement is done with a non-stretched strip, such as
a tape or a strip of marked X-ray film.
– How does this measurement detect the growth failure?
• Normally there is little change in a child’s arm circumference
between one and five years of age. During this time the arm grows
in length but not get fatter.
• At birth the mid upper circumference average is 11 cm
• By one year the average is 16, i.e. a gain of 5 cm
• By five years the average is 17 cm, i.e. a gain of a 6 cm
• Therefore healthy children over one year normally have a mid
circumference of 16 cm. Any child over one year with an arm
circumference between 12.5 and 13.5 cm is considered
moderately malnourished and at high risk.
• Any child over one year with a mid arm circumference below
12.5 cm is considered severely malnourished.

• Advantages:
– Measuring strips are available
– Minimal training is required,
– Can be used where weight for age graphs are not possible to use
– It is very quick to do and to interpret
 Diagnosis of Acute Malnutrition
• Selection Criteria for Acute Malnutrition
• Admission criteria for acute malnutrition are determined by a child’s weight
and height, by
• calculating weight-for-height as “z-score” (using WHO Child Growth
Standard, 2006)2, and
• presence of oedema. All patients with bi-lateral oedema are considered to
have severe acute
• malnutrition. See Table 1.3 for anthropometric criteria.
• Mid-Upper Arm Circumference (MUAC) is often the screening tool used to
determine malnutrition
• for children in the community under five years old. A very low MUAC
(<11.5cm for children
• under five years) is considered a high mortality risk and is a criteria for
admission with severe
• acute malnutrition. See Table 1.2 below for MUAC criteria for children
under-five years.
 MUAC criteria to identify malnutrition of
children under five years in the community

Severely Malnourished Moderately At Risk of malnutrition

Malnourished

less than 11.5cm 11.5cm to 12.4cm 12.5cm to 13.4cm

 Admission Criteria for Adolescents and
Adults
• International guidelines that recognize cut-off measurements to identify moderate
acute malnutrition and severe acute malnutrition in adolescents and adults do not
yet exist.
• Body Mass Index (BMI) varies considerably in different populations. In the
adolescent age bracket (13 to 18 years) BMI-for-age can be used, but is not
applicable in the event of growth retardation or when age is indeterminate.
Adolescents experience growth spurts (rapid growth), therefore anthropometric
measurements to determine wasting can be difficult.
• For adults (older than 18 years), BMI is the main way to identify acute malnutrition,
however it is important to include clinical signs such as bi-lateral oedema and
dehydration that affect BMI results. Other underlying medical conditions, such as
TB and HIV and AIDS, must also be considered. For adults, MUAC in combination
with clinical signs can also identify patients who need specialized nutrition
interventions.
• During pregnancy MUAC does not change considerably, while a pregnant woman’s
weight should increase. A low MUAC of <21cm during pregnancy can indicate a
need for extra nutritional support due to the pregnancy. A low MUAC for the
mother during pregnancy increases the risk of growth retardation of the foetus.
 Clinical examination for nutrition
• When clinical signs are present, the malnutrition is more severe.

• Laboratory tests for malnutrition

– Are useful in hospital inpatients, but not practical in clinics, in
outpatients or in most survey because they are expensive and
take time and skilled personnel.
– Some examples are: haemoglobin level estimations, blood
counts, serum protein levels, urine creatinine and X-ray for
rickets.
 Steps to Identify Acute Malnutrition in Children
•Children who are malnourished are at high risk of mortality and morbidity.
•It is important that malnourished children, or those at risk of malnutrition, are
identified and appropriate care commenced.
•Community Health Workers (CHWs) may identify children at risk of malnutrition
in the community. Health facility staff can determine if children who are brought for
other reasons are in fact at risk of malnutrition.
•Ministry of Health (MoH) programmes such as Integrated Management of
Childhood Illness (IMCI) and Mother & Child Health (MCH) focus on children
under five years old, and screening for malnutrition is part of the programme
process.
•When nutrition screening is available in the community, CHWs identify children
who are malnourished with anthropometric measurements (e.g. MUAC) or where
oedema is evident.
•Malnourished children are referred to the nearest health facility, nutrition unit,
health post, or hospital out-patient department.
•The child’s anthropometric measurements are re-checked by a nurse or health
worker. Those who appear very sick, weak, emaciated or underweight require fast-
 Triage of Acute Malnutrition
•Community Health Workers (CHWs) can screen children in the
community using MUAC and the presence of oedema. They refer those
who are malnourished to a health facility.
•However, the diagnosis of malnutrition for children under five years
old is the responsibility of health staff at a health clinic, health
dispensary, or an out-patient department (OPD) and hospital casualty
department.
Triage to determine treatment of either severe or moderate
malnutrition
1. Has there been any weight loss in previous month?

2. Does the patient have an appetite.

ASK: 3. Does the patient have any medical condition that will
impair nutritional status?

4. Is the breast-feeding child suckling well?

LOOK AND FEEL FOR: Visible signs of wasting

MUAC

Weight
CHECK:
Height/length

Bilateral-oedema

DETERMINE: Level of malnutrition using W/H reference charts

LOOK AT SHAPE OF GROWTH CURVE: 1. Has the child lost weight?

2. Is the growth curve flattening?

Integrated Management of Acute Malnutrition
 Taking Anthropometric Measurements
•Taking a Child’s Middle Upper Arm Circumference (MUAC)
•MUAC is an alternative way to measure “thinness” (alternative to weight-
for-height). It is especially used for children six months old to five years
old.
•Figure 1.1: How to Measure MUAC
• Ask the mother to remove any clothing covering the child’s left arm.
• Calculate the midpoint of the child’s left upper arm: first locate the tip of
the child’s shoulder (arrows 1 and 2 in diagram below) with your finger
tips.
• Bend the child’s elbow to make the right angle (arrow 3).
• Place the tape at zero, which is indicated by two arrows, on the tip of the
shoulder (arrow 4) and pull the tape straight down past the tip of the
elbow (arrow 5).
Read the number at the tip of the elbow to the
nearest centimetre. Divide this number by two to
estimate the midpoint. As an alternative, bend the
tape up to the middle length to estimate the
midpoint. A piece of string can also be used for
this purpose; it is more convenient and avoids
damage to the tape.
•Mark the midpoint with a pen on the arm (arrow
6).
•Straighten the child’s arm and wrap the tape
around the arm at the midpoint. Make sure the
numbers are right side up. Make sure the tape is
flat around the skin (arrow 7).
•When the tape is in the correct position on the
arm with correct tension, read and call out the
measurement to the nearest Inspect the tension of
the tape on the child’s arm. Make sure the tape has
the proper tension (arrow 7) and is not too tight or
too loose (arrows 8 and 9). Repeat any step as
necessary

0.1cm (arrow 10).

•Immediately record the measurement.
Taking a Child’s Weight
Children are weighed with a 25 kg hanging sprint scale, graduated to 0.100
kg. Do not forget to re-adjust the scale to zero before each weighing. A
plastic wash basin should be supported by four ropes that attach (are knotted)
underneath the basin. The basin is close to the ground in case the child falls
out and to make the child feel secure during weighing. If the basin is soiled,
first clean it with disinfectant. The basin is more comfortable and familiar for
the child, can be used for ill children, and is easily cleaned. In the absence of
a basin, weighing pants can be used although are sometimes inappropriate for
very sick children. When the pant is soiled, it can be cleaned and disinfected
to reduce the risk to pass an infection to the next patient.
When the child is steady in the basin or pant, record the measurement to the
nearest 100 grams, recording with the frame of the scale at eye level. The
scales must be checked for accuracy by using a known weight on a regular
basis, i.e. weekly.
Figure 1.3: Taking a child’s length
For children less than 87 cm the measuring board is
placed on the ground.
•The child is placed lying down along the middle of
the board.
•The assistant holds the sides of the child’s head
and positions the head until it firmly touches the
fixed headboard with the hair compressed.
•The measurer places her hands on the child’s legs,
gently stretches the child and then keeps one hand
on the thighs to prevent flexion.
While positioning the child’s legs, the sliding foot-
plate is pushed firmly against the bottom of the
child’s feet. To read the height measurement, the
foot-plate must be perpendicular to the axis of the
board and vertical.
•The height is read to the nearest 0.1cm
Figure 1.4: Taking a child’s
height
For children taller than 87 cm
the measuring board is fixed
upright on level ground.
•The child stands, upright
against the middle of the
measuring board.
•The child’s head, shoulders,
buttocks, knees, and heels are
held against the board by the
assistant.
•The measurer positions the
head and the cursor.
•The height is read to the
nearest 0.1 cm
•Measurement is recorded
immediately
 Calculating Weight-for-Height
Refer to Appendix 1.5 and 1.6 for examples below.
Example 1: A child (boy) is 63 cm tall and weighs 6.8 kg.
•Look in the table’s first column for the figure 63 (the height).
•Take a ruler or a piece of card, place it under the figure 63 and look across to the other
figures on the same line.
•Find the figure corresponding to the weight of the child, in this case 6.8kg.
•Look to see what column this figure is in. In this case it is in the “Weight Normal”
column. In this example the child’s weight is normal in relation to his height. He
therefore has an appropriate weight for height.
Example 2: A child (boy) is 78 cm tall and weighs 8.2 kg.
This child’s weight is between the -3SD and -2SD column. He is too thin in relation to
his height. He is moderately malnourished.
NOTE: It may be that the weight or the height is not a whole number.
Example 3: A child (boy) is 80.4 cm tall and weighs 7.9 kg. These exact figures are not
in the table.
For the height: The height measurement has to be rounded to the nearest 0.5cm, see
example below.
 Assessing the nutritional status of a
community
• An epidemiological survey is needed to find
out about the distribution and causes of
nutritional problems in a whole community.
• On a large scale, this requires specialist and
research team.
 Purpose of large scale nutritional
surveys are:
• To determine the extent of under-nutrition in a
community.
• To assess the influence of socio-economic,
agricultural and climatic factors (e.g. rainfall
fluctuations, subsistence or cash economy food
taboos, family size, types of diet, alcoholism, level
of education, soil fertility etc) on the nutritional
status of the people in the area or community.
• To gain sufficient information to plan a sound
nutrition programme within a community.
• Investigating predisposing factors of under-nutrition
– If there is significant under-nutrition in a community, it is necessary
to identify some of the main predisposing or risk factors. This can be
done by use of a checklist on every undernourished child so that the
commonest factors will emerge. Any or several of the following
things may apply:
• Alcoholism
• An inadequate weaning diet
• Particular food beliefs or customs
• Many children in the family with short birth intervals.
• Insufficient fuel cooking
• The child is not immunized; has many infections
• Poor agricultural methods
• Nutritious foods are sold for cash
 Nutritional interventions by health
workers
• Health workers understanding nutritional theory can advise on the following:
– Encourage breast feeding throughout the weaning period and until the child is two
or three years old
– Emphasize the nutritional value of many local and traditional foods, especially in
mixture
– Assess the food values of locally grown foods and encourage production and use of
the good ones
– Advice on the storage and preservation of local foods
– Calculate the cheapest source of energy and protein at local market prices
– Organise nutrition education in schools, clinics and committees
– Prepare a set of weaning recipes using local foods and if possible demonstrate them
to mothers at regular MCH clinics
– Start a demonstration garden at the health centre
– Advise on foods to be given at day care centres
– Try to improve nutrition through local development committees
 NUTRITIONAL MANAGEMENT
OF PATIENTS WITH LIFE LIMITING ILLNESSES
Nutrition is a process by which the nutrients derived from foods are
made accessible to the cells.
Nutritional care for patients with life limiting illnesses requires a lot of
nutritional monitoring and aggressive therapies.
 WHY DO WE EAT

• To promote body tissue repair

• To prevent excessive muscle atrophy
• To meet the increased needs during illness
• Build up the severely malnourished individuals
• To maintain a positive nitrogen balance
• The diet therefore is designed to provide protein in
amounts higher than the usual requirements
• The diet should provide 1.2-1.5gm of proteins per
Kg of ideal body weight per day and 40-50
calories per day for adults.
• For children-150-200 calories and 3-4gm of
protein perkg/day.
• The use of high biological value protein eg meat,
milk, cheese, eggs is emphasized for optimum
protein utilization. Fats, oils and sugars increase
the energy density of the diet.
 NUTRITIONAL CHALLENGES
IN PALLIATIVE CARE

Food availability-
• Access by the individual –affordability and ultimate access to the
body cell.
• Malabsorption-diarrhoea, vomiting
• GIT cancers-oral, tongue, esophageal, gut
 Appetite affected by-

• Chronic illness
• Multiple drugs
• Bad odours from fungating tumors
• Food presentation
 Environment

• Home setup-no alternative mode of feeding except oral

• Hospital:

Food restrictions-what to avoid? Foods with carcinogens?

Getting balanced diet-consider amount and quality of the foods
Infections such as mouth sores, inflammations oral thrush will interfere
with oral food intake
 MODES OF FEEDING

• Oral feeding
• Enteral feeding
• Parenteral feeding
ORAL FEEDING
• The mode of feeding that is best encouraged in all patients with
functional gastro-intestinal tract.
• The foods given should be modified in accordance to patients’
preferences e.g. give soft easily digestible light diet.

ENTERAL NUTRITION/ FEEDING

• It refers to nutrition support using liquid formula diet via oral intake or
by tube feeding.
• The aim is to provide adequate nutrition so as to prevent or
reverse the development of malnutrition in patients who are
unable to ingest or derive sufficient from ordinary foods despite
having functional gastro intestinal tract
• The feeding formulas may be commercial preparations or
blenderized mixtures prepared from regular feeds.

EXAMPLE OF BLENDERIZED MIXTURES

• Ordinary porridge(white or white),1raw egg, 2 teaspoonful of
corn oil or vegetable oil, sugar to taste, fresh milk
• Fresh milk, 1 raw egg,2 spoons of corn oil, sugar to taste
PARENTERAL NUTRITION
• This is nutrition directly into the veins hence bypassing the
gastrointestinal tract. It must be in liquid form-solutions/emulsions.
a) Patial parenteral Nutrition.
• It is also referred to as peripheral parenteral nutrition. Provides partial
nutritional requirements for a period of 3-6 as a sole source of nutrients.
The catheter should be changed every 24-48 hours to reduce the risk of
thrombophlebitis
b) Total parenteral Nutrition
• This provides total nutritional requirements i.e. availing the
nutrients directly to the cell.
• The solutions used are of high osmolarity(600m0sm/l)
administered into central veins.
• The dosage should be according to requirements and must be
complete in nutrients i.e. amino acids, carbohydrates, electrolytes,
trace elements, vitamins and water.
• TPN can be administered over unlimited period of time.
Osmolarity of common parenteral solutions
• 5% glucose=300 m0sml/l
• 10% glucose=600 m0sml/l
• 20%glucose=1200 m0sml/l
• 10% aminacid solution(withoutadditives0=600 m0sml/l
• Contra-indication for TPN
• Presence of a functional gut
• Existence of an advanced terminal condition for which aggressive
therapy is risky.
 COMMON CONDITIONS AND THEIR
MANAGEMENT

NAUSEA AND VOMITING

• Have small frequent meals alternating dry foods and fluid diet
• Eat promptly when hunger is first felt
• Avoid cooking if the food aroma is the problem
• Avoid/use in moderation fatty/sugary foods as appropriate.
• Avoid liquids at meal time-take 30-60 minutes before or after foods.
• For early morning nausea, try unbuttered bread or plain biscuits.
• Try cold foods-they have less smells
• Avoid lying flat at least 2 hours after meals
• Use anti-emetics before meals as prescribed by the doctor
 SORENESS OF MOUTH

• Use soft moist foods

• Avoid spicy, very salty foods-use bland diet
• Use nourishing drinks- special uji, milk, mala, soups
• Avoid carbonated drinks e.g. sodas, beers
• Avoid very hot foods
• Use a straw
• Avoid rough or very dry foods
• Avoid highly acidic foods e.g. oranges, pineapples as
appropriate
 DRY MOUTH
– Have frequent drinks
– Suck ice cubes, or lemon slices if available
– Have regular mouth washes.
 DIARRHOEA
• Have plenty of fluids to replace potassium lost during diarrhea.
• Eat low fiber diet eg eat white bread instead of brown, animal proteins
instead of vegetable proteins.
• Eat cooked vegetables as opposed to raw vegetables and whole fruits.
• If lactose intolerant, avoid using fresh milk, use mala, soya milk or
soya based milk products eg Alsoy or Prosobee.
• Avoid gassy foods eg beans, cabbage, cauliflower
• Try boiled, baked,or steamed foods instead of fried foods if fat is
intolerable.
• Treat any identified underlying cause, review the use of laxatives
 CONSTIPATION

– Have a diet high in fibre e.g. brown bread, beans, pease, lentils
– Take plenty of fluids-8glasses a day
– Review the use of the laxatives.
 LOSS OF WEIGHT AND APPETITE

• Improve oral hygiene

• Serve small attractive meals, frequently
• Have snacks eg biscuits in between meals
• Serve foods at room temperatures
• Eat your favorite food when your appetite is particularly poor.
• Eat slowly in a relaxed atmosphere.
• Use spices and seasonings (as appropriate) to improve food
aroma and taste.
• Avoid very hot foods-foods taste better at room temperatures
• Eliminate foods that taste bad
 Severe malnutrition
• Severe malnutrition is both a medical and a social disorder.
• That is, the medical problems of the child result, in part, from the
social problems of the home in which the child lives.
• Malnutrition is the end result of chronic nutritional and, frequently,
emotional deprivation by carers who, because of poor understanding,
poverty or family problems, are unable to provide the child with the
nutrition and care he or she requires.
• Successful management of the severely malnourished child requires
that both medical and social problems be recognized and corrected.
• If the illness is viewed as being only a medical disorder, the child is
likely to relapse when he or she returns home, and other children in
the family will remain at risk of developing the same problem.
• Management of the child with severe malnutrition is divided into three
phases.
• These are:
• Initial treatment: life-threatening problems are identified and
treated in a hospital or a residential care facility, specific deficiencies are
corrected, metabolic abnormalities are reversed and feeding is begun.
• Rehabilitation: intensive feeding is given to recover most of
the lost weight, emotional and physical stimulation are increased, the
mother or carer is trained to continue care at home, and preparations are
made for discharge of the child.
• Follow-up: after discharge, the child and the child’s family are
followed to prevent relapse and assure the continued physical, mental and
emotional development of the child.
 Initial treatment
• Initial treatment begins with admission to hospital and lasts until the child’s
condition is stable and his or her appetite has returned, which is usually
after 2–7 days.
• If the initial phase takes longer than 10 days, the child is failing to respond
and
• additional measures are required. The principal tasks during initial
treatment are:
• — to treat or prevent hypoglycaemia and hypothermia;
• — to treat or prevent dehydration and restore electrolyte balance;
• — to treat incipient or developed septic shock, if present;
• — to start to feed the child;
• — to treat infection;
• — to identify and treat any other problems, including vitamin deficiency,
severe anaemia and heart failure.
 Hypoglycaemia

• All severely malnourished children are at risk of

developing hypoglycaemia (blood glucose <54 mg/dl
or <3 mmol/l), which is an important cause of death
during the first 2 days of treatment.
• Hypoglycaemia may be caused by a serious systemic
infection or can occur when a malnourished child has
not been fed for 4–6 hours, as often happens during
travel to hospital.
• To prevent hypoglycaemia the child should be fed at
least every 2 or 3 hours day and night.
• Signs of hypoglycaemia include low body temperature (<36.5 °C), lethargy, limpness
and loss of consciousness.
• Sweating and pallor do not usually occur in malnourished children with hypoglycaemia.
• Often, the only sign before death is drowsiness.
• If hypoglycaemia is suspected, treatment should be given immediately without
laboratory confirmation; it can do no harm, even if the diagnosis is incorrect.
• If the patient is conscious or can be roused and is able to drink, give 50 ml of 10%
glucose or sucrose, or give F-75 diet by mouth (see section 4.5), whichever is available
most quickly. If only 50% glucose solution is available, dilute one part to four parts of
sterile water.
• Stay with the child until he or she is fully alert.
• If the child is losing consciousness, cannot be aroused or has convulsions, give 5 ml/kg
of body weight of sterile 10% glucose intravenously (IV), followed by 50 ml of 10%
glucose or sucrose by nasogastric (NG) tube.
• If IV glucose cannot be given immediately, give the NG dose first.
• When the child regains consciousness, immediately begin giving F-75 diet or glucose in
water (60 g/l). Continue frequent oral or NG feeding with F-75 diet to prevent a
recurrence.
• All malnourished children with suspected hypoglycaemia should also be treated with
broad-spectrum antimicrobials for serious systemic infection
 Hypothermia
• Infants under 12 months, and those with marasmus, large areas of damaged
skin or serious infections are highly susceptible to hypothermia.
• If the rectal temperature is below 35.5 °C (95.9 °F) or the underarm
temperature is below 35.0 °C (95.0 °F), the child should be warmed.
• Either use the “kangaroo technique” by placing the child on the mother’s
bare chest or abdomen (skin-to-skin) and covering both of them, or clothe
the child well (including the head), cover with a warmed blanket and place
an incandescent lamp over, but not touching, the child’s body.
• Fluorescent lamps are of no use and hotwater bottles are dangerous.
• The rectal temperature must be measured every 30 minutes during
rewarming with a lamp, as the child may rapidly become hyperthermic.
• The underarm temperature is not a reliable guide to body temperature
during rewarming.
• All hypothermic children must also be treated for hypoglycaemia and for
serious systemic infection
 Dehydration and septic shock
• Dehydration and septic shock are difficult to differentiate in a child with severe
malnutrition.
• Signs of hypovolaemia are seen in both conditions, and progressively worsen if
treatment is not given. Dehydration progresses from “some” to “severe”, reflecting 5–
10% and >10% weight loss, respectively, whereas septic shock progresses from
“incipient” to “developed”, as blood flow to the vital organs decreases.
• Moreover, in many cases of septic shock there is a history of diarrhoea and some degree
of dehydration, giving a mixed clinical picture.

Diagnosis
• Many of the signs that are normally used to assess dehydration are unreliable in a child
• with severe malnutrition, making it difficult or impossible to detect dehydration reliably
• or determine its severity. Moreover, many signs of dehydration are also seen in septic
• shock. This has two results:
• — dehydration tends to be overdiagnosed and its severity overestimated; and
• — it is often necessary to treat the child for both dehydration and septic shock.
• (a) Signs of dehydration and/or septic shock that are reliable in a child with severe
malnutrition include:
• History of diarrhoea. A child with dehydration should have a history of watery
diarrhoea.
• Small mucoid stools are commonly seen in severe malnutrition, but do not cause
dehydration. A child with signs of dehydration, but without watery diarrhoea,
should be treated as having septic shock.
• Thirst. Drinking eagerly is a reliable sign of “some” dehydration. In infants this
may be expressed as restlessness. Thirst is not a symptom of septic shock.
• Hypothermia. When present, this is a sign of serious infection, including septic
shock. It is not a sign of dehydration.
• Sunken eyes. These are a helpful sign of dehydration, but only when the mother
says the sunken appearance is recent.
• Weak or absent radial pulse. This is a sign of shock, from either severe
dehydration or sepsis. As hypovolaemia develops, the pulse rate increases and the
pulse becomes weaker. If the pulse in the carotid, femoral or brachial artery is
weak, the child is at risk of dying and must be treated urgently.
• Cold hands and feet. This is a sign of both severe dehydration and septic shock. It
should be assessed with the back of the hand.
• Urine flow. Urine flow diminishes as dehydration or septic shock worsens. In severe
dehydration or fully developed septic shock, no urine is formed.

(b) Signs of dehydration that are not reliable include:

• Mental state. A severely malnourished child is usually apathetic when left alone and
irritable when handled. As dehydration worsens, the child progressively loses
consciousness. Hypoglycaemia, hypothermia and septic shock also cause reduced
consciousness.
• Mouth, tongue and tears. The salivary and lacrimal glands are atrophied in severe
malnutrition, so the child usually has a dry mouth and absent tears. Breathing through
the mouth also makes the mouth dry.
• Skin elasticity. The loss of supporting tissues and absence of subcutaneous fat make
the skin thin and loose. It flattens very slowly when pinched, or may not flatten at all.
• Oedema, if present, may mask diminished elasticity of the skin.
• (c) Additional signs of septic shock:
• Incipient septic shock. The child is usually limp, apathetic and profoundly
anorexic, but is neither thirsty nor restless.
• Developed septic shock. The superficial veins, such as the external jugular and
scalp veins, are dilated rather than constricted. The veins in the lungs may also
become engorged, making the lungs stiffer than normal. For this reason the child
may groan, grunt, have a shallow cough and appear to have difficulty breathing.
As shock worsens, kidney, liver, intestinal or cardiac failure may occur. There may
be vomiting of blood mixed with stomach contents (“coffee-ground vomit”), blood
in the stool, and abdominal distension with “abdominal splash”; intestinal fluid
may be visible on Xray.
• When a child reaches this stage, survival is unlikely.

Treatment of dehydration
• Whenever possible, a dehydrated child with severe malnutrition should be
rehydrated orally.
• IV infusion easily causes overhydration and heart failure and should be
used only when there are definite signs of shock.
Oral rehydration salts (ORS) solution for severely malnourished
children
• Because severely malnourished children are deficient in potassium
and have abnormally high levels of sodium, the oral rehydration salts
(ORS) solution should contain less sodium and more potassium than
the standard WHO-recommended solution. Magnesium, zinc and
copper should also be given to correct deficiencies of these minerals.
• Intravenous rehydration
• The only indication for IV infusion in a severely malnourished child is circulatory
collapse caused by severe dehydration or septic shock. Use one of the following
solutions (in order of preference):
– — half-strength Darrow’s solution with 5% glucose (dextrose)
– — Ringer’s lactate solution with 5% glucose2
– — 0.45% (half-normal) saline with 5% glucose.2
• Give 15 ml/kg IV over 1 hour and monitor the child carefully for signs of
overhydration.
• While the IV drip is being set up, also insert an NG tube and give ReSoMal
through the tube (10 ml/kg per hour). Reassess the child after 1 hour. If the child
is severely dehydrated,there should be an improvement with IV treatment and his
or her respiratory and pulse rates should fall. In this case, repeat the IV treatment
(15 mg/kg over 1 hour) and then switch to ReSoMal orally or by NG tube (10
ml/kg per hour) for up to 10 hours. If the child fails to improve after the first IV
treatment and his or her radial pulse is still absent, then assume that the child has
septic shock and treat accordingly
• Composition of oral rehydration salts solution for
• severely malnourished children (ReSoMal)
Component Concentration (mmol/l)
• Glucose 125
• Sodium 45
• Potassium 40
• Chloride 70
• Citrate 7
• Magnesium 3
• Zinc 0.3
• Copper 0.045
• Osmolarity 300
• Feeding during rehydration
• Breastfeeding should not be interrupted during
rehydration.
• Begin to give the F-75 diet as soon as possible, orally or
by NG tube, usually within 2–3 hours after starting
rehydration. If the child is alert and drinking, give the F-
75 diet immediately, even before rehydration is
completed. Usually the diet and ReSoMal are given in
alternate hours. If the child vomits, give the diet by NG
tube. When the child stops passing watery stools,
continue feeding.
• Treatment of septic shock
• All severely malnourished children with signs of incipient or developed septic
shock
• should be treated for septic shock. This includes especially children with:
• — signs of dehydration, but without a history of watery diarrhoea;
• — hypothermia or hypoglycaemia;
• — oedema and signs of dehydration.
• Every child with septic shock should immediately be given broad-spectrum
antibiotics
• and be kept warm to prevent or treat hypothermia. The child should not be
handled any more than is essential for treatment. Nor
• should the child be washed or bathed; after the child has defecated, his or her
bottom
• can be cleaned with a damp cloth. Iron supplements should not be given.
Incipient septic shock
• The child should be fed promptly to prevent hypoglycaemia, using the F-75 diet
with added mineral mix. As these children are nearly always anorexic, the diet
must be given by NG tube.
Developed septic shock
• Begin IV rehydration immediately, using one of the fluids listed on page 11.
Give 15 ml/kg per hour. Observe the child carefully (every 5–10 minutes) for
signs of overhydration and congestive heart failure (see section 4.9). As soon as
the radial pulse becomes strong and the child regains consciousness, continue
rehydration orally or by NG tube as described on pages 10–11. If signs of
congestive heart failure develop or the child does not improve after 1 hour of IV
therapy, give a blood transfusion (10ml/kg slowly over at least 3 hours). If blood
is not available, give plasma. If there are signs of liver failure (e.g. purpura,
jaundice, enlarged tender liver), give a single dose of 1mg of vitamin K1
intramuscularly.
• During the blood transfusion, nothing else should be given, so as to minimize
the risk of congestive heart failure. If there is any sign of congestive heart failure
(e.g. distension of the jugular veins, increasing respiratory rate or respiratory
distress), give a diuretic (see section 4.9) and slow the rate of transfusion.
Steroids, epinephrine or nikethamide are of no value and should never be used.
• Dietary treatment
• Children who do not require other emergency treatment, especially for
hypothermia, dehydration or septic shock, should immediately be given a
formula diet. They should also continue to be breastfed.

Initial treatment
• Formula diets for severely malnourished children
• Almost all severely malnourished children have infections, impaired liver and
intestinal function, and problems related to imbalance of electrolytes when first
admitted to hospital. Because of these problems, they are unable to tolerate the
usual amounts of dietary protein, fat and sodium. It is important, therefore, to
begin feeding these children with a diet that is low in these nutrients, and high in
carbohydrate. The daily nutrient requirements of severely malnourished children
are given in Appendix 5.
• Two formula diets, F-75 and F-100, are used for severely malnourished children.
F-75 (75 kcalth or 315 kJ/100 ml), is used during the initial phase of treatment,
while F-100 (100 kcalth or 420 kJ/100 ml) is used during the rehabilitation
phase, after the appetite has returned. These formulas can easily be prepared
from the basic ingredients: dried skimmed milk, sugar, cereal flour, oil, mineral
mix and vitamin mix (see Table 7). They are also commercially available as
• Preparation of F-75 and F-100 diets
• Ingredient Amount F-75a–d F-100e,f
• Dried skimmed milk 25 g 80 g
• Sugar 70 g 50 g
• Cereal flour 35 g —
• Vegetable oil 27 g 60 g
• Mineral mixg 20 ml 20 ml
• Vitamin mixg 140mg 140mg
• Water to make 1000 ml 1000 ml
 sugar, 35 g of cereal flour, 17 g of oil, 20 ml of mineral mix, 140 mg of vitamin
mix and water to make 1000 ml. Alternatively, use 300 ml of fresh cows’ milk,
70 g of sugar, 35 g of cereal flour, 17 g of oil, 20 ml of mineral mix, 140 mg of
vitamin mix and water to make 1000 ml.
• c Isotonic versions of F-75 (280 mOsmol/l), which contain maltodextrins instead
of cereal flour and some of the sugar and which include all the necessary
micronutrients, are available commercially.
• d If cereal flour is not available or there are no cooking facilities, a comparable
formula can be made from 25 g of dried skimmed milk, 100 g of sugar, 27 g of
oil, 20 ml of mineral mix, 140 mg of vitamin mix and water to make 1000 ml.
However, this formula has a high osmolarity (415 mOsmol/l) and may not be
well tolerated by all children, especially those with diarrhoea.
• e To prepare the F-100 diet, add the dried skimmed milk, sugar and oil to some
warm boiled water and mix. Add the mineral mix and vitamin mix and mix
again. Make up the volume to 1000 ml with water.
• f A comparable formula can be made from 110 g of whole dried milk, 50 g of
sugar, 30 g of oil, 20 ml of mineral mix, 140 mg of vitamin mix and water to
make 1000 ml.
• Alternatively, use 880 ml of fresh cows’ milk, 75 g of sugar, 20 g of oil, 20 ml of
mineral mix, 140 mg of vitamin mix and water to make 1000 ml.
• g If only small amounts of feed are being prepared, it will not be feasible to
• Feeding on admission
• To avoid overloading the intestine, liver and kidneys, it is essential that food be given frequently
and in small amounts. Children who are unwilling to eat should be fed by NGtube (do not use IV
feeding). Children who can eat should be given the diet every 2, 3 or 4 hours, day and night. If
vomiting occurs, both the amount given at each feed and the interval between feeds should be
reduced.
• The F-75 diet should be given to all children during the initial phase of treatment.
• The child should be given at least 80 kcal or 336 kJ/kg, but no more than 100 kcal or 420 kJ/kg per
th th

day. If less than 80 kcal or 336 kJ/kg per day are given, the tissues will continue to be broken down
th

and the child will deteriorate. If more than 100 kcal or 420 kJ/kg per day are given, the child may
th

develop a serious metabolic imbalance.

• Table 9 shows the amount of diet needed at each feed to achieve an intake of 100 kcal or 420 kJ/kg
th

per day. For example, if a child weighing 7.0 kg is given the F-75 diet every 2 hours, each feed
should be 75 ml. During the initial phase of treatment, maintain the volume of F-75 feed at 130
ml/kg per day, but gradually decrease the frequency of feeding and increase the volume of each
feed until you are giving the child feeds 4-hourly (6 feeds per day).
• Nearly all malnourished children have poor appetites when first admitted to hospital.
• Patience and coaxing are needed to encourage the child to complete each feed. The child should be
fed from a cup and spoon; feeding bottles should never be used, even for very young infants, as
they are an important source of infection. Children who are very weak may be fed using a dropper
or a syringe. While being fed, the child should always be held securely in a sitting position on the
attendant’s or mother’s lap. Children should never be left alone in bed to feed themselves.
Nasogastric feeding
• Despite coaxing and patience, many children will not take sufficient diet
by mouth during the first few days of treatment. Common reasons include
a very poor appetite, weakness and painful stomatitis. Such children should
be fed using a NG tube. However, NG feeding should end as soon as
possible. At each feed, the child should first be offered the diet orally. After
the child has taken as much as he or she wants, the remainder should be
given by NG tube. The NG tube should be removed when the child is
taking three-quarters of the day’s diet orally, or takes two consecutive feeds
fully by mouth. If over the next 24 hours the child fails to take 80 kcalth or
336 kJ/kg, the tube should be reinserted. If the child develops abdominal
distension during NG feeding, give 2 ml of a 50% solution of magnesium
sulfate IM.
• The NG tube should always be aspirated before fluids are administered. It
should also be properly fixed so that it cannot move to the lungs during
feeding. NG feeding should be done by experienced staff.
• Feeding after the appetite improves
• If the child’s appetite improves, treatment has been successful. The
initial phase of treatment ends when the child becomes hungry. This
indicates that infections are coming under control, the liver is able to
metabolize the diet, and other metabolic abnormalities are improving.
• The child is now ready to begin the rehabilitation phase.
• This usually occurs after 2–7 days. Some children with complications
may take longer,
• whereas others are hungry from the start and can be transferred
quickly to F-100.
• Nevertheless, the transition should be gradual to avoid the risk of heart
failure which can occur if children suddenly consume large amounts of
feed. Replace the F-75 diet with an equal amount of F-100 for 2 days
before increasing the volume offered at each feed.
• It is important to note that it is the child’s appetite and general
condition that determine the phase of treatment and not the length of
time since admission.
Milk intolerance
• Clinically significant milk intolerance is unusual in severely malnourished
children.
• Intolerance should be diagnosed only if copious watery diarrhoea occurs promptly
after milk-based feeds (e.g. F-100) are begun, the diarrhoea clearly improves
when milk intake is reduced or stopped, and it recurs when milk is given again.
Other signs include acidic faeces (pH < 5.0) and the presence of increased levels
of reducing substances in the faeces. In such cases, the milk should be partially or
totally replaced by yoghurt or a commercial lactose-free formula. Before the child
is discharged, milk-based feeds should be given again to determine whether the
intolerance has resolved.
Recording food intake
• The type of feed given, the amounts offered and taken, and the date and time must
be recorded accurately after each feed. If the child vomits, the amount lost should
be estimated in relation to the size of the feed (e.g. a whole feed, half a feed), and
deducted from the total intake. Once a day the energy intake for the past 24 hours
should be determined and compared with the child’s weight. If the daily intake is
less than 80 kcalth or 336 kJ/kg, the amount of feed offered should be increased.
If more than 100 kcalth or 420 kJ/kg have been given, the amount of feed offered
should be reduced.
Infections
Bacterial infections
• Nearly all severely malnourished children have bacterial infections when first admitted
to hospital. Many have several infections caused by different organisms. Infection of
the lower respiratory tract is especially common. Although signs of infection should be
carefully looked for when the child is evaluated, they are often difficult to detect.
• Unlike well-nourished children, who respond to infection with fever and inflammation,
malnourished children with serious infections may only become apathetic or drowsy.
• Early treatment of bacterial infections with effective antimicrobials improves the
nutritional response to feeding, prevents septic shock and reduces mortality.
• Because bacterial infections are common and difficult to detect, all children with severe
malnutrition should routinely receive broad-spectrum antimicrobial treatment when first
admitted for care. Each institution should have a policy on which antimicrobials to use.
• These are divided into those used for first-line treatment, which are given routinely to
all severely malnourished children, and those used for second-line treatment, which
are given when a child is not improving or a specific infection is diagnosed. Although
local resistance patterns of important bacterial pathogens and the availability and cost
of the antimicrobials will determine the policy
• First-line treatment
• Children with no apparent signs of infection and no complications
should be given cotrimoxazole (25 mg of sulfamethoxazole + 5 mg
of trimethoprim/kg) orally twice daily for 5 days.
• Children with complications (septic shock, hypoglycaemia,
hypothermia, skin infections, respiratory or urinary tract infections,
or who appear lethargic or sickly) should be given:
– • ampicillin, 50mg/kg IM or IV every 6 hours for 2 days,
followed by
– amoxicillin,15mg/kg orally every 8 hours for 5 days (if
amoxicillin is unavailable, give ampicillin,25mg/kg orally every
6 hours) and
– gentamicin, 7.5 mg/kg IM or IV once daily for 7 days.
• Second-line treatment
• If the child fails to improve within 48 hours, add chloramphenicol, 25mg/kg
IM or IV every 8 hours (or every 6 hours if meningitis is suspected) for 5
days.
• Further details of antimicrobial treatment are given in Appendix 6. The
duration of treatment depends on the response and nutritional status of the
child. Antimicrobials should be continued for at least 5 days. If anorexia still
persists after 5 days of treatment, give the child another 5-day course. If
anorexia still persists after 10 days of treatment, reassess the child fully.
Examine the child for specific infections and potentially resistant organisms,
and check that vitamin and mineral supplements have been correctly given.
• If specific infections are detected for which additional treatment is needed, for
example dysentery, candidiasis, malaria or intestinal helminthiasis, this should
also be given (see section 7.3). Tuberculosis is common, but antituberculosis
drugs should be given only when tuberculosis is diagnosed.
• Note:
– Some institutions routinely give malnourished children metronidazole, 7.5 mg/kg
every 8 hours for 7 days, in addition to broad-spectrum antimicrobials. However, the
efficacy of this treatment has not been established by clinical trials.
• Measles and other viral infections
• All malnourished children should receive measles vaccine
when admitted to hospital.
• This protects other children in hospital from catching the
disease, which is associated with a high rate of mortality. A
second dose of vaccine should be given before discharge.
• There is no specific treatment for measles, disseminated
herpes or other systemic viral infections. However, most
children with these infections develop secondary systemic
bacterial infections and septic shock, which should be treated
as described in section 4.4. If fever is present (body
temperature >39.5 °C or 103 °F), antipyretics should
• be given.
• Vitamin deficiencies
• Vitamin A deficiency
• Severely malnourished children are at high risk of developing blindness due to vitamin A
deficiency. For this reason a large dose of vitamin A should be given routinely to all
malnourished children on day 1, unless there is definitive evidence that a dose has been given
during the past month. The dose is as follows: 50 000 International Units (IU)
1

• orally for infants <6 months of age, 100 000 IU orally for infants 6–12 months of age and
200000 IU orally for children >12 months of age. If there are any clinical signs of vitamin A
deficiency (e.g. night blindness, conjunctival xerosis with Bitot’s spots, corneal xerosis or
ulceration, or keratomalacia), a large dose should be given on the first 2 days, followed by a
third dose at least 2 weeks later (see Table 10). Oral treatment is preferred, except at the
beginning in children with severe anorexia, oedematous malnutrition or septic shock, who
should be given IM treatment. For oral treatment, oil-based preparations arepreferred, but
water-miscible formulations may be used if oil-based formulations are not available. Only
water-miscible formulations should be used for IM treatment.
• Great care must be taken during examination of the eyes, as they easily rupture in children
with vitamin A deficiency. The eyes should be examined gently for signs of xerophthalmia,
corneal xerosis and ulceration, cloudiness and keratomalacia. If there is ocular inflammation
or ulceration, protect the eyes with pads soaked in 0.9% saline.
• Tetracycline eye drops (1%) should be instilled four times daily until all signs of
inflammation or ulceration resolve. Atropine eye drops (0.1%) should also be applied and the
affected eye(s) should be bandaged, as scratching with a finger can cause rupture of an
• Other vitamin deficiencies
• All malnourished children should receive 5 mg
of folic acid orally on day 1 and then 1mg
orally per day thereafter. Many malnourished
children are also deficient in riboflavin,
ascorbic acid, pyridoxine, thiamine and the fat-
soluble vitamins D, E and K. All diets should
be fortified with these vitamins by adding the
vitamin mix
• Very severe anaemia
• If the haemoglobin concentration is less than 40 g/l or the
packed-cell volume is less than 12%, the child has very
severe anaemia, which can cause heart failure. Children
with very severe anaemia need a blood transfusion. Give 10
ml of packed red cells or whole blood per kg of body
weight slowly over 3 hours. Where testing for HIV and
viral
• hepatitis B is not possible, transfusion should be given only
when the haemoglobin concentration falls below 30 g/l (or
packed-cell volume below 10%), or when there are signs of
life-threatening heart failure. Do not give iron during the
initial phase of treatment, as it can have toxic effects and
may reduce resistance to infection.
• Congestive heart failure
• This is usually a complication of overhydration (especially when an IV infusion or standard ORS
solution is given), very severe anaemia, blood or plasma transfusion, or giving a diet with a high
sodium content. The first sign of heart failure is fast breathing (50 breaths per minute or more if
the child is aged 2 months up to 12 months; 40 breaths per minute or more if the child is aged 12
months up to 5 years). Later signs are respiratory distress, a rapid pulse, engorgement of the
jugular vein, cold hands and feet, and cyanosis of the fingertips and under the tongue. Heart
failure must be differentiatedfrom respiratory infection and septic shock, which usually occur
within 48 hours of admission, whereas heart failure usually occurs somewhat later.
• When heart failure is caused by fluid overload, the following measures should be taken:
1

• 1. Stop all oral intake and IV fluids; the treatment of heart failure takes precedence over
• feeding the child. No fluid should be given until the heart failure is improved, even if
• this takes 24–48 hours.
• 2. Give a diuretic IV. The most appropriate choice is furosemide (1 mg/kg).
2

• 3. Do not give digitalis unless the diagnosis of heart failure is unequivocal (jugular venous
pressure is elevated) and the plasma potassium level is normal. In that case, 5mg/kg of body
weight of digoxin may be given IV as a single dose, or orally, if the IV preparation is not
available.
• Dermatosis of kwashiorkor
• This is characterized by hypo- or hyperpigmentation, shedding of the skin in scales or
• sheets, and ulceration of the skin of the perineum, groin, limbs, behind the ears and
• armpits. There may be widespread weeping skin lesions which easily become infected.
• Spontaneous resolution occurs as nutrition improves. Atrophy of the skin in the
perineum leads to severe diaper dermatitis, especially if the child has diarrhoea. The
diaper area should be left uncovered. If the diaper area becomes colonized with
Candida spp., it should be treated with nystatin ointment or cream (100000 IU (1 g))
twice daily for 2 weeks and the child should be given oral nystatin (100 000 IU four
times daily). In other affected areas, application of zinc and castor oil ointment,
petroleum jelly or paraffin gauze dressings helps to relieve pain and prevent infection.
The zinc supplement contained in the mineral mix is particularly important in these
children, as they are usually severely deficient.
• Bathe the affected areas in 1% potassium permanganate solution for 10–15 minutes
daily. This dries the lesions, helps to prevent loss of serum, and inhibits infection.
• Polyvidone iodine, 10% ointment, can also be used. It should be used sparingly,
however, if the lesions are extensive, as there is significant systemic absorption.
• All children with kwashiorkor-related dermatosis should receive systemic antibiotics
ADEQUATE NUTRITION IS
THE CORNERSTONE OF
MANAGEMENT
OF THE PATIENTS WITH
LIFE LIMITING
ILLNESS.