Nutrition😍

Obesity

• Indicators:
• Body mass index (BMI): m/c
• Quetelet index
• BMI = Weight (in kgs) / Height² (in metres)
• Ideal BMI (India): 18.5 – 22.9 kg/m ².
• Others: Broca’s index, corpulence index.

ㅤ	Reference male	Reference female (Non-pregnant)
Weight (Kg)	65	55
Age (years)	19 to 39	=
Height (95th centile)	1.77 m	1.62 m
BMI (Kg/m2) Normal: 18.5 to 22.9	20.75	20.95
Activity	• Occupation: 8 hours  • Sleep: 8 hours  • Sitting/moving around: 4 to 6 hours  • Walking (Active recreation): 2 hours	ㅤ

• Obesity cut-offs



Measure	Males	Females
Waist circumference	<102	<88
Waist hip ratio	<0.9	<0.85
Skin fold thickness : ↳ Using herpenden's calliper (4 sites)	<40 mm	<50 mm

RDA Update (2020)

• 1 Kcal = 4.184 KJ

Macronutrients

• Pregnancy : Average +350 Kcal/day

• Trimester Kcal/day

Trimester	Calorie (Kcal/day)	Protein (g/day)
Non-pregnant	• 1660	• 45
ㅤ	Additional	ㅤ
1st Trimester	• 70–80 OR • No additional calorie requirement	• Nil
2nd Trimester	• 280	• + 10g
3rd Trimester	• 450	• +20g

• Lactation:
• 0 to 6 months: + 600 Kcal/day
• 6 to 12 months: + 520 Kcal/day

• Carbs in females:
• Non-pregnant: 130 g/day .
• Pregnant: 175 g/day .
• Lactating: 200 g/day .

• Fat req:
• 28 g/day

Micronutrients

• Sodium: 2000 mg/day (5g of salt)
• Double of calcium

• Potassium: 3500 mg/day.
• Triple of calcium

• Iodine (I2) req. : 250 mcg/day.

• Vitamin A = Calcium

Nutritional Requirement ↑

• During pregnancy:
• Iron, Folic Acid, Protein, Zinc

• During lactation:
• Calcium, Vitamin A, Iodine, Vitamin C, Carbohydrate
• Ac yil irunn choru thinn paalu kudikkanam

• Iodine requirement in pregnancy
• 280 µg/day

• Iodine requirement for children
• 90-120 µg/day

Recommended Weight Gain in Pregnancy

• In normal BMI females: 11-12.5 kg

• In females with low BMI (Thin females): 12.5 - 18 kg

• In females with BMI >30 (Obese): 7 kg (5 - 9 kg)

Limiting Amino Acids

Phrynoderma / follicular hyperkeratosis/ Toad Skin

Without 13-cis retinoic acid:

• Earliest skin manifestation: Dryness

• Caused by Vitamin A or essential fatty acid deficiency.

• Small papillary lesions
• Dry, rough, hyperkeratotic papules
• Small keratin plug is at the tip.
• Near back of elbows, knees, joint areas

• Pathology: Impaired follicular keratinisation (Vit A essential)

Source

• Leafy green vegetables

• Gut microbiota

• Absorbed in jejunum

Folate trap

• Cause:
• Vitamin B₁₂ deficiency
• THFA is trapped as Methyl THFA
• ↑↑ N5-methyl THFA
• Functional folate deficiency → Megaloblastic anemia

Deficiency

• Megaloblastic anemia.

• Neurological manifestation is not seen

Biochemical Tests

• Serum homocysteine ↑
• thrombosis risk

• Normal Methylmalonyl CoA

• Histidine load test:
• FIGLU excretion in urine

• Serum AICAR

Important Information:

• Form used in treatment:
• N5-formyl THF (due to its high stability).
• Formulate as tab → formyl

• Main form in circulation:
• Methyl THF (most abundant in plasma).
• Main in circulation → Methyl

• Form used in 1C transfer reactions:
• Methylene THF (involved in DNA synthesis and amino acid metabolism).
• Serine (3C) + THF → Glycine (2C) + Methylene THF
• TransferEnce → methylEne

Prevention of Neural Tube Defects:

• Folic Acid Supplementation:
• 400 µg/day in all women of childbearing age.
• 4000 µg/day in high-risk women.
• Started at least one month before conception.
• Decrease risk of neural tube defects by 70%.

Folic Acid in Pregnancy

• 400 mcg/day
• All females → prevention
• Diabetic
• On anti epileptic → before conception

• 1 mg/day
• Treat folic acid deficiency

• 4 mg/day
• Prev h/o NTD
• Antiepileptic → after conception

• 5 mg/day
• Thalassemia or thalassemia trait.
• Sickle cell anemia

• To prevent NTD:
• 400 mcg/day given to all pregnant females
• Start 1 month before conception
• Continue till 3 months after conception

• To prevent recurrence of NTD:
• 4 mg/day given to females with h/o baby with NTD
• Start 3 months before conception
• Or from day a female plans pregnancy
• Continue 3 months after conception

• To treat folic acid deficiency: 1 mg/day

• In diabetic patients who are pregnant: 400 mcg/day

• In patients on antiepileptic:
• Before conception: 400 mcg/day
• After conception: 4 mg/day

Differences between B12 deficiency and Folate deficiency

• Nutritional (strict vegans)

• M/c: Alcohol

• Gastric
• ↓ intrinsic factor:
• Autoimmune pernicious anemia,
• Gastrectomy
• Gastric bypass surgery

• Intestinal
• Crohn's disease
• Diphyllobothrium latum (Fish tapeworm)
• Stagnant loop syndrome
• SIBO
• Terminal ileum resection
• Malabsorption

• Measure Methylmalonic acid level in urine after fasting

NOTE:

• In Orotic aciduria, PS shows
• Hypochromic Megaloblastic anemia
• Seen in
• Type 2 hyperammonemia
• No anemia
• Allopurinol

Clinical Features:

• Pale, fatigued.

• Reversible dementia in old age.

• Pure vegetarian diet

• Hyperpigmentation of knuckles and phalanges.

• Subacute Combined Degeneration of Spinal Cord
• Dorsal column + UMN

Peripheral Smear Findings (Megaloblastic Anemia):

• Howell-Jolly bodies

• Cabot ring

• Fine Basophilic stippling

• Macroovalocytes (Macrocytes),

• Hypersegmented neutrophils
• ≥ 5% neutrophils with ≥ 5 lobes /
• ≥ 1 neutrophil with ≥ 6 lobes.

Vitamin D

Form	Source
D2 (Ergocalciferol)	Plants,
D3 (Cholecalciferol)	Animal sources, synthesized in skin
Storage	25-OH D3
Active (most potent)	1,25-(OH)₂ D3 (Calcitriol)

 

Rickets

Deficiency causes:

• Rickets in children

• Osteomalacia in adults

Richest source:

• Cod fish.

Clinical feature in children:

• Bow legs (Genu varum)

Note:

• Genu valgum = Knock-knee syndrome

Vitamin D Toxicity → Hypercalcemia

• d/t intake of 60000 IU tabs

• Rx:
• Glucocorticoids
• → ⛔ Vitamin D → ↓ intestinal absorption of calcium → ↑ Urinary excretion of calcium → Resulting in negative calcium balance

Richest sources of vitamins and minerals

• Vitamin A: Halibut fish.
• A → Alia bhatt → halibut

• Vitamin C: Amla (Indian gooseberry).
• Camala (C → Amla)

• Vitamin B1:
• Gingelly seeds
• Organ meat, husk of grains and nuts (Parboiled grains).

• Vitamin B12:
• Organ meat (No plant sources).

• Vitamin D:
• Cod fish.
• De (Vit D) code (Cod fish)

• Iodine: Japanese seaweed.

• Iron: Heme sources, pumpkin seeds.

Metal cofactor Enzymes

Iodine

Cretinism

• Condition with irreversible intellectual abnormalities.

Endemic Cretinism

• Cause: Nutritional deficiency of iodine

• Types:
• Neurological cretinism
• Features: Strabismus, spastic diplegias
• Myxedematous cretinism

Mineral Iron

Sources

• Heme:
• Animal source (20 - 40% bioavailability).

• Non-Heme:
• Plant source (6 - 9% bioavailability):
• Pumpkin seeds (Rich).
• Pista.
• Dates.
• Green leafy vegetables.
• Poor man’s source: Jaggery
• Note: Iron in jaggery due to iron vessel used for production.

• Pregnancy:
• Iron cannot be fully supplemented by diet alone
• Supplementation required regardless of Hb or socioeconomic status

• Mass prophylaxis:
• Use Tablet ferrous sulphate
• (Us Ate)
• Withhold in:
• Acute illness (fever, pneumonia, diarrhea)
• Known thalassemia major
• History of repeated blood transfusion

• Always continue iron for 3 months after Hb normalizes
• To replenish iron stores

WHO Anemia Definition (Hemoglobin Levels):

• Best for epidemiological surveys

• Insensitive for early nutrient depletion

• Levels:
• Healthy Adult Male: <13 g/dL
• Healthy Adult Female: <12 g/dL
• Pregnant Woman: <11 g/dL
• CKD Patient: <10 g/dL
• Children 6 months—5 years: Hb <11 g/dl
• Children 6-14 years: Hb <12 g/dl

Causes

• Dietary, blood loss (trauma, PUD, colon cancer, menorrhagia)

• Hookworm infection

Approach to anemia in children:

Iron Deficiency Anemia

• Most common cause of nutritional disorders in the world

• Most common cause of anemia in the world

• Vitamin C helps in the absorption of iron

• Associated with celiac disease

Calcium

• Richest grain:
• Ragi

• Sources: Milk, eggs, fish, meat

• Used as an important weaning food

• Metabolism requires: Vitamin D

• Sources: Breast milk (picolinic acid aids absorption)

• Function:
• Essential for 100+ enzyme activities.
• 2nd most common trace element in body after Iron
• Important in forming zinc fingers (transcription factor motif) → part of gene transcription
• Major antioxidant → part of SOD

Disorders

• WHO dose in diarrhea:
• <6 months: 10 mg/day × 14 days
• >6 months: 20 mg/day × 14 days

• Deficiency causes:
• Diarrhoea
• Delayed wound healing
• Hypogonadism
• Male hypogonadism and sexual dysfunction
• Suppressed immunity
• Dysgeusia (altered taste), anosmia (loss of smell)
• Predispose to alcoholic cirrhosis.

• Zinc deficiency → ↓ Retinol dehydrogenase → Visual disturbance

Acrodermatitis Enteropathica

 

 

 

• Autosomal Recessive

• Daily requirement: 5–10 mg/day

Types of Zinc Deficiency

1. Congenital:
• Autosomal recessive (Zip4 transporter protein deficiency).
• After 6 months / weaning (maternal milk aids zinc absorption)

2. Acquired: Chronic alcoholics

Main Features (DDA Mnemonic)

• Dermatitis
• acral, periorificial
• Presents with extensive inflammatory rashes
• oral cavity,
• genital region.
• Rash distribution:
• Cheeks
• Mouth
• Anal region

• Diarrhoea

• Alopecia

• Mnemonic: Z → vayil kude keri appi pokunnath

Treatment:

• Zinc supplementation

Selenium

• Daily requirement: 50–60 mcg/day

• Functions as an important antioxidant

• Selenocysteine:
• 21st amino acid
• Coded by UGA (Stop codon)
• Formed by co-translational modification
• Serine → Selenocysteine
• Found in:
• Glutathione peroxidase
• Protects against oxidative stress
• Thioredoxin reductase
• Redox balance in cells
• Glycine Reductase
• Deiodinase
• Thyroid hormone conversion: T4 → T3
• Selenoprotein P
• Transports selenium in plasma
• NOT GLUTATHIONE REDUCTASE (Dep on Vit B2)
• ”Mneumonic: Selena’s sister serena from UGAnda“
• "Selena glue thinnu diarrhea aayi"

• Pyrrolysine:
• 22nd Amino acid
• Coded by UAG
• From Lysine

• Both 21 22 due to cotranslational modification

Disorders

National Program for Prevention and Control of Fluorosis

• Normal fluoride level in drinking water: 0.5–0.8 mg/L

• Fluorine is called a "Double-edged sword"

Disorders

Dental Fluorosis

• Fluoride in water is >1.5 mg/L

• Manifestation: Mottling of upper incisors

Dental Caries

• Fluoride in water is <0.5 mg/L

• Due to fluoride deficiency

Genu Valgum (Knock-knee syndrome)

 

 

 

• Cause: Excess fluorine

 

 

 

Crippling Fluorosis

• Occurs when fluoride in water is >10 mg/L

Nalgonda Technique

• Purpose: Defluoridation of water (removes excess fluoride)

• Method:
• Addition of: (LAB)

Component	Function
Lime	• Precipitation of fluoride • Form dense floc
Alum	• Coagulant • + H2O ⇒ AlOH adsorbs fluoride ions
Bleaching powder / Sodium hypochlorite	• Disinfects

• to fix vaishna’s teeth → Put Lime and bleaching powder in Aluminium pathram

• Developed by: NEERI Institute, Nagpur
• National Environmental Engineering Research Institute

Composition of breast milk Vs Cow milk

• Casein : Albumin ratio = 1:1

• Vitamin C:
• maximum of all milk sources (↑ Iron absorption).

Breast Milk deficient

• Vitamin D (400 IU/day)
• Recommended to all babies till 1 year

• Vitamin K –
• Given to all babies
• 1 mg IM at birth
• Prevents hemorrhagic disease of the newborn

• Iron ???
• Adequate (↑ Bioavailability).

Babies predominantly cow milk fed:

• ↑ Risk of hypocalcemia, tetany, seizures

• ↑ Risk of scurvy
• Due to Vitamin C deficiency in cow's milk
• Vitamin C is heat labile (gets destroyed when cow's milk is boiled)

Breast milk contains Anti-infective substances

• Mnemonic - Teach for PLAB

• Transforming growth factor β

• Phagocytic macrophages

• Lactoferrin

• Lysozyme

• Antibodies especially IgA

• Bifidus factor

• Bile stimulated lipase

Ergottism

• Cause: Ergotamine → vasoconstriction.

• Site: End arteries of fingers.

• Effect: Ischemic necrosis → dry gangrene (ergotism).

• Mnemonic: Er (Err) got (got) i (in) sm (small art.)

• Treatment:
• Nitroprusside (vasodilator).

Neurolathyrism

• Lathyrus sativa → Khesari dal

• Beta Oxalyl Amino Alanine (BOAA)

• UMN lesion (Spastic paralysis).

• Prevention:
• Vit C, steeping, and parboiling

• Joints involved: Knee > Hip & ankle.

Stage	Name of Stage	Clinical Features
I	Asymptomatic (Latent)	-
II	No stick	Limping
III	One stick	Crossed gait
IV	Two stick	Cannot walk without support
V	Crawler	Unable to walk

• Mnemonic:
• Neurolathyrism → Bent (bow) BCD
• Walking with Laathi (Lathyrus) → we Boooo (BOAA)
• Kesariya thera → Paadi nadakkunnu → Stick vach
• Bow (BOAA) legs (spastic paralysis) → B (parBoiling) C (Vitamin C) D (Dal)

Epidemic dropsy

• Adulterated mustard oil
• Toxin:
• Sanguinarine
  (Argemone mexicana)
 

• Sangi (Sanguinarine) mexica (mexicana) yil oil (mustard oil) theych Veenu (dropsy) neeradichu (fluid overload) → neela color ayi (Nitric acid chromatography)

• Thatti veenathu (dropsy) eduthu kalayanam (deweeding)

• MOA: Sanguinarine → ⛔ → Glucose metabolism → ↑ Pyruvic acid.

• Clinical features:
• Non-inflammatory, bilateral swelling of legs, with diarrhoea
• Glaucoma.
• Ascites.
• Pedal edema.
• Pleural effusion.
• Congestive cardiac failure.

• Management:
• Pre-testing:
• Nitric acid chromatography test (More sensitive). 
• De-weeding