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Applied Human Nutrition ANU 306 (2+0)

What is Nutrition? According to Robinson nutrition is the science of foods, nutrients, and other
substances ; therein; their action, interaction, and balance in relationship to health, and diseases; the
processes by which the organism ingests, digests, absorbs, transports, and utilizes nutrients and
disposes of their end products.
What are the frontiers of nutrition science? The frontiers of science of nutrition include the followings:

Mental-well being
Prevention of degenerative diseases and cancer.

Relation of nutrition to human health

1. Nutrition and immunity: nutrition is an important determinant of immunological status; and that
under nutrition could impair immune-competence and increase susceptibility and vulnerability
to infections. Immune system could be affected by nutritional deficiencies and under nutrition
usually implies deficiencies of more than one nutrient. These can impair the immune system.
Under nutrition can affect both humoral and cellular immunity. T-cell, B-cell and macrophage
can all be affected. Several nutrients such as proteins, lipids, and micronutrients such as zinc,
iron, vitamin A, vitamin B6 and copper have been shown to affect immune system.
The lymphoid tissues which play a dominant role in immunity are highly vulnerable to under nutrition.
Thymus shrinks in malnutrition and the cortico-medullary differentiation is lost; mature fully
differentiated T-lymphocytes are reduced in number and their maturation is impaired. There is also a
distortion in the relative proportions of helper (inducer) and suppressor T-cells. Many cells of the
immune system including T-cells have to depend for their functions on metabolic pathways which need
various nutrients such as carotenoids, zinc, iron, copper, and vitamin B6 and other micronutrients as
cofactors. Short supply of these nutrients impairs the functioning of the cells.
The process of phagocytosis a major defense mechanism is also impaired in the under nutrition. The
role of vitamin C, zinc, and other nutrients in phagocytosis are well established. The production of
several cytokines-including interleukins and interferon is decreased in under nutrition.
Low birth weight infants born to under nutrition mothers have sub-optimal immune responses and are
therefore susceptible to infections. There is a high neonatal mortality in low birth weight infants.

Role of bioactive phytochemicals in foods

Foods contain disease preventing and health promoting bioactive phytochemicals. Some bioactive
phytochemicals present in foods are as follows:
-----------------------------------------------------------------------------------------------------------------------------------------phenolic compounds


Isoflavonoids, isothiocyanates




Bioactive phytochemicals in foods act in three ways:
1. Antioxidants
2. Detoxifying agents
3. Blocking/suppressing agents
The normal functioning of cells depends on a proper balance of pro-oxidants and antioxidants. Prooxidants promote the release of oxygen to provide the energy needed for cell functioning. Antioxidants
help to neutralize and counteract the deleterious free radicals. Oxidation produces free radicals
generated as a result of natural metabolic process. Free radicals could promote lipid peroxidation
impairing cell functioning. They could damage cellular proteins and DNA. They can damage cellular
proteins and DNA.
Antioxidants present in some foods help to neutralize free radicals through protective mechanisms as
oxygen quenching, chain termination, radical scavenging. Some nutrients as carotenoids , ascorbic acid,
and tocopherols act as antioxidants. They act synergistically with such other antioxidants as phenols
and flavonoids present in foods. They help to contain the deleterious effects of free radicals. Prominent
common foods possessing such antioxidants are green leafy vegetables, fruits, like amla, and guava,
palm oil and sunflower oils and spices like turmeric and cloves.
Detoxifying agents
Toxic chemicals in the environment are removed from the body by two processes. Firstly, the toxic
molecules are transferred into rapidly extractable form through a number of reactions largely mediated
through the microsomal mixed function oxidase system (MFO).
In the second phase, the toxic molecules are converted into still more extractable form by a set of
enzymes. Examples of foods which contain such detoxifying chemicals are Brussels sprout, cabbage,
tomatoes, strawberries, pineapples, green peppers, and green and black tea. These foods contain
chemicals which are in the nature of indole derivatives, that act by inducing glutathione Stransferase,
a key phase 2 enzymes. Other foods such as broccoli and green onions exert similar protective effects
through induction of another key phase -2 enzymes, namely quinine reductase.

Blocking /suppressing agents

Bioactive phytochemical in foods sequester and prevent potential toxic agents and carcinogens from
reaching the target tissues, or by suppressing their action. Garlic, for example, is known to contain allelic
sulphides which can not only induce phase -2 enzymes, but also inactivate carcinogens. Agoene , a
chemical in garlic prevent platelet aggregation . The beneficial effect of garlic in heart disease could be
attributed to these chemicals. Chemical allin contained in garlic, cloves get converted to allicin when the
garlic is crushed because of the action of enzymes in garlic.
Flavonoids present in foods have been shown to act by scavenging superoxide anion, single oxygen and
lipid peroxide radicals. Thus, quercetin , a major flavonoid has been shown to inhibit oxidation and
cytotoxicity of LDL. Flavonoids have also been shown to inhibit cytooxygenase leading to inhibition of
platelet aggregation and reduced thrombotic tendencies. Regular intake of flavonoids in their natural
form through vegetables and fruits reduce the risk of deaths from coronary heart disease and reduce
the risk of lung cancer.
Foetal undernutrition and adult chronic disease
Body tissues of the foetus have a long " elephantine memory" and nutritional injuries inflicted to them
are not forgiven or forgotten. McKeigue and coworker have reported a greater vulnerability of Indians
migrants to foreign countries to coronary heart diseases and diabetes as compared to European and
other ethnic groups. This increased susceptibility is part of syndrome X, characterized by abdominal
obesity, hyperinsulinaemia, hypertriglyceridaemia, low concentration of high density lipoprotein (HDL)
and hypertension. Increased susceptibility to syndrome X could be the result of maternal nutritional
deprivation during critical phases of fetal growth, leading to intrauterine growth retardation (IUGR).
Barker et al studied on white indigenous population of Britain and concluded the following results:
1. Mortality rates from coronary heart diseases were three times higher in men who had weighed
18 lbs or less at one year of age than in those who had weighed 27 lbs or more.
2. The prevalence of diabetes fell from 27 % in subjects who had weighed 5.5 lbs or less at birth to
6 % in those who had weighed 7.5 lbs or more.
3. The prevalence of syndrome X fell from 30 % in men who had 5.5 lbs or less at birth to 6 % in
those who had weighed 9.5 lbs or more.
Nutrition and ageing
Nutrition plays an important role in:
1. Retarding the ageing process and in ensuring that the reduction in functional enzymes-a central
attribute of ageing-is minimized.
2. Overcoming suboptimal immune-competence largely responsible for increased vulnerability to
infection in old age
3. Improving mental function.
Retardation of ageing
The ageing process is attributed to the accumulation of somatic mutations in DNA resulting in defective
RNA unable to produce essential functional enzymes in adequate amounts. The mutations in DNA are
the result of oxidative damage caused by free radicals generated in the course of cell metabolism in the
absence of an adequate supply of key antioxidants. Bioactive chemicals in several plant foods (fruits and
vegetables) could help to dispose of free radicals and to detoxify mutagen. Nutrients like vitamin E,
carotenoids and ascorbic acid also contribute to this process.

Improving immune-competence
Ageing is also associated with impaired immune-competence and consequent increased vulnerability to
infection related morbidity-especially respiratory diseases. The most common nutrient deficiencies
contributing to suboptimal immunity in old age are those of iron, zinc, and vitamin c; correction of these
deficiencies has been shown to improve immunity.
Improving mental function
Good nutrition contributes to the minimization of impairment of mental function in old age. Three
classes of nutrients may play a role in this regard.
1. There are some nutrients which are the precursor of neurotransmitters. Tryptophan is the
precursor for serotonin synthesis. This is related to sleep, food intake and mood. Tyrosine is
needed for the synthesis of catecholamine neurotransmitter, namely dopamine, adrenaline, and
noradrelanine. Choline is the precursor for the synthesis of acetylcholine-the neurotransmitter
most severely impaired in senile dementia and Alzheimer's disease. This is related to memory.
2. Nutrients such as pyridoxine, vitamin C, and thiamin affect neurotransmitter because of their
roles in metabolic pathways in the synthesis of the neurotransmitter. For example pyridoxine in
the synthesis of dopamine and serotonin and vitamin C and copper in the conversion of
dopamine to noradrenaline.
3. Some nutrients like folate, vitamin B12 , riboflavin, and nicotinic acid play role in brain
Nutrition and coronary heart disease
As is now well known, there are two processes involved in the pathogenesis of CHD, namely thrombosis
and atherosclerosis. Dietary factors modulate them.
Nutrient guidelines for prevention of heart diseases (WHO, 1990)

Calorie should be sufficient to maintain appropriate body weight for a given height.
Cholesterol should not exceed 300 mg/day in diet.
Saturated fat should be less than 10 % of total calories.
Polyunsaturated fat should not exceed 8 % of the total calories.
Linoleic acid should range between 3-7 5 of calories.
Alpha- linolenic acid should not be less than 1 % of the calories.
Proteins should provide around 10-15 % of total calories.
Carbohydrates should contribute 55-65 % of calories, with emphasis on complex carbohydrates.
Sugar should be less than 10-15 % total calories.
Salt intake should be between 5-7 g/day.
Dietary fiber should be around 40 g/day.

Weight control
Body mass index (wt in kg /ht m2) exceeding 25 could be considered overweight and above 30 obesity.
Ideal body weight must be achieved not only through dietary discipline, but also through optimal
exercise. Abdominal obesity, characterized by elevated waist/hip ratio appears to be particularly

Abdominal obesity
CHD and diabetes have been found to part of syndrome X in the development of which two
components are believed to be involved.
Syndrome X (Insulin Resistance Syndrome)
Insulin Resistance
Low HDL levels
Abdominal obesity (elevated waist/hip ratio)
A waist-hip ratio exceeding 0.85 is indicative of abdominal obesity.
Feed intake
It is now known that not all saturated fats are hypercholesterolaemic; while lauric and myristic acids do
raise blood cholesterol, stearic acid and short-chain fatty acids do not. Oleic acid which is a
monounsaturated fatty acid lowers blood cholesterol almost as effectively as the essential fatty acidlinoleic acid. The rise in triglycerides (VLDL) often observed in subjects on high carbohydrate diets can be
reduced by oleic acid.
Carbohydrates and lipids are interrelated in their metabolism and hormonal action. Carbohydrates
contribute significantly to endogenous synthesis of triglycerides. Complex carbohydrates have a low
glycaemic index as compared to sugar and jiggery. Populations subsisting on diets high in complex
carbohydrates and low in fat have lower levels of total and LDL cholesterol than those subsisting on high
fat, high sugar, and high meat diets. High carbohydrates diets contribute to low HDL levels, which are
non-beneficial. Optimal levels of exercise could help to combat this.
Nutrition and cancer
Changes in dietary practices could make a major contribution towards the prevention and containment
of the cancer problem. Dietary factors could play a significant role in the initiation, promotion and
progression of cancers. High fat intakes and especially of saturated fats are considered to favor
development of rectal and breast cancers; high animal protein and red meat intake to favor the
development of prostrate, uterine and ovarian cancers and high salt /nitrate and nitrosamine in drinks
and salted foods to favor the development of stomach and esophageal cancers.
Certain dietary factors play a protective inhibitory role, such as dietary fiber with respect to colon
cancer, micronutrients such as beta-carotene, vitamin A , riboflavin, vitamin C , iron, zinc, and selenium
with respect to cancers of epithelial origin-especially those of alimentary and respiratory tract.
Vegetables and fruits rich in such micronutrients are protective against such cancers of epithelial origin.
Apart from micronutrients, bioactive phytochemicals such as isothiocyanate indoles, flavones, phenols,
protease inhibitors, allilium compounds have been found to protect against several steps in
carcinogenesis. There is recent evidence that Chinese tea has a cancer-protective agent. Some phytoesterogens in foods such as soya products are claimed to be beneficial in hormone-related cancer,
curcumin in turmeric, Protease inhibitors in soya have also been credited with beneficial effects in

Some dietary factors could be pro-carcinogenic. The process of cooking foods such as grilling, broiling or
smoking could result in the formation of carcinogenic compounds. Contamination of foods with fungi
such as aflatoxin (in the case of liver cancer) or ochratooxin A (in the case of cancer of kidney and
oesophagus) can also have harmful effects on health.
Apart from the possible role of dietary factors in the causation of cancer, there are also nutrient
supplements to protect against cancer. Post-operative morbidity in cancers can be reduced by proper
nutritional support
Impact of advancing knowledge

Return to breast feeding as the preferred method of infant rearing.

Recognition of dietary fiber.
Reduction in the intake of red meat and cream.
Increase the intake of vegetables and fruits
Increasing the recognition of virtues of vegetarianism.

Dietary guidelines for heart disease prevention (American Heart association, 1982)
1. Eat a variety of foods.
2. Maintain ideal weight.
3. Avoid too much fat, saturated fat, and cholesterol: excess fat leads to high levels of blood fats
and cholesterol carried in lipoprotein compounds. Elevated serum levels of these fats and
cholesterol are associated with a higher risk of coronary heart disease. Reduce the dietary fat
kilocalories to no more than 30 to 35 % of the total kilocalories.
4. Eat foods with adequate starch and fiber: certain types of dietary fiber may help control chronic
bowel diseases, contribute to improved blood glucose management for persons with diabetes
mellitus, and bind dietary lipids such as cholesterol. Increase carbohydrate kilocalories to
replace reduced fat, with 50 to 55 % of the total calories coming from carbohydrates.
5. Avoid too much sugar.
6. Use protein in moderation, about 12 to 30 % of the diet's total calories, with less use of animal
protein, which carries more fat.
7. Cholesterol: limit dietary cholesterol to 300 mg or less per day.
8. Avoid too much sodium: excessive sodium is not healthy for anyone. A reasonable limit of 2 to 3
g of sodium a day can be achieved by using salt lightly in cooking.
9. If you drink alcohol, do so in moderation: alcohol beverages tend to be high in kilocalories and
low in other nutrients. Limited food intake may accompany large alcohol intake. Heavy drinking
contributes to chronic liver disease and some neurologic disorders, as well as some throat and
neck cancers.
Dietary guidelines for cancer prevention (the committee on Diet, Nutrition, and cancer of the national
cancer Institute, 1982).

Fat: reduce fat intake to 30 % of the total calories and avoid obesity.
Dietary fiber: include fruits, vegetables and whole-grain cereals in the daily diet.
Preserved food: limit use of food preserved by salt-curing, smoking, or nitrite curing.
Contaminated food should be avoided.
Alcohol: in moderation, if at all.
Include fruits and vegetables in daily diets.

Functions of carbohydrates
1. Energy: when carbohydrate is burned in the body, it renders 4 kilocalories of energy per gram.
To function properly, the body tissues require a daily dietary supply of carbohydrate providing
50 to 55 % of the total kilocalories.
Carbohydrate energy reserves: the amount of carbohydrate in the body is important for maintaining
energy reserves. For example, in an adult male about 300 g is stored in the liver and muscle tissues
as glycogen, and about 10 g is present in circulating blood sugar. This total amount of available body
glucose provides energy sufficient for only about half a day of moderate activity. Therefore,
carbohydrate foods must be ingested regularly and at moderately frequent intervals to meet the
constant energy demands of the body.
Available carbohydrate
Of the total carbohydrate ingested, three general factors affect the amount that will be available for
use and the way the body will use it:
a. The state of the mucous membrane of the digestive tract and the time carbohydrate is held in
contact with this absorbing surface affect the bioavailability of carbohydrates. Intestinal disease
of the mucosal lining or hyper-motility, which causes rapid passage of the food mass, greatly
decreases the proportion of the ingested carbohydrate that will be used by the body.
b. Endocrine function is also important in carbohydrate bioavailability. Several hormones play
important roles in the use of carbohydrates. Among these are insulin and the several insulin
antagonists such as hormones from the pituitary gland, steroids from the adrenal gland,
glucagon from the pancreas, and epinephrine from the adrenal medulla. Imbalance among
these various regulatory agents can greatly affect the use of carbohydrate in the body.
c. Vitamins must be present in adequate amounts. Vitamins of the B-complex especially are
involved in the metabolism of carbohydrate. Thiamin, niacin, riboflavin, and others perform key
functions as coenzymes in the enzyme systems for the oxidation of carbohydrate to yield
2. Special functions of carbohydrate in body tissues:
Glycogen reserves: liver and muscle glycogen reserves provide a constant interchange with the body's
overall energy balance system and protects cells from depressed metabolic function and injury.
Protein-sparing action: carbohydrate helps to regulate protein metabolism. The presence of sufficient
carbohydrates to meet energy demands prevents the channeling of too much protein for this purpose.
This protein sparing action of carbohydrate allows a major portion of protein to be used for its basic
structural purposes of tissue building.
Anti-ketogenic effect: the amount of carbohydrate present determines how much fat will be broken
down to supply a back-up energy source, thus affecting the formation and disposal rates of ketones.
Ketones are intermediate product of fat metabolism, which normally are produced at a low level during
fat oxidation to maintain the body supply. However, in extreme conditions such as starvation or
uncontrolled diabetes in which carbohydrate is inadequate or unavailable for energy needs, excess fat is
oxidized and ketones accumulate. The result is ketoacidosis. Thus sufficient dietary carbohydrate helps
prevent a damaging excess formation of ketones.
Heart: heart action is a life-sustaining muscular exercise. Although fatty acids are the preferred regular
fuel of the heart muscle, the glycogen in cardiac muscle is an important emergency source of contractile

energy. In damaged heart, poor glycogen stores or low carbohydrate intake may cause cardiac
symptoms or angina.
Central nervous symptoms: a constant amount of carbohydrate is necessary for the proper functioning
of the central nervous system. Brain depends on a minute-to minute supply of glucose from the blood.
Sustained and profound hypoglycemic shock may cause irreversible brain damage. In all nerve tissue,
carbohydrate is indispensible for functional integrity.
Classification of carbohydrates
There are two basic types of carbohydrates: simple and complex carbohydrates or polysaccharides.
Simple carbohydrates:
1. Monosaccharides: monosaccharides include trioses, tetroses, pentoses , hexoses and heptoses.
The three hexose sugars most important in human nutrition are glucose, fructose, and
Physiologic and nutritional significance of monosaccharides




formed through metabolic


component element of
nucleic acid and coenzyme


fruit juices, honey, hydrolysis of

Starch, cane sugar, maltose and
fruits, juices, honey, hydrolysis
of sucrose from cane sugar
hydrolysis of lactose (milk sugar)


hydrolysis of plant mannosans, gums


cell fuel
changed to glucose
in the liver.
changed to glucose
In the liver.
component of polySaccharide of albumins,
Globulins, mucoprotein,

2. Disaccharides: Sucrose = glucose + fructose

Lactose = glucose + galactose
Maltose = glucose + glucose
Physiologic and nutritional significance of disaccharides
starch digestion by amylase, commercial
hydrolyzed to D-glucose, basic
Hydrolysis, malt and germinating cereals
body fuel
cane and beet sugar
hydrolyzed to glucose and
Fructose, basic body fuel
hydrolyzed to glucose and
Galactose, basic body fuel

They are composed of many single monosaccharide units. These polysaccharides include starch,
glycogen, and dietary fiber.
Starch: it is the most significant polysaccharide in human nutrition. It yields glucose on hydrolysis or
digestion. It is made up of amylase (15 to 20 %, soluble part of starch) and amylopectin (80 to85 % , the
insoluble part of starch, forms past with hot water and thickens during cooking ). Amylase is better than
amylopectin in maintaining normal blood sugar through a slower, more even rate of digestion and
glucose absorption. When foods high in amylase starch are developed they could benefit obese persons
and those with diabetes. The cooking of starch improves the flavor and softens and ruptures these
starch cells, which facilitates enzymatic digestive processes. Starch mixtures thicken when cooked
because of the amylopectin that encases the starch granules. About 50 to 55 % of total kilocalories in
human 's diet should come from starch.
It is the storage polysaccharide and has significant function in the human energy balance system. It is an
important link in energy metabolism because it helps sustain normal blood sugar levels during fasting
periods such as sleep hours and provides immediate fuel for muscle actions.
Dietary fiber:
Dietary fiber refers to the total amount of naturally occurring material in foods, mostly plants, that is not
digested. It includes cellulose, hemicelluloses, pectin, gums, mucilage and algal substances.
Summary of dietary fiber classes
Dietary fiber class

Dietary fiber


Plant parts
Main cell

Main chain
wall Glucose

reduces elevated
Plant parts
Main chain
Side branches
cell Glucose, mannose, Galactose and , Insoluble,
wall material
water, increases
stool bulk, reduces
colonic pressure,
binds bile acids.
Galaturonic acid
Rhamnose, xylose, Soluble,
cement material
arabinose, fucose
cholesterol, and
bile acids.
Cell secretions
xylose, galactose
galacturonic acidcholesterol, and
bile acid, slows
galacturonic acidgastric emptying ,

Side branches



Cell secretions

Algal substances

Algae, seaweeds

Galactosemannose, glucosemannose,
glacturonic acidrhamnose
Glucose, mannose,
xylose, glucuronic

Non carbohydrate: Woody parts of Phenyl



with production of
VFA and gas
gastric emptying
time; fermentable
colonic bacteria,
binds bile acids
gastric emptying
time, fermentable
bile acids.
3-dimentional net Insoluble,
antioxidants, bind
bile acids, and

Physiologic effects of crude fiber in human health

1. Water absorption: fiber contributes to bulk-forming laxative effect and influence the transit time
of the food mass through the digestive tract. This accelerated passage of the food mass in turn
affects the rate of absorption of the various nutrients in the food mix.
2. Binding effect: certain fibers bind bile salts and cholesterol, preventing their absorption. Excess
dietary fiber binds minerals such as iron, zinc, and calcium.
3. Relation to colon bacteria: nun-dietary cellulose such as gums provides fermentation substances
for colon bacteria, producing volatile short chain fatty acids and gas.
4. Satiety: it adds bulk to the mixed feed. High fiber foods usually take more time to eat. Both
these factors may help control the amount of food consumed and together with the increased
transit time in the body, may contribute to the management of obesity and diabetes.
Relation of dietary factors to gastrointestinal problems, cardiovascular disease, diabetes mellitus, and
colon cancer.
1. Gastrointestinal problems: water-insoluble dietary fibers such as cellulose and hemi-cellulose
affect gastrointestinal problems such as constipation. Water held by the fibers increases the
volume of the feces and softens the stool, causing the colon muscles to contract and propel the
food residue quickly. The fecal volume is also influenced by the effect of water-soluble dietary
fibers such as gums, which increase the bacterial growth and colon flora production of volatile
fatty acid. The bile acids that some dietary fibers transport to the colon may have similarly
cathartic effects. An insoluble dietary fiber prevents and treats prevention of diverticular
disease. The basic cause of diverticula is a rise in intraluminal pressure in a segment of colon. ,
usually in the sigmoid region. A high fiber diet prevents the segmental pressure rise, reducing
the incidence of symptoms from diverticular disease


2. Cardiovascular disease: certain soluble dietary fibers, gums in foods such as oat-bran and beans
have been shown to effectively reduce high levels of serum cholesterol. In the colon, soluble
fibers are almost completely fermented to short-chain fatty acids. Then these fatty acids,
absorbed directly into the portal vein, may in turn inhibit hepatic and peripheral cholesterol
synthesis and increase LDL cholesterol clearance.

Diabetes mellitus: they help in the following ways:

Increased insulin receptor binding.
Delayed gastric emptying
Reduced intestinal transit time with subsequent nutrient absorption.
Slower ingestion of bulky food.

4. Colon cancer:
a. A high-fat diet increases the level of fecal bile acids, which may promote tumor directly or
indirectly through conversion by colon bacteria to secondary bile acids that act as tumor
b. Dietary fiber interacts to reduce tumor risk by increasing fecal volume thus reducing the
concentration of potentially carcinogenic substances in the bowl, reducing transit time through
the colon, thus reducing the contact between fecal carcinogens and the colonic mucosa, altering
colon bacterial metabolism to favor decreased carcinogen production.
Dietary fiber recommendation: at least 15 to 20 g of total dietary fiber per day from a variety of plant
sources. Indiscriminate use of bran is not justified. This can easily be achieved through generous use of
whole grains, legumes, vegetable, fruits, seeds and nuts. Indiscriminate use of bran is not justified
because too much dietary fiber can cause nutrient loss resulting from binding of iron, zinc, and calcium.
Lactose intolerance: most adults are intolerant of milk because they are deficient in lactase. Nearly all
children and infants are able to digest lactose. In lactase deficient adult, lactose accumulates in the
lumen of the small intestine after ingestion of milk because there is no mechanism for the uptake of this
disaccharide. The large osmotic effect of the unabsorbed lactose leads to an influx of fluid into the small
intestine. Hence, the clinical symptoms of lactose intolerance are abdominal distention, nausea,
cramping, pain, and a watery diarrhea. Lactose deficiency appears to be inherited as an autosomal
recessive trait and is usually first expressed in adolescence or young adulthood. Human populations that
do not consume milk in adulthood generally have a high incidence of lactase deficiency. Milk treated
with lactase is available for consumption by lactose-intolerant people.
Fats are a group of organic substances fats, oils and maxes, and related compounds that are greasy to
the touch and not soluble in water.
Classification of lipids
1. Simple lipids: they are neutral fats and waxes. Neutral fats are compounds of fatty acids and
glycerol, in the ratio of three fatty acids to each glycerol base. Thus they are called triglycerides.
Similarly, waxes are compounds of fatty acids with straight chain alcohols. Waxes have no
importance in human nutrition.
2. Compound lipids: compound lipids are various combinations of neutral fat with other
components. Three examples of compound lipids important in human nutrition are:
phospholipids example is lecithin, glycolipids composed of fatty acids, nitrogen and
carbohydrates, found chiefly in brain tissue as cerebrosides, and lippoproteins, complexes of
various lipids with protein and transport fat in the blood.

3. Derived lipids: fat substances may be derived from simple and compound lipids by hydrolysis or
enzymatic breakdown. Three important members of this group are fatty acids, glycerol, and
steroids that contain cholesterol.
Fatty acids:
The fatty acids of biological importance are mostly straight chain aliphatic, monocarboxylic acids with
an even number of carbon atoms and general formula CH3 (CH2) n = COOH, where n varies from 2 to 22.
Depending upon the chain length they can be classified as short chain (2 to 8 carbon atoms) , medium
chain (10-14 carbon atoms), and long chain (16-24 carbon atoms) fatty acids. They are further classified
into saturated (carbons linked by single bonds), monounsaturated (two adjacent carbons joined by a
double bond) and polyunsaturated fatty acids (PUFA) with more than one double bond and chain length
16,20 and 22 carbon atoms. The numbering of carbon atoms of fatty acids can be from carboxyl group (
numbering system) , or from terminal methyl group ( W or n numbering system) of the fatty acids. The
carbon numbers for stearic acid in the two systems are as follows:
W or n numbering

16 17
H3C (CH2)14 CH2 CH2 COOH
3 2

Four groups of PUFA (n-9, n-7, n-6, and n-3) are present in the mammalian tissues. The number after n
denotes the position of the first double bond. First two series, namely n-9 and n-7 are synthesized from
palmitooleic (16:1 n-9) acid, which in turn are derived from palmitic and stearic acids respectively by
the action of 9desaturasebof liver microsomes. The other two series, namely n-6 and n-3 are derived
from linoleic (18:2, n-6) and linolenic (18:3 , n-3 ) acids with first double bond at sixth and third carbons
respectively. These two fatty acids are required for growth and development, but cannot be synthesized
by most of the animals and humans and are therefore called essential fatty acids (EFA). Long chain PUFA
are obtained from their four precursors fatty acids by the action of various liver microsomal desaturases
and elongases. The same enzyme systems are involved in the biosynthesis of all the four series of PUFA
and hence there is a competition among the substrates for these enzymes. 6 desaturase enzyme is
absent in carnivores such as animals of cat family and hence arachidonic acid is also essential for these
Saturated fatty acids

Number of carbon



Unsaturated fatty acids

Eicosapentanoic acid
Docosahexaenoic acid

18:2(9, 12)
18:3(9, 12, 15)
20:4 (5, 8, 11, 14)
20:5 (5, 8, 11, 14, and 17)
22:6 (4, 7, 10, 13, 16, and 19)

Functions of fatty acids:

Non-eccosanoid functions
Fatty acids as constituents of membrane phospholipids are involved in the homeoviscous control of
membrane bilayer and fluidity of most cells. In this capacity they may directly or indirectly affect the
properties of membrane proteins (transporters, ion channels, hormones and receptors).
Eicosanoids and their functions
Eicosanoids are the oxidation products of 20-carbon PUFA, (arachidonic and eicosapentaenoic acids)
derived from essential fatty acids by the action of enzymes cyclo-oxygenase and lipo-oxygenase
Cyclo-oxygenase products: three series of prostaglandin may be derived from three precursor fatty acids
, namely dihomo--linolenic acid, arachidonic and eicosapentaenoic acids. Prostaglandins of I-series
namely PGE1, PGD1 and PGF1 are formed from dihomo- -linolenic acid. Arachidonic acid generates
prostaglandins of 2-series ( PGE2, PGD2 and PGF2) while eicosapentanoic acid generates prostaglandins
3- series ( PGE3, PGD3 and PGF3). In addition, in platelates, cyclooxygenase product of arachidonic and
eicosapentaenoic acids are converted to thromboxane A2 and A3 ( TXA2 and TXA3) by the action of
thromboxane synthetase. TXA2is a potent platelet aggregator and vasoconstrictor with a short biological
half life. In the vascular endothelial cells, arachidonic acid is converted to prostacycline I2 ( PGI2) which
has vasodilator and antiaggregatory effects. Therefore PGI2 and its synthetic analogues are used in the
treatment of thrombotic disorders. In human platelets and endothelial cells TXA3 and PGI3 are not
formed in appreciable amounts both due to lower intake of the precursor n-3 fatty acids as well as
various metabolic constraints. However, high dietary intake levels of n-3 fatty acids can increase
eicosapentaenoic acid and docosahexaenoic acids levels in membranes and increase the production of
TXA2 and PGI3.
Since, dietary fat is the only source of n-6 and n-3 fatty acids. , optimal health benefits can be derived by
maintaining a balance in the intake of these two polyunsaturated fatty acids. The n-6 and n-3 patty acids
play important role in growth and development.
Lipoxygenase products: Leukotriens : Leukocytes generate leukotriens (LT) A4 and A5 from arachidonic
and eicosapentaenoic acids. They act as a potent chemotactic agent involved in the migration and
aggregation of macrophages and neutrophils at the site of infection.
Essential fatty acids: fatty acids that is necessary for body metabolism and cannot be manufactured by
the body so must be supplied in the diet. The essential fatty acid is linoleic acid.


Linoleic acid serves important functions in the body:
1. Capillary and cell membranes: linoleic acid strengthens membrane structure, helping to prevent
an increase in skin and membrane permeability. A linoleic deficiency leads to a breakdown in
skin integrity, resulting in a characteristic eczema and skin lesions. Like other fatty acid, linoleic
acid combines with cholesterol to form cholesterol esters. Fatty acids are also part of the
phospholipids and lipproteins
2. Cholesterol esters: cholesterol occurs only in animal fats and tissues and not in plants. Linoleic
acid combines with cholesterol to form cholesterol esters. Fatty acids are also part of the
phospholipid and lipoprotein lipid combinations.
3. Blood clotting: linoleic acid helps prolong blood clotting time and increase fibrinolytic activity.
4. Local hormone-bile effects: linoleic acid is a major metabolic precursor of physiologically and
pharmacologically active compounds known as prostacyclins, prostaglandins, thromboxanes and
leukotriens. They have extensive local hormone-like effects, are synthesized in the body from
arachidonic acid derived from essential linoleic acid.
Omega-3 fatty acids:
Classification and food sources of omega fatty acids:

fatty acid
linolenic acid
Eicosapentaenoic acid (EPA)
Docosahexaenoic acid (DHA)

food sources
vegetable oils
sea food, fatty fish
sea food, fatty fish


linoleic acid
Arachidonic acid
oleic acid

vegetable oils
animal food sources.
vegetable oils (mainly olive, peanut)
Meat fats (mainly pork, beef, chicken}


Functions of fat in human nutrition and health

1. Energy: a major function of fat in human nutrition is to supply a concentrated available fuel for
energy production.
2. Thermal insulation: a padding of adipose tissue surrounds vital organs such as the kidneys, and
protects them from mechanical shock or injury.
3. Nerve impulse transmission: fat insulation surrounding myelinated nerve fibers provides both
electrical insulation and aid for the transmission of nerve impulses.
4. Tissue structure: fat serves as a vital constituent of cell membrane structure and participates in
the transport of nutrient materials and metabolites across cell membranes. The cell membrane
is composed of a lipid matrix with receptors protein molecules dispersed throughout.
5. Cell metabolism: combinations of fat and protein are important as cell constituents and
lipoprotein carriers of fat throughout the body's blood circulation to all tissues.
6. Essential precursor substances: fat supplies necessary components for the synthesis of many
materials required for metabolic functions and tissue integrity. These precursors' materials
include fatty acids and cholesterol.


Health problems with fat

Health problems with fat focus on two main issues:
1. Too much dietary fat
2. Too much of that fat from animal food sources.
Amount of fat
Too much fat in the diet provides excessive kilocalories, more than that required for immediate energy
needs. The excess is stored as increasing adipose tissue and body fatness. The increased obesity has
been associated with diabetes, hypertension, and heart disease.
Type of fat
Excesses in the diet of saturated fat, which comes mainly from animal food sources, and of cholesterol,
which comes only from animal food sources, have been associated with increased blood lipids linked to
atherosclerosis, the underlying blood vessel disease process that contributes to heart attacks and
Dietary fats:
Fats (triglycerides) in the diet are referred to as saturated or unsaturated fat. If there is a predominance
of unsaturated fatty acids, the fat is called unsaturated fat. If there is predominance of saturated fatty
acids, the fat is called a saturated fat. Generally, the more unsaturated a fat, the lower its melting point
and the more likely it is to be liquid at room temperature. Saturated fats tend to remain solid at room
temperature. Foods from animal sources such as meat, eggs, and milk fat contain more saturated than
unsaturated fat. Conversely, foods from plant sources such as vegetable oils contain more unsaturated
fat. The proportion of saturated and unsaturated fatty acids in a fat will vary from one food to another
and affect its physical properties.
Visible and hidden food fats
In most cases the food sources of fat are quite evident in fatty acids, these are called visible fats. They
include butter, margarine, oil, bacon, and cream. Less obvious hidden fats in foods are contained in lean
meat, egg yolks, nuts, seeds, olives, and avocardo. A large part of hidden fat comes from relatively high
consumption of meats. Even when all the fat is trimmed off a piece of meat, its lean portion still
contains 4 to 12 % hidden fat. The higher grade of meat has considerable "marbling" tiny fat deposits
within the muscle tissue.
Cholesterol is not a fat itself. It is a fat-related compound by its ability to combine with fatty acids to
form cholesterol esters.
Cholesterol is a vital substance in human metabolism. It is a precursor of to all steroid hormones. A
cholesterol product in the skin, 7-dehydrocholesterol, is irradiated by the sun's ultraviolet rays to make
vitamin D hormone. it is also essential in forming bile acids, which are required for the digestion and
absorption of fats in the intestine. Cholesterol is widely distributed in all body cells, and large amounts
occur in brain and nerve tissues. It is an essential component of all cell membranes. The endogenous

supply is synthesized mainly in the liver. If a person consumed no exogenous supply of dietary
cholesterol at all, the body would still synthesize an adequate amount for metabolic needs.
Food sources
Cholesterol occurs naturally in all animal foods and only in animal foods. Its main food sources are egg
yolks, and organ meats such as liver and kidney. Vegetable oils and their food products do not contain
cholesterol. Although the plant oils vary in their degree of saturation, none of them contain cholesterol.
Health concern
Atherosclerosis is the underlying disease process in blood vessels in which fatty deposits or plaques
containing cholesterol build up in and on the walls of arteries. This occurs as a result of elevated serum
cholesterol levels. Thus the American Heart Association recommends the intake 300 mg of cholesterol
/day. An increase in some types of dietary fiber is also recommended because these fibers bind bile
acids and helps eliminate excess cholesterol from the body. Other major risk factors associated with
development of atherosclerosis are hypertension and cigarette smoking.
The lipoproteins are highly significant in human nutrition. They are important combinations of fat and
other lipid components such as cholesterol, allowing them to travel in the blood stream.
Because fat is insoluble in water , a means of transporting fat throughout the body in a water based
circulatory system , the blood presents a problem. The body has solved this problem through the
development of the lipoproteins, a package of fat wrapped in water soluble protein. These plasma
lipoproteins contain triglycerides, cholesterol, unesterified fatty acids, phospholipids, and traces of other
related materials such as fat-soluble vitamins and the steroid hormones. Because the densities of the
various lipoproteins vary according to their fat load, they have been separated and studied by a process
of electrophoresis. The high or low density of the lipoprotein transport complex is determined by its
relative ratio of fat and protein. The higher the protein ratio , the higher the density. The higher the fats
and other related lipids such as cholesterol, the lower the density. Thus the lipoproteins are classified
according to density and by relative fat and cholesterol loads as (1) chylomicrons, formed in the
intestinal wall and carrying the large fat load from meal just consumed. (2) very-low density lipoprotein,
(VLDL) , formed from the chylomicrons in the continuing process of lipid transport and metabolism; (3)
low density lipoproteins (LDL), formed from VLDL fragments and carrying cholesterol in the cells; and
(4) high-density lipid protein (HDL), carrying cholesterol from cells to the liver for breakdown and
elimination from the body.
All proteins , whether it is tissue protein in our bodies or food protein in our diet , is made up of
building units or compounds called amino acids. These compounds form the structural units of protein.
Out of a total of 20 or more, 10 are considered dietary essentials, indispensible to life. These amino
acids are joined in specific chain sequence to form specific proteins.


Functions of dietary protein:

1. The primary function of dietary protein is to supply amino acids in the quantity and kind
necessary for growth and maintenance of body tissues. Thus the age and physical activity of an
individual influence amounts needed.
2. Specific physiologic roles:
a. Methionine: an essential amino acids , is a methylating agent that participates in the formation
of nonprotein cellular constituents such as choline which is a precursor of acetylcholine, one of
the neurotransmitters. Methionine is not only the precursor of the nonessential amino acid
cystine, but also carnitine and taurine.
b. Tryptophan: it is the precursor of niacin and vasoconstrictor and neurotransmitter serotonine.
c. Phenylalanine: it the precursor of non-essential amino acid tyrosine. Together with tyrosine,
phenylalanine leads to formation of the hormones thyroxine and epinephrine.
3. Available energy: protein also contributes to the body's overall energy metabolism. After
removal of the nitrogenous portion of the constituent amino acids, the amino acid residue may
be either glycogenic (glucogenic) , capable of being converted to glucose or ketogenic , capable
of being converted to ketones. Only leucine, phenylalanine, and tyrosine are fully ketogenic. The
remaining amino acids are glucogenic. It is estimated that on the average, 58 % of the total
dietary protein may become available as glucose according to need and is oxidized as such to
yield available energy.
Functions of recently discovered amino acids
Taurine: it is one of the most abundant free amino acids in human milk. Dietary sources of taurine are
largely animal protein foods. It is virtually absent in plant foods. Taurine functions in the formation of
bile acids, regulation of heart beat, control of brain neurons, and central nervous system activity,
maintenance of membrane stability, and integrity of retinal and vision function
Carnitine: it is formed from methionine and lysine, with vitamin C, vitamin B6, niacin and iron acting as
necessary nutrient cofactors with the cell enzymes in its synthesis. the major metabolic role is
associated with the transport of long-chain fatty acids across the mitochondria membranes , thus
stimulating the oxidation of these fuel substrates for metabolic energy. It forms complex esters with
many of the acyl compounds , metabolic intermediary products from fats and carbohydrates. An
accumulation of such metabolites in cells can inhibit cell enzyme functions and become toxic, creating a
carnitine deficiency. Carnitine converts many of the acyl compounds to less toxic forms and removes
them from the cell. Dietary sources of carnitine are largely limited to animal protein foods. It is absent
from plant proteins
Amino acid required in human nutrition
Essential amino acids
Eight amino acids are called essential amino acids because they are the only ones we cannot make.
Essential amino acids

Semiessential amino acids



nonessential amino acids

aspartic acid
Cystine (cysteine)
glutamic acid



X semi-essential because the rate of synthesis in the body is inadequate to support growth, therefore
they are essential for children.
Complete and incomplete food proteins
Complete proteins are those that contain all the essential amino acids in sufficient quantity and ratio to
meet the body's needs. These proteins are of animal origin: eggs, milk, cheese, and meat.
Incomplete protein: these proteins are those deficient in one or more of the essential amino acids.
These proteins are mostly of plant origin: grains, legumes, nuts, and seeds. In a mixed diet, however,
animal and plant proteins complement one another. Even a mixture of plant proteins may provide an
adequate balanced ratio of amino acids if planned carefully.
Types of proteins:
1. Simple proteins: simple proteins contain only amino acids or their derivatives. Some examples
include serum albumin, insulin, and the enzymes.
2. Complex proteins: complex proteins are made up of simple proteins plus some other non
protein group. Examples include:
a. Nucleoproteins: one or more proteins plus nucleic acid, such as DNA protein complex in cell
b. Glycoproteins and mycoproteins: protein and carbohydrate, such as mucin. , found in secretions
from mucous membranes.
c. Phosphoproteins: protein and a phosphorus containing compounds such as casein in milk.
d. Chromoproteins: protein and pigmented group, such as hemoglobin in red blood cells.
e. Lipproteins: protein and a triglyceride
f. Metalloproteins: protein and a mineral such as copper or iron such as heme, the iron binding
portion of hemoglobin.
Tissue proteins
Based on their role in body structure and metabolism.

Structural protein: collagen in connective tissue.

Contractile proteins: myosin (muscle)
Antibodies: Gammaglobulin.
Blood proteins: albumin, fibrinogen, hemoglobin.
Hormones: insulin.
Enzymes: all the enzymes.

Protein requirement:
Factors affecting requirement:
1. The rate at which protein tissue is synthesized in the body at a given time and the nature and
caloric value of the diet as a whole.
2. Nature of the diet influences the quantitative protein requirement because of the protein
sparing effect of the carbohydrate and fat energy sources contained in the diet.

3. Timing of meals also plays a role. Allowing time intervals between eating protein feeds lowers
the competition for absorption sites and enzymes.
4. Clinical factors such as fever, disease processes , medications, traumatic injury, and the post
surgical state.
Measures of protein requirements
Two basic measures of protein requirements must be considered: quantity and quality.
Protein quantity: The US RDA standard has generally been set for adults at 0.8 g/kg of body weight. This
amount is about 56 g daily for a man weighing 79 kg and 50 g daily for a women weighing 63 kg. a total
of at least 60 and 50 g daily for a woman weighing 63 kg. a total of at least 60 to 65 g daily is needed
during pregnancy, and lactation. The requirements for infants and children vary according to age and
growth patterns.
Protein quality: the nutritive value of a protein is often expressed in terms of its chemical score. The
nutritive value of a protein is often expressed in terms of its chemical score. Using the amino acid
pattern of a high-quality protein food such as egg and giving it a value of 100, other foods are compared
according to their ratios of the essential amino acids. The essential amino acid showing the greatest
deficit limits the body's utilization of that protein and thus is termed its limiting amino acid. The
percentage of that amino acid present in the food , in comparison with the standard protein , provides
the chemical score. The three essential amino acids most often limiting in proteins are tryptophan,
lysine and methionine.
Measures to determine protein quality
1. Biological value: BV is the percentage of absorbed nitrogen retained in the body.
2. Net protein utilization (NPU) : this is the product of BV and the degree of proteins digestibility.
3. Protein efficiency ratio ( PER): this is based on the weight gain of a growing test animal divided
by its protein intake over a study period of about 10 days.
Comparative protein quality of selected foods according to chemical score , Biological value, Net
protein utilization, and protein efficiency rato


chemical score




Cow's milk
Unpolished rice
Polished rice
Whole wheat
Sesame seeds






Vegetarian diets
Types of diets
Protein requirements in various vegetarian diets may be met by applying the principle of
complementary plant proteins to achieve the necessary balance amino acids.
There are four basic types of vegetarian diets:
1. Lactoovovegetarian: one who accepts milk products and eggs and no other animal products.
2. Lactovegetarian: one who accepts dairy products?
3. Pure vegetarian : one who rejects all animal protein foods and uses only plant food sourcesgrains, legumes, vegetables, fruits, seeds and nuts
4. Ovovegetarians : who allows eggs as their only source of animal protein.
5. Animal vegetarians:
a. Prescovegetarians: who permits fish as the only animal product in their diet.
b. Pollovegetarians: who allows poultry as the only animal product in their diets.
c. Red meat abstainers: who eat any animal product except red meat but still consider
themselves vegetarians.
Does a vegetarian diet offer important nutrients?
Vegetarians can meet the recommended dietary allowances for most major nutrients without taking
supplements. However, a few key nutrients create problems if the vegetarian is not careful.
Vitamin B12: the vitamin is found only in animal products. Vegetarians are at the greatest risk for a
deficiency. A deficiency can be avoided by including fortified foods or by taking a vitamin B12.
Vitamin A : vegetarians tend to get major pro -vitamin A, carotene, than they need. This usually isnot a
problem, unless they are also taking supplements that include vitamin A. these may include as much as
10 times the RDA for vitamin A. as a fat soluble vitamin, vitamin A can build up in the body tissues and
reach toxic levels. The results could be irritability, dry skin, and hair loss. Vegetarians should be careful
to keep their vitamin A intake near the recommended amount of 800 retinol equivalents (RE) per day.
Iron: grains and legumes have iron, but much of it is poorly absorbed from the gut. Absorption can be
enhanced by including a good source of vitamin C in the same meal.
Minerals in human nutrition
Metabolic roles of minerals are as follows:
1. They are builders: calcium and phosphorus provide structural body frame work. Oxygen hungry
iron provides the core of heme in hemoglobin. Cobalt is a component of vitamin B12.
2. They are activators. The minerals are active participants in the overall metabolic proces
3. They are regulators.
4. They are transmitters of nerve impulses.
5. They are controllers: ionized sodium and potassium exercise all-important control over shifts in
body fluids.


Major minerals: elements for which the requirement is greater than 100 mg/day. They constitute 60 to
80 % of all the inorganic material in the human body.
Trace elements: those needed in much smaller amounts are called trace elements.
-----------------------------------------------------------------------------------------------------------------------------------------Major minerals
trace elements
Essentiality unclear
(Required intake over 100 mg/day
(required intake under 100 mg/day
-----------------------------------------------------------------------------------------------------------------------------------------Calcium ( Ca )
iron ( Fe )
silicon ( Si )
Phosphorus (P )
Iodine (I )
Vanadium ( V )
Magnesium (Mg )
Zinc ( Zn )
Nickel ( Ni )
Sodium ( Na )
Copper ( Cu )
Tin ( Sn )
Potassium ( K)
Manganese ( Mn )
Cadmium ( Cd )
Chloride ( Cl )
Chromium ( Cr )
Arsenic ( As )
Sulfur ( S )
Cobalt ( Co )
Aluminium ( Al )
Selenium ( Se )
Boron ( B ).
Molybdenum ( Mo )
Fluorine ( Fu )
Major minerals:
Factors increasing calcium absorption:
1. Body need: calcium absorption is increased by greater body need.
2. Plasma ion concentration: even small decreases in the concentration of ionized calcium in the
body fluids are reflected in a rise in calcium absorption. The calcium ion concentration in turn is
is mediated by an intracellular receptor protein, calmodulin, that binds calcium ions when their
concentration increases in response to a stimulus. It is in this ionized form that ionized calcium
in plasma modulates the activities of a greater variety of metabolic functions.
3. Dietary protein: a greater percentage of calcium is absorbed when the diet is high in protein.
However, this larger amount absorbed results in increased renal excretion, with a negative
calcium balance following. Thus, high protein diets in effects induce increased calcium
requirement to maintain calcium balance.
4. Dietary carbohydrates: lactose generally enhances the absorption of calcium in the ikeum,
through the action of the lactobacilli, to produce lactic acid, which lowers the pH
5. Acidity: lower pH (increased acidity) favors solubility of calcium and consequently its absorption.
Factors decreasing calcium absorption:
1. Vitamin D deficiency: calcium cannot be absorbed normally when there is a deficiency of vitamin
2. Dietary fat: excess dietary fat or poor absorption of fats result in an excess of fat in the intestine
, which inhibits calcium absorption through formation of insoluble calcium soaps. These
insoluble soaps are excreted, with the consequent loss of the incorporated calcium.
3. Calcium phosphorus ratio: in the diet, the optimal dietary calcium phosphorus ratio is 1.0 to
1.5 for children and women during the latter half of pregnancy and during lactation. Other
adults require a 1 : 1 dietary ratio. If either mineral is taken in excess, absorption of both is
hindered , and excretion of the lesser mineral is increased. For example, excess phosphorus in
relation to the amount of calcium in the intestine will form more calcium phosphate, which
binds the calcium and make it unavailable for absorption.

4. Fiber and other binding agents: an excess of fiber in the diet binds calcium and hinders its
absorption. Other binding agents include oxalic acid, which combines with calcium to produce
calcium oxalate and phytic acid which forms calcium phytate and prevents its absorption. Oxalic
acid is a constituent of green leafy vegetables, but the amount of oxalate varies in these
vegetables so that some are better sources of calcium than others. Phytic acid is found in the
outer hulls of many cereal grains, especially wheat.
5. Alkalinity: calcium is insoluble in an alkaline medium and therefore is poorly absorbed.
6. Excretion: dietary calcium taken in excess of need remains unabsorbed in the intestine and is
eliminated in the feces.
Physiologic functions:
1. Bone formation :
2. Tooth formation.
3. Blood clotting. The calcium ions are required for cross-linking of fibrin, giving stability to the
fibrin threads.
4. Nerve transmission: calcium is required for normal transmission of nerve impulses. A current of
calcium ions triggers the flow of signals from one nerve cell to another and on to the waiting
target muscles. The calcium ions in the extracellular fluid at the neuromuscular junction cause
the neurotransmitter acetylcholine to pass through the separating membranes at the tips of the
many nerve branches and excite the muscle fiber.
5. Muscle contraction and relaxation: each muscle fiber contains hundreds of small contractile
units called myofibrils, which are composed of the muscle protein filaments, myosin and actins.
Alongside of each myofibril is a fine system of tubes, the tubular reticulum. Calcium is firmly
bound to this reticulum. When the signal for contraction comes, the calcium is suddenly
released, ionized, and mobilized. The free calcium ions activate the chemical reaction between
myosin and actin a filament that releases a large amount of energy from ATP and brings about
contraction. The calcium are then immediately bound back on to the reticulum, causing
6. Cell membrane permeability: ionized calcium controls the passage of fluid through cell
membranes by affecting cel wall permeability. It influences the integrity of the intercellular
cement substance.
7. Enzyme activation: calcium ions are important activators of certain enzymes such as ATPase in
the release of energy for muscle contraction
Clinical problems:
1. Tetany : a decrease in ionized serum calcium causes tetany, a state marked by severe,
intermittent spastic contractions of the muscle and muscular pain.
2. Osteoporosis: this is characterized by loss of bone mineral, occurs mostly in older persons
especially postmenopausal women.
3. Resorptive hypercalciuria.: two conditions are known to tilt the usually fine-tuned calcium
deposition -mobilization balance by the modulating hormones. When these conditions occur ,
there is excess calcium withdrawal resorption from bone and subsequent elevated calcium
excretion in the urine. One of these conditions is prolonged immobilization , such as occurs with
a full body cast after orthopedic surgery or spinal cord injury or with a body brace following a
back injury. In such cases the risk of renal stone formation is increased. A second example is the
hypercalciuria observed in astronauts.
4. Hyperparathyroidism and hypoparathyroidism : because calcium and phosphorus metabolism
are directly controlled by parathyroid hormone, conditions of the parathyroid gland that
increase or decrease the secretions of its hormone will immediately be reflected in abnormal
metabolism of these two minerals

Calcium requirement:
Adults : 800 mg daily.
Women during pregnancy and lactation: 1200 mg daily.
Infants under 1 year of age : 400 to 600 mg
Children: 800 to 1200 mg.
Food sources:
Dairy products provide the bulk of dietary calcium, eggs, green leafy vegetables, broccoli, legumes, nuts,
and whole grains.
Physiologic functions
1. Bone and tooth formation.
2. General metabolic activities: its presence in every living cell reflects its vital metabolic role.
3. Absorption of glucose and glycerol: by the process of phosphorylation , Phosphorus combines
with glucose and glycerol from fat to promote the absorption of these substrates from the
intestine. Phosphorylation also promotes the renal tubular reabsorption of glucose, by which
this sugar is conserved and returned to the blood.
4. Transport of fatty acids: by combining with fat as phospholipids , phosphorus helps provide a
vehicular form of fat.
5. Energy metabolism: phosphorus containing compounds are widespread in the cell and include
such examples as DNA, phosphhatides, and ATP.
6. Buffer system: the phosphate buffer system and phosphoric acid and phosphate contribute
additional control of acidosis and alkalosis states in the blood.
Clinical problems:
1. Physiologic changes:
a. Recovery from diabetic acidosis: increases in carbohydrate absorption and metabolism use
much phosphorus in the activation of enzymes for producing glycogen and for glycolysis, thus
causing temporary hypophosphatemia.
b. Growth needs: growing children usually have high serum phosphate levels, resulting from high
levels of growth hormone.
c. Pathologic changes: situations involving pathologic changes in serum phosphate levels include
the following:
Hypophosphatemia: low serum phosphate levels occur in intestinal diseases such as sprue and
celiac disease, which hinder phosphorus absorption or bone disease such as rickets or osteomalacia
which upset the calcium phosphorus serum ratio. The serum phosphate level is also low in primary
hyperparathyroidism because the excess quantity of parathyroid hormone secreted results in
excessive renal tubular excretion of phosphorus. Symptoms of hypophosphatemia include muscle
weakness, because the muscle cells are deprived of phosphorus essential for energy metabolism.
Hyperphosphatemia: renal insufficiency or hypoparathyroidism, causes excess accumulation of
serum phosphate. As a result, the calcium side of the calcium phosphorus serum ratio is low,
causing tetany.

Phosphorus requirements:
During growth and pregnancy, lactation, the ideal dietary calcium is about 1.0 to 1.5 for men and
non-pregnant women; the recommended intake of phosphorus is the same as that for calcium. In
general , an adequate adult intake of phosphorus is about 800 to 1500 mg/day. The RDA standard
recommends a phosphorus allowance equal to that for calcium for all ages (800 1200 mg) except
the young infant, for whom the proportion of phosphorus is lower than for calcium ( 300 -500 mg).
Calcium /phosphorus ratio:
The dietary ratio of 1 :5 is ideal for periods of rapid growth , 1 :1.5 for normal adult functions. The
normal serum ratio for adults is 40 ( 10 mg/DL calcium x 4 mg /DL phosphorus ), and for children is
50 ( 10 mg/DL calcium x 5 mg /DL phosphorus ).
Food sources
Milk and milk products are the most significant sources of phosphorus, lean meats are good sources.
Metabolic functions:
1. Carbohydrate metabolism: ionized magnesium serves as an activator of many enzymes in the
reactions of the initial glycolytic pathway for glucose oxidation oxidative phosphorylation.
2. Protein metabolism: ionized magnesium is a coenzyme in protein synthesis in the cell
3. Cell reproduction and growth: magnesium is a constituent of molecules formed in the process of
cell growth and maintenance of tissues.
4. Hormonal action: magnesium is related to cortisone in the regulation of the blood phosphorus
5. Smooth muscle action: decreased plasma ionized magnesium causes vasodilation and inhibits
smooth muscle action. Any changes in its intracellular fluid concentration produce
neuromuscular irritability.
Clinical problems:
Malabsorption: in various gastrointestinal disorders, such as prolonged diarrhea or vomiting or diseases
characterized by intestinal malabsorption, excessive amounts of magnesium are lost. Rehydration must
be accompanied by adequate magnesium replacements or the resulting low serum magnesium level will
cause general neuromuscular irritability manifested by tremor, spasm, and increased startle response to
sound and touch. Avoiding a rapid re-feeding program following a period of malnutrition will prevent
serious metabolic and neurologic disturbances.
Magnesium requirements
250 to 300 mg /day
Food sources:
Magnesium is relatively widespread in nature. Its main sources include nuts, soybeans, cocoa, seafood,
whole grains, dried beans and peas.

Sodium Metabolic functions

1. Fluid balance: ionized sodium is the major cation of the extracellular fluid and serves as the
guardian of this fluid compartment.
2. Acid-base balance: through its association with chloride and bicarbonate ions, ionized sodium is
an important factor in the regulation of the acid-base balance in the body.
3. Cell permeability: the sodium pump- Na +, K +-ATPase is associated with glucose metabolism
and cellular exchange of ionized sodium. In this active transport mechanism , sodium is essential
to the passage of metabolic materials through cell walls.
4. Normal muscle irritability: sodium ions play a large part in transmitting electrochemical impulses
along nerve and muscle membranes and therefore in maintaining normal muscle irritability or
Clinical problems:
Fluid-electrolyte and acid-base balance:
Muscle action: abnormal serum levels of sodium adversely affect the functions of muscles- for example
heart muscle.
Sodium requirement: adults 2 to 3 g daily. 2 g sodium would equal about 5 g salt ( 1 tsp).
Food sources: NaCl. Natural food sources include milk, meat, eggs, certain vegetables such as carrots,
beets, spinach, and other leafy greens, celery and asparagus.
Metabolic functions:
1. Fluid-electrolyte balance
2. Acid-base balance
3. Muscle activity: ionized potassium plays a significant role in the activity of striated skeletal
muscle and cardiac muscle.
4. Carbohydrate metabolism: when blood glucose is converted to glycogen for storage, 0.36 mmol
of potassium is stored for each 1 g of glycogen. When a patent in diabetic acidosis is treated
with insulin and glucose, glycogen, glycogen is rapidly produced and stored, drawing potassium
from the serum. Serious hypokalemia can result unless adequate potassium replacement
5. Protein synthesis: potassium is required for the storage of nitrogen in the muscle protein and
general cell protein.
Clinical problems:
Hyperkalemia: elevated potassium levels occur in renal failure, which prevents the normal adjustment
and clearance of ionized potassium and causes potassium to rise to toxic levels. Hyperkalemia brings
weakening of the heart action, mental confusion, poor respiration caused by weakening of the
respiratory muscles, and numbness of extremities.
Hypokalemia: decreased serum potassium of dangerous degrees may be caused by prolonged wasting
disease with tissue destruction and malnutrition or prolonged gastrointestinal loss of potassium, as in
diarrhea, vomiting, or gastric sunction. Continuous use of some diuretic drugs, increases ionized
potassium excretion and may leave the serum potassium levels abnormally low. Heart failure and
subsequent depletion of ionized potassium in heart muscle make myocardial tissue more sensitive to

digitalis toxicity and arrhythmia (irregular contractions). To prevent these complications of cardiac
failure, potassium is usually given, especially when potassium-depleting diuretics are used.
Hypertension: inadequate intake of potassium contributes to the development of essential hypertension
and high potassium intake will lower blood pressure.
Requirement: The RDA standard estimates a minimum daily intake for a healthy adult of 2000 mg. the
usual diet contains about 1500 to 4000 mg daily, which is ample for common need.
Food sources: potassium is widely distributed in natural foods. Legumes, whole grains, fruits such as
oranges and bananas, leafy vegetables, broccoli, potatoes, and meats supply considerable amounts.
Chlorine (Chloride):
Metabolic functions:
1. Acid-base balance
2. Gastric acidity: chloride secreted by the mucosa of the stomach in gastric hydrochloric acid,
provides the necessary acidic medium for digestion in the stomach and for the activation of
enzymes such as conversion of pepsinogen to active pepsin for initial protein-splitting.
Clinical problems:
1. Gastrointestinal disorders: large amounts of chloride may be lost during continued vomiting,
diarrhea. This loss would add the complications of hypochloremic alkalosis to the clinical state of
2. Alkalosis: when gastric secretions and the component HCL are lost, bicarbonate replaces the
depleted chloride ions. A type of metabolic alkalosis called hypochloremic alkalosis results.
3. Endocrine disorder: Cushing's disease is an endocrine disorder caused by hyperactivity of the
adrenal cortex or by excessive quantities of adrenocorticotropic hormone (ACTH) or cortisone
given as therapy. It may produce hypokalemia, with resulting hypochloremic alkalosis.
The RDA is a minimum daily need for healthy adults of 750 mg. adequate sodium intake = adequate
chloride intake.
Food sources: NaCl
Metabolic functions:
1. Maintenance of protein structure: disulfide linkages (-S-S-) form an important secondary
structure between parallel peptide chains to maintain the structural stability of proteins.
2. Enzyme activity: many enzymes need a free sulfhydryl group (-SH) for their activity. Therefore,
sulfur participates in tissue respiration.
3. Energy metabolism: the sulfhydryl group also forms a high-energy sulfur bond similar to the
high-energy phosphate bond.
4. Detoxification: sulfur participates in several important detoxification reactions by which toxic
materials are conjugated with active sulfate and converted to a nontoxic form for excretion in
the urine.


Clinical problems:
1. Cystine renal calculi: a relatively rare hereditary defect in renal tubular reabsorption of the
amino acid cystine causes excessive urinary excretion of cystine, cystinuria and repeated
production of kidney stones formed of cystine crystals. This type of renal calculus is yellowish in
color because of the high sulfur content. A low methionine diet is given to reduce the intake and
synthesis of these sulfur containing amino acids.
Sulfur requirement: no quantitative requirement has been specified for sulfur.
Food sources: proteins containing methionine and cystine.
Trace elements:
Metabolic function:
1. Oxygen transport: iron is the core of the heme molecule, which is the fundamental non-protein
conjugate of hemoglobin in the red blood cells. As such iron functions as a major transporter of
vital oxygen to the cells for respiration and metabolism. Iron is also a constituent of the similar
compound myoglobin in muscle tissue.
2. Cellular oxidation: iron functions in the cells as a vital component of enzyme system for
oxidation of glucose to produce energy. For example, iron is a constituent of the cytochrome
compounds, which are part of the electron transport system producing high-energy ATP bonds.
Clinical problems:
1. Anemia: blood condition characterized by decrease in number of circulating red blood cells,
Iron requirement: adult 10 mg /day for men and 15 mg/day for pregnant women.
Food sources: liver, meats, seafood, egg yolk, whole grains, legumes, green leafy vegetables and nuts.
Metabolic function:
Iodine participates in the synthesis of thyroid hormone. The thyroid hormone, thyroxine stimulates cell
oxidation and regulates basal metabolic rate, increasing oxygen uptake and reaction rates of enzyme
systems handling glucose.
Clinical problems:
Goiter: characterized by great enlargement of the thyroid gland.
Iodine requirement: adult 100 to 200 mcg of iodine daily.
Food sources: iodized salt.


Metabolic functions
1. Enzyme component: essential constituents of cell enzyme systems such as carbonic anhydrase,
lactate dehydrogenase, glutamate dehydrogenase, alkaline phosphatase, superoxide dismutase,
and thymidine kinase. It is nosurprise, therefore, that a deficiency of zinc brings multiple
repercussions in the dysfunction of many body systems.
2. Carboxipeptidase: zinc is a cofactor in this protein-splitting enzyme that removes amino acids
one at a time from the C-terminus of proteins. Zinc therefore has a key role in protein digestion.
3. Carbonic anhydrase: this enzyme, of which zinc is an integral part , acts as a carbon dioxide
carrier in red blood cells, and catalyzes the reaction. It takes up carbon dioxide from cells,
combines it with water to form carbonic acid (H2CO3) and then releases carbon dioxide from the
capillaries into the alveoli of the lung. This enzyme also functions in the renal tubule cells in the
maintenance of acid-base balance, in mucosal cells , and in glands of the body.
4. Lactate dehydrogenase: as a part of this enzyme, zinc is essential for the inter conversion of
pyruvate and lactate in the glycolytic path way for glucose oxidation. Thus zinc also plays a part
in carbohydrate metabolism.
Clinical problems
1. Hypogonadism: diminished function of gonads and dwarfism from pronounced human zinc
deficiency during growth periods.
2. Hypogeusia and hyposmia: impaired taste (hypogeusia) and smell (hyposmia).
3. Wound healing:
4. Chronic illness in ageing: older patients with poor appetites who subsist on marginal diets and
have unhealed wounds and illness may be particularly vulnerable to zinc deficiency. As a result
of such deficiency, they often suffer from reduced immune function.
5. Acrodermatitis enteropathica: it is a rare autosomal recessive genetic disease characterized by
typical symptoms of zinc deficiency such as hair loss, skin lesions, diarrhea, and mal--digestion.
6. Mal-absorption disease: zinc deficiency is associated with mal-absorption disease when lesions
in the mucosal surface hinder its absorption. Causes of the deficiency include impaired intestinal
absorption, increased losses with attendant diarrhea and low zinc intake caused by anorexia.
Zinc requirement
The RDA standards recommends a daily adult intake of 12 to 15 mg , with 10 to 15 mg for children and 5
mg for infants.
Food sources: the best sources are seafood, meat, and eggs, and less rich sources are legumes and
whole grains. Because animal food sources supply the major portion of dietary zinc, pure vegetarians,
especially women, may be at risk for marginal zinc deficiency.
Metabolic function
1. Cooper is associated with iron in several important metabolic functions such as cytochrome
oxidation system and hemoglobin synthesis.
2. Metalloprotein enzymes: copper is a constituent of a number of important catalytic processes
through its role as a component of many cell enzymes. Some of these enzymes include
tyrosinase, monoamine oxidase, superoxide dismutase, and cytochrome oxidadase.

Clinical problems:
1 Hypocupremia, owing to urinary loss of ceruplasmin in patient suffering from nephrosis, a wasting
renal disease
3. Genetic disease: (a) Wilson's disease: it is an autosomal recessive defect in the incorporation of copper
into the apoprotein to form ceruloplasmin. The patients have an impaired ability of the liver to excrete
copper into the bile. Thus copper retention increases, bringing damage to the liver, brain, kidney and
cornea. (b) Menkes syndrome: commonly called "kinky (or steely) hair syndrome" is an X-linked
disorder of intestinal copper absorption. Here the transport of copper across the serosal membrane of
the intestinal wall for movement into the bloodstream is defective.
Copper requirement:
Adults 1.5 to 3.0 mg/day
Infants 0.4 to 0.7 mg /day
Children and adolescent 0.7 to 2.5 mg /day
Food sources of copper:
Copper is widely distributed in natural foods. Its main sources include meat, shellfish, nuts, seeds,
Metabolic functions:
1. Protein metabolism: manganese activates much amino acid inter conversion with specific
enzymes such as arginase, cysteine desulfhtdarase, dipeptidases, and leucine aminopeptidase.
2. Carbohydrate metabolism: manganese activates several conversion reactions of the glycolytic
pathway and citric acid cycle in glucose oxidation.
3. Fat metabolism: manganese activates the serum fat-clearing factor, lipoprotein lipase and
operates as a cofactor in the synthesis of long-chain fatty acids and cholesterol.
Clinical problems
Manganese deficiency: low serum manganese levels have been reported in diabetes and pancreatic
insufficiency and are found in protein-calorie malnutrition states such as kwashiorkor.
Manganese toxicity: an industrial disease syndrome, inhalation toxicity, occurs in miners and other
workers who undergo prolonged exposure to manganese dust. The excess manganese accumulates in
the liver and central nervous system eventually producing severe neuromuscular symptomsthat
resembles those of Parkinson's disease. a form of manganese neurotoxicity associated with dopamine
function and neurologic disorder has been due to poor diets and large alcohol intakes. Deficiencies of
two key nutrients that effectively inhibit dopamine oxidation result vitamin C (poor diet) and thiamin
(excessive alcohol) .
Manganese requirement:
Adults 5 mg daily
Adolescents 2 to 5 mg daily
Children 1 to 3 mg daily
Infants 0.3 to 1 mg daily.
Cereal grains, legumes, nuts, leafy vegetables, tea and coffee. Animal food sources are relatively poor


Metabolic functions:
It is an essential component of the organic complexes glucose-tolerance factor. This factor potentiates
the action of insulin, by facilitating the binding of insulin in cell membranes by forming a bridge between
the insulin molecule and the membrane.
Clinical problems
Diabetes mellitus: there is a positive relationship between chromium and GTF to insulin activity and
glucose tolerance.
Lipid disorder: significant reductions in serum cholesterol have been observed in patients treated with
chromium supplementation. There is a lowering of LDL and increase in HDL.
Chromium requirement:
Adult 50 to 200 mcg/day
Food sources: brewer's yeast is rich source. Good sources include nuts, mushrooms, wine and beer.
Lesser amounts are found in most grains, and cereal products.
Metabolic function
It is a constituent of vitamin B12. This vitamin is an essential factor in the formation of red blood cells.
Clinical problems
There are no known cases of cobalt deficiency in humans. Excess of cobalt has led to polycythemia , a
condition characterized by the formation of an excess number of red blood cells that contain a relatively
high concentration of hemoglobin.
Cobalt requirement: unknown
Food sources: animal food sources. It is synthesized in animals by intestinal bacterial flora.
Metabolic functions
Selenium is an integral component of the antioxidant enzyme glutathione peroxidase, a catalyst
transferring reducing agents from reduced glutathione to hydrogen peroxide or to lipid peroxides, which
protects cells and membranes against oxidative damage. In this role , selenium balances with vitamin E,
each sparing the other.
Structural component: selenium is also incorporated into the protein matrix of the teeth.
Adults: 55 to 70 mcg
Children lower intakes.
Food sources:
Sea-food, legumes, whole grains, low-fat meats, and dairy products, vegetables.

Metabolic functions
It is a catalytic component of the metallo enzymes xanthin oxidase, aldehyde oxidase, and sulfite oxidase, which catalyzes the oxidation of xanthine to uric acid.
Requirement: adult 75 to 250 mcg/day.
Food sources: milk and milk products, legumes, liver and kidney, grain products, and leafy vegetables.
Metabolic function
Inhibit dental caries.
Clinical problems:
Dental health
Requirement: adults 1.5 to 4.0 mg /day
Food sources: fish, fish products and tea
Role of vitamins in human nutrition
Fat soluble vitamins
Vitamin D:
Physiologic functions: it is associated with calcium and phosphorus metabolism. It influences the
absorption of these minerals and their deposit in bone tissue.
1. Absorption in the intestine and deposition of these minerals in bone tissue.
2. Bone mineralization and rickets: vitamin D hormone facilitates the absorption of calcium and
phosphorus and directly increases the rate of mineral deposit and resorption in bone, by which
the bone tissue is built and maintained. When the body is deficient in vitamin D , the disease
rickets follows, a condition characterized by malformation of skeletal tissue in growing children.
Chemical and chemical nature of vitamin D
The two compounds with vitamin D activity involved in nutrition are ergocalciferol ( vitamin D2) and
cholecalciferol (vitamin D3). Vitamin D2 is formed by irradiating ergosterol (provitamin D2) , which is
found in ergot is fungus growth on rye and other cereal grains and yeast. The more important product is
vitamin D3 ) , which is formed by irradiating 7-dehydrocholesterol ( provitamin D3) in skin to D3. Vitamin
D3 also occurs as such in fish liver oils.
Absorption: absorption of dietary vitamin D3 occurs in the small intestine. Since vitamin D3 is fat-soluble,
this absorption requires the presence of bile salts. It mixes with the intestinal micelles and is absorbed in
these lipid packets. Vitamin malabsorption disease such as celiac syndrome, sprue, and colitis hinder
vitamin D absorption.


The synthesis of the active hormonal form 1, 25, -dihydrooxycholecalciferol ( 1,25 ( OH)2 D3 is
accomplished by the combined action of skin, liver, and kidneys.
Skin : in the skin, 7-dehydrocholesterol, the precursor of cholesterol compound, is irradiated by the
sun's ultraviolet rays to produce vitamin D3 in turn , vitamin D3 combines with a special protein carrier , a
globulin, for transport within the body.
Liver: after synthesis in the skin, vitamin D 3 is transported by its special globulin protein carrier and
taken to the liver. In the liver, a special liver enzyme forms the intermediate product 25hydrooxycholecalciferol. In turn, this compound is once more carried by the same transport globulin to
the kidney for final activation.
Kidneys: in the kidney special enzymes form the physiologically active form of the vitamin D hormone
Vitamin A:
Physiologic functions:
1. Vision: the ability of the eye to adapt to changes in light depends on the presence of a lightsensitive pigment, rhodopsin (visual purple) in the rods of the retina. The retinoid substance
retinal combines with the protein opsin to form the visual pigment rhodopsin. When light hits
the retina, rhodopsin splits into its two parts, opsin and retinal. In the dark the two components
recombine to form rhodopsin again. Normally, there is more than enough retinal in the pigment
layer behind the rods and cones to ensure constant adjustments to variances in light. But when
the body is deficient in vitamin A, less retinal is available for formation of visual purple. The rods
and cones then become increasingly sensitive to light changes, which causes night blindness.
This condition can usually be cured rapidly by an injection.
2. Epithelial tissue: vitamin A has a vital role in the formation and maintenance of healthy
functioning of epithelial tissue. Without vitamin A the epithelial tissues become dry and flat and
gradually harden to form keratin, a process called keratinization. Keratin is a protein that forms
dry, scale-like tissue such as nails and hair. When the body is deficient in vitamin A, many
epithelial tissues may undergo keratinization.
a. Eye: the cornea dries and hardens, a condition called xeropthalmia. This process may progress
to blindness in extreme deficiency of vitamin A.
b. Respiratory tract: ciliated epithelium in the nasal passage dries, and the cilia are lost. A barrier
to entry of infection is therefore removed. The salivary glands dry, and the mouth becomes dry
and cracked, open to invading organisms.
c. Gastrointestinal tract: the secretary function of mucous membranes is diminished so that tissue
sloughs off, which affects both digestion and absorption.
d. Genitourinary tract: as epithelial tissue breaks down, urinary tract infections, calculi, and
vaginal infections become more common.
e. Skin: as skin becomes dry and scaly, small pustules or hardened pigmented, popular eruptions
may appear around the hair follicle , a condition called follicular hyperkeratosis.
f. Tooth formation: certain epithelial cells surrounding tooth in fetal gum tissue become
specialized cup-shaped organs called ameloblasts. These organs from the enamel structure of
the developing tooth. Each cell carries out the task of producing and depositing minute prisms
of enamel substance that eventually form the erupted tooth.
3. Growth: vitamin A deficiency is associated with retarded growth.
4. Reproduction: the retinoids are necessary to support normal function of the reproductive
system in both males and females. Vitamin A deficiency causes glandular degeneration and

Vitamin A requirement:
Food sources: liver and kidney. Yellow and green vegetables
Hypervitaminosis A: because the human liver has a great storage capacity for vitamin A and because
some persons take mega doses of vitamin A on their own, it is clearly possible to take potentially toxic
jaundice. Excess vitamin A may also cause liver injury with resulting portal hypertension and ascites.
Vitamin E (Ttocopherol):
Physiologic functions:
1. Antioxidants: vitamin E acts as nature's most potent fat-soluble antioxidants. The
polyunsaturated fatty acids in structural lipid membranes in body tissues are particularly
vulnerable to oxidative breakdown by free radicals in the cell. The tocopherols can interrupt
process by donating electrons, thus protecting the cell membrane polyunsaturated fatty acids
from the oxidative damage.
2. Selenium metabolism: even with adequate vitamin E some damaging cell peroxides are formed
and a second line of defense is needed to destroy them before they can damage cell
membranes. The agent providing this added defense is the enzyme system glutathione
peroxidase , of which selenium is an integral components. Thus selenium spares vitamin E by
reducing its requirement. Similarly, in this partnership role, vitamin E reduces the selenium
Requirement: adults: 10 mg for men and 8 mg for women and needs during childhood growth periods
range from 3 to 8 mg.
Food sources: the richest sources of vitamin E are the vegetable oils. Other food sources include milk,
eggs, muscle, meats, fish, cereals, and leafy vegetables.
Vitamin K ( Phylloquinone)
Chemical nature
There are three main vitamin K
1. Phylloquinone ( vitamin K1) is the major form found in plants.
2. Menaquinone ( vitamin K2) is synthesized by intestinal bacterial flora and contributes about half
of our daily supply.
3. Menadione ( vitamin K3) is a water soluble analog and it does not require bile salts for the
absorption and go directly into the portal blood system.
Physiologic function
1. Blood clotting: vitamin k is required to maintain normal levels of four blood-clotting factors
a. Factor II, prothrombin
b. Factor VII, serum prothrombin conversion accelerator (SPCA)
c. Factor IX, plasma thromboplastin component (PTC)
d. Factor X, stuart-prower factor.
Each of these specific clotting factors is a protein synthesized by liver in an inactive precursor form
dependent on vitamin K for activation. Vitamin K produces the active form of these precursors, mainly
prothrombin, by carboxylation of the amino acid glutamic acid. This process enables them to combine
with calcium (factor IV), an element essential in the clotting process.
Adults 80 mcg /day and children 15 to 30 mcg/day.

Food sources
Vegetables, especially green leafy vegetables such as cabbage, spinach, kale, and cauliflower. Lesser
amounts in animal food sources.
Water soluble vitamins
1. Food sources: all are synthesized by plants except vitamin B12
2. Storage: all have no stable storage form and therefore be provided regularly in the diet-except
cobalamin (vitamin B12)
3. Function: all serve as coenzyme factors in cell enzyme except vitamin C.
Physiologic function
1. Coenzyme role: when actively combined with phosphorus as the coenzyme thiamin
pyrophosphate (TPP) , thiamin plays a key role in carbohydrate metabolism. Two types of cell
reactions, decarboxylation (COOH removal) transketolation (ketoaldehyde removal ) depend on
this important thiamin coenzyme.
Clinical effects of thiamin deficiency
1. Gastrointestinal system: anorexia, indigestion, severe constipation, gastric atony, and deficient
hydrochloric acid secretion, may occur as a result of thiamin deficiency.
2. Nervous system: the central nervous system is extremely dependent on glucose for energy to do
its work. Without sufficient thiamin to help provide this need, neuronal activity is impaired,
alertness and reflex responses are diminished and general apathy and fatigue result. If thiamin
deficiency continues, lipogenesis is hindered and damage or degeneration of myelin sheaths
(lipid tissue) covering nerve fiber follows. This causes increasing nerve irritation, pain, and
prickly or deadening sensations. If the process continues unchecked in a severe deficiency state ,
paralysis results, a characteristics feature of beriberi ( a disease of the peripheral nerve caused
thiamin deficiency).
3. Cardiovascular system: with continuing thiamin deficiency, the heart muscle weakens and
cardiac failure results.
Thiamin requirement: adult 0.5 mg /1000 kcal
Food sources: thiamin is widespread in almost all plant and animal tissues.
Physiologic functions
The enzymes of which riboflavin is an important constituent are called flavoproteins. Two such
riboflavin enzymes , flavin mononucleotide (FMN) and flavin-adenin dinucleotide (FAD), operate at vital
reaction points in the respiratory chain of cellular energy metabolism.


Clinical effects of riboflavin deficiency

1. Ariboflavinosis: the lips become swollen; crack and characteristic cracks develop at the corners
of the mouth-a condition called cheilosis. The tongue becomes swollen and reddened-a
condition called glossitis. A scaly grease skin - seborrheic dermatitis may develop especially in
the skin folds.
Riboflavin requirement
0.6 mg /1000 kcal.
Food sources: the most important food sources of riboflavin are milk. Other good sources are meats,
liver, kidney and heart, whole grains and vegetables.
Physiologic functions
1. Coenzyme and tissue oxidation: niacin is a partner with riboflavin in the cellular coenzyme
systems that converts proteins and the small amount of glycerol from fats to glucose and that
oxidize glucose to release energy. The two niacin coenzymes that operate in these cell
respiratory chains are nicotinamide-adenine dinucleotide (NAD) and nicitinamide-adenine
dinuckeotide phosphate ( NADP).
Clinical effects of niacin deficiency
Weakness, lassitude, anorexia, indigestion, and skin eruptions. More specific symptoms involve the skin
and nervous system. Skin areas exposed to sunlight are especially affected and develop a dark , scaly
dermatitis. If deficiency continues, the central nervous system becomes involved, and confusion, apathy,
disorientation, and neuritis develop.
Niacin requirement
6.6 mg /1000 kcal
Food sources:
Meat is a major source of niacin. Good sources include peanuts, beans, and peas. Fruits and vegetables
are generally poor sources.
Pyridoxine (B6)
Physiologic functions
1. Decarboxylation: converts glutamic acid to gamma-aminobutyric acid, a substance found in gray
matter in brain. Pyridoxine coenzyme converts tryptophan to serotonin, a potent
vasoconstrictor, which stimulates cerebral activity and brain metabolism.
2. Deamination: renders carbon residues available for energy by removing the amino group from
amino acid such as serine and threonine.
3. Transsulfuration: transfur sulfur from methionine to another amino acid, serine, to form the
derivative amino acid cysteine.
4. Transamination: removes the amino group and transfer it to a new carbon skeleton forming a
new amino acid.

5. Nicotinic acid formation: participates in nicotinic acid formation from tryptophan.

6. Hemoglobin synthesis: incorporates the amino acid glycine and succinate, a glucose metabolite
in the citric acid cycle into heme , the essential nonprotein core of hemoglobin.
7. Amino acid transport: actively transport amino acids from the intestine into circulation and
across cell walls into the cells.
8. Coenzyme in carbohydrate and fat metabolism
Clinical effects:
1. Anemia
2. Central nervous system disturbances
Requirement: for adults 1 mg daily is a minimal.
Toxic effects: pyridoxine abuse with mega doses up to 5 mg a day resulted in severe nerve damage.
Food sources: it is widespread in foods. Good sources include grains, seeds, liver, and kidney. There are
limited amounts in milk, eggs, and vegetables.
Pantothenic acid
Physiologic functions
1. Coenzyme role in metabolism: in its role as an essential constituent of the body's key activating
agent, coenzyme A , pantothenic acid is vital to overall body metabolism. The process of
acetylation by coenzyme A is one of the prime metabolic reactions in the body.
Adult 4 to 7 mg daily.
Food sources
Liver, kidney, meats, milk, eggs, legumes, and vegetables.
Physiological function
Biotin functions as a coenzyme with specific cell enzymes involved in the process of carboxylation. Here
biotin serves as a partner with acetyl CoA in reaction that transfer carbon dioxide from one compound
and fix it onto another.
Clinical problems: a deficiency of biotin is unlikely because they are so widespread in foods.
Requirement and Food sources: adults 30 to 100 mcg daily. Much of the body's requirement can be
supplied from intestinal bacterial synthesis. Biotin is widely distributed in natural foods. Biotin of corn
and soya meal is completely available whereas that of wheat is almost unavailable. Excellent food
sources include egg yolk, kidney, and other animal tissues as well as tomatoes among the vegetables.


Folic acid
Physiologic function
1. Purines and pyrimindine synthesis.
2. Hemoglobin synthesis.
Clinical problems:
1. Anemia: megaloblastic anemia, characterized by formation of large immature red blood cells.
2. Sprue: folic acid is an effective agent in the treatment of sprue, a gastrointestinal disease
characterized by intestinal lesions, mal-absorption defects, and diarrhea.
Folic acid requirement: adult 180 to 200 mcg daily.
Food sources: green leafy vegetables, liver, kidney, and asparagus.
Cobalamin ( B12 ):
Physiologic function
1. Methylation in general metabolism. In this process of methylation, key methyl groups are
formed or transferred from one compound to another.
2. Hemopoiesis: The formation of blood.
Clinical problems:
1. Pernicious anemia: in the absence of intrinsic factor (glycoprotein) , a component of the gastric
secretions that is required for vitamin B12 absorption , pernicious anemia develops, adequate
hemoglobin cannot be synthesized.
2. Sprue: it is effective in the treatment of the intestinal syndrome of sprue.
Requirement: minimum is 0.6 to 1.2 mcg daily.
Food sources: it is supplied by animal foods. Natural dietary deficiency is rare and is observed in strict
vegetarian. One cup milk , I egg and 4 oz.of meat provide 2.4 mcg.
Ascorbic acid (vitamin C):
Physiologic functions
1. Intercellular cement substance: we require vitamin C to build and maintain bone matrix,
cartilage, dentin, collagen, and connective tissue. When vitamin C is absent , the important
ground substance does not develop into collagen. The hydroxylation of proline in collagen
requires vitamin C. vascular tissue is weakened without the cementing substance of vitamin C to
provide firm capillary walls. Therefore vitamin C deficiency states are characterized by fragile,
easily ruptured capillaries with consequent diffuse tissue bleeding.
2. General body metabolism: there are a greater concentration of vitamin C in the more
metabolically active tissues such adrenal glands, brain, kidney, liver, pancreases, thymus spleen.
In the formation of hemoglobin and maturation of red blood cells, vitamin C influences the
removal of iron from ferritin, the protein-iron-phosphorus complex in which iron is stored,
particularly in reticuloendothelial cells of the liver, spleen, and bone marrow. Because of this
reaction more iron is made available in the body fluids. Vitamin C also influences the conversion
in the liver of folic acid to folinic acid. Oxidation-reduction reactions of the amino acid
phenylalanine and its metabolites, including tyrosine requires vitamin C for maximal activity.


Clinical problems:
1. Wound healing:
2. Fevers and infections
3. Reactions to stress
Growth periods: additional vitamin C is required during the growth periods of infancy and childhood. It
is also required during pregnancy to supply demands for fetal growth ad maternal tissues.
Vitamin C requirement and food sources: adult 60 mg daily. Well known sources include citrus fruits
and tomatoes. Other sources are cabbage, sweet potatoes white potatoes and green and yellow
Vitamin C: wonder drug of the 80's
1. Cancer prevention: this claim is often associated with vitamin c's ability to build intracellular
connective tissue, which is believed to create a barrier between healthy and malignant tissue.
2. Prevention of colds
3. Mental illness: vitamin C is supposed to improve short-term memory and cure schizophrenia
and depression.
4. Stress: adrenal glands respond to stress by producing epinephrine and other hormones. They
respond best when their tissues are saturated with vitamin c.
5. Heart diseases: vitamin c tends to lower total cholesterol while raising high-density lipoprotein.
6. Wound healing
Vitamin E in search of a disease:
1. Smoking and air pollution: vitamin E seems to neutralize the free radicals in cigarette smoke and
polluted air that damages the lining on the lungs.
2. Benign breast cysts: among women with non-cancerous breast cysts help reduce pain and cyst
3. Calf muscle pain (intermittent claudination): help reduce this pain.
4. Sickle cell anemia: reduced risk
5. Infant blindness: the incidence and severity of retrolental fibroplasias, caused by giving
premature infants too much oxygen at birth, reduced in newborns.
6. Ageing adrenal glands: vitamin e seems to protect against the formation of lipoperoxide, a
substance associated with adrenal aging.
7. Cancer: high vitamin E intake protects against cancer.
Role of energy in human body
Energy: energy is that force or power that enables our bodies to carry on their life sustaining activities.
Metabolism is the total of all those chemical processes in the body by which substances initially in food
are " thrown beyond themselves " to be changed into other substances .
Energy cycle:
Form of human energy
In the body energy is available in four basic forms for life processes : chemical, mechanical, electrical and

Energy control in human metabolism:

The energy in any system may be uncontrolled and destrictive, or it may be controlled and constructive.
Likewise in the human body , the energy produced in its many chemical reactions, if "exploded" all at
once, could be destructive. The mechanism by which energy is controlled in the human system is
chemical bonding. The chemical bonds that hold the elements of the compounds together consist of
energy. As long as that compound remains constant, energy is exerted to maintain its atomic
constellation . it is in this sense that potential energy is stored in the compound. When the compound is
broken into parts, energy is released and becomes free energy. It is characteristics of free energy that it
immediately involves itself in the bonding of other atoms, which results either in a rearrangement of the
atom within the same compound or in new compounds. Examples of chemical bonds transferring energy
in the body include bonds , hydrogen bonds, covalent bonds, and high-energy phosphate bond.
Types of metabolic reactions
1. Anabolism: anabolism synthesizes more complex substances. Energy is required to generate this
2. Catabolism: catabolism breaks down compounds to simpler substances. It releases free energy,
but it also uses up some free energy for the breakdown. as a result, there is a constant energy
deficit that must be supplied by food. When food is not available , as in periods of fasting or
starvation , the body draws on its own stores for energy:
a. Glycogen: only a 12 to 48 hours reserve of glycogen exists in liver and muscle; this reserve is
quickly depleted.
b. Muscle mass: storage of energy as protein exists in limited amounts in muscle mass , but in
greater volume than glycogen stores.
c. Adipose tissue: the capacity for storage in the adipose tissue is virtually unlimited. This storesd
fat provides needed energy, but the supply varies from person to person and from
circumstances to circumstances.
Measurement of energy
Calorie: the term kilocalorie (1000 calories) is the amount of heat required to raise 1 kg of water 1 0 C
Joule: it expresses the amount of energy expended when 1 kg of a substance is moved 1 meter by a
force of 1 Newton. 1 Kcal = 4.184 kj
Food energy: the energy in various foods is generally measured in two basic ways: calorimetry and
proximate composition.
The measurement of heat loss. An instrument for measuring heat output of the body or the energy
value of foods is called calorimeter. In this process a metal container called a bomb calorimeter is used.
A weighed amount of food is placed inside, and the instrument is immersed in water. The food is the
ignited by an electric spark in the presence of oxygen and burned. The increase in temperature of the
surrounding water indicates the number of kilocalories given off by the oxidation of the food.
Proximate composition:
An alternative method of measuring food energy is by computing the approximate nutrient composition
of a given food using values in food values tables. These values are based on the average kilocalories
value of each of the three major energy nutrients, which are known as their respective fuel factors: 1 g
of carbohydrate yields 4 kcal , 1 g of fat yields 9 kcal, and 1 g of protein yields 4 kcal.

Basal metabolism:
The amount of energy needed by the body for maintenance of life when the person is at digestive,
physical, and emotional rest. The amount of oxygen consumed at rest is used as a measure of the basal
energy requirements and is expressed as kilocalories per square meter of body surface per hour. This
rate (BMR) is reported as the percent of variation in the person above or below the normal number of
kilocalories required for a person of like height, weight, and sex.
Influencing factors:
1. Lean body mass: the major influencing factor of BMR is lean body mass. Using a person's height
and weight.
Basal metabolism: use general formula: women 0.9 kcal /kg body weight/hr
Men: 1.0 kcal /kg body weight/hr
Covert weight (lb) to kg: 1kg = 2.2 lb
Multiply according to formula: 1 (or 0.9 ) x kg x 24( hours in a day)
Physical activity:
Estimate your general level of physical activity.
Find energy cost of activity (% of BMR) and add it to your BMR.
Average activity level
energy cost : % of BMR
20 %
Very light
30 %
40 %
50 %
For example, if you are sedentary (mostly siting)
BMR ( first step) + ( 20 % x BMR)
Food intake: specific dynamic action (SDA) or thermo genesis of food 10 % of total calories in food.
Total energy output = BMR + physical activity + SDA
2. Growth: growth hormone stimulates cell metabolism and raises BMR 15 to 20 %.
3. Fever and disease: fever increases the BMR about 7 % for each 1 0F rise.
4. Cold climate: BMR rises in response to lower temperatures as a compensatory mechanism to
maintain body temperature.
5. Food intake effect: food ingestion stimulates metabolism and require energy to meet the
multiple activities of digestion, absorption and transport of the nutrients.
6. Physical activity needs:
Total energy requirements:
The basic components of energy required during weight maintenance are: (1) the energy demands of
the basal metabolic rate (BMR) or the resting metabolic rate (RMR), (2) the variable requirements of
physical activity, and (3) the thermogenic effect of food intake (4) adaptive thermo genesis due to the
change in resting metabolic rate associated with adaptation to environmental stress, such as changes in
dietary intake, ambient temperature, and emotional status.


Average energy allowance (kcal) per day




Age (years)
0.0 -0.5
50 +
50 +
1st trimester
2nd trimester
3rd trimester
1st six months
2nd six months

Weight in kg

Energy allowance
+ 300
+ 300
+ 500

Energy expenditure /hour during various activities

Light activities
Light to moderate activities
Moderate activities
Heavy activities

120-150 kcal /hour

150-300 kcal /hour
300 -420 kcal/hour
420-600 kcal /hour.

Gender and energy: body surface area is used as basis for calculating resting metabolic rate (RMR).
Since body surface is gender specific, RMR values are assumed to be lower for women. Women have a
smaller proportion of muscle mass to fat. Menstruating women has a 9 % increase in their energy
expenditure in 24 hours because of progesterone from the corpus luteum. A majority of the women
showed 8 % to 16 % increases in energy expenditure during the 14-day luteal phasefollowing ovulation.
Water electrolyte balance
Water functions:
The body water performs three functions that are essential to life:
1. It helps give structure and form to the body through the turgor it provides for tissue.
2. It creates the aqueous environment necessary for cell metabolism.
3. It provides the means for maintaining a stable body temperature.
Water compartments
1. The extracellular fluid compartment (ECF) is made up of water outside the cells
2. The intracellular fluid compartment (ICF) is made up of all the water inside the cells.


ECF: the collective water outside thcells makes up about 20 % of the total body weight. It consists of
four parts.

Blood plasma, which accounts for approximately 25 % of the ECF and 5 % of body weight
Interstitial fluid: which accounts for the water surrounding the cells
Secretory fluid: which accounts for water in transit
Dense tissue fluid: which accounts for water in dense connective tissue, cartilage and bone.

ICF: the total water inside the body cells makes up about 40 to 45 % of the total body weight.
Overall water balance: input and output
The average adult metabolizes from 2.5 to 3.o liter of water per day in a constant turnover balance
between intake and output. Normally water enters and leaves the body by various routes, controlled by
basic mechanisms such as thirst and hormonal controls.
Thirst and drinking
The thirst and drinking mechanisms are complex interactions involving control centers located in the
brain and the hypothalamus and related hormonal activities that regulate water intake.
Hormonal controls
The hormonal regulation of renal water excretion for maintaining water balance is under the control of
vasopressin the antidiuretic hormone (ADH secreted by the pituitary gland and aldosterone from the
adrenal gland.
Water intake:
1. Preformed water in liquids: water and other beverages are the main source of ingested fluid.
About 1200 to 1500 ml of liquid is ingested daily in this form
2. Preformed water in foods: foods vary in their water content. The water ingested in foods
contributes about 700 to 1000 ml daily.
3. Water of oxidation: when nutrients are burned or oxidized in the body , one of the end product
is water. On the whole about 200 to 300 ml of water is contributed daily from the body's
metabolic activity. This brings the daily water intake to about 2100 to 2800 ml daily..
100 g of fat yields 107 g of water, 100 g carbohydrate 55 g and 100 g protein 41 g water.
Water output
Water leaves our bodies normally by four routes.
1. Kidneys: normal adult kidneys excrete about 1 to 2 liter of urine daily. The water in this total
amount is made up of two portions: obligatory and facultative water excretion.
Obligatory water excretion: the kidney is "obligated" to excrete some water to rid the body of its daily
load of urinary solutes.
Facultative water excretion: in addition to obligatory water loss, an additional 500 ml , more or less , is
excreted according to body need for maintaining water balance and the rate of the kidney's water
Skin: about 300 ml of water is lost daily through the skin by diffusion. Because we are unaware of this
loss, it is called insensible water loss. We may lose an additional 100 ml in normal perspiration. Heavier
sweating caused by heat or increased activity may cause the loss of 250 ml of water, more or less,
according to body's need. Drinking to replace these heavier losses is stimulated when the body fluid
volume decreases by 0.5 % to 1.0 % .

Lungs: an insensible water loss of about 350 ml occurs through normal respiration vapour. This amount
varies with climate.
Intestine: a small amount of water , about 150 ml to 200 ml , is usually lost daily through intestinal
Forces influencing water distribution
Forces that influence and control the distribution of water in the body resolve around two factors : (!)
the solutes, which are particles in solutions in body water; and (2) the membranes that separate the
water compartments.
Two major types of solute particles control body water distribution by their varying concentrations in
body fluids and forces these concentrations create. These controlling types of solute particles are
specific electrolytes and plasma protein.
Certain inorganic compounds , usually an acid, alkali, or a salt, partly break down into their constituent
ions when they are dissolved in water. Ions are atoms or groups of atoms that carry electrical charges.
These charges may be positive or negative. The ions carrying electrical charges are called electrolytes.
Cations and anions
The two forms of ions are called cations and anions. A cation carries a positive charge: examples are Na+,
K+ Ca ++, and Mg++. An anion carries a negative charge: examples are: Cl--, HCO3-, HPO4- and SO4-. These
contribute a major force controlling fluid balances within the body through their
concentration s in different places and their shifts from one place to another in varying circumstances to
restore balance.
Plasma proteins
Organic substances of larger molecular size, mainly albumin and globulin of the plasma proteins ,
influence the shift of water from compartment to another. They are called colloids and form colloidal
Organic compounds of small molecular size:
These small organic compounds include such substances as urea, glucose, and amino acids. Because of
their small size, they diffuse freely and therefore affect water balances only if they occur in unusually
large amounts. For example , the large amounts of glucose in the urine of a patient with uncontrolled
diabetes causes an abnormal osmotic dieresis or excess water output.
Separating membranes
Two basic types of membranes are involved in the movement of water and solutes within the body: the
capillary membrane and cell membrane. The capillary membrane is relatively free and allows rapid
passage of substances. On the other hand the cell membrane is a more complex, semipermeable
(permitting only some substances to pass through) structure.


Mechanism moving water and solutes across membranes

According to the type of membrane and the number of particles in the involved solution, water and
solutes move across membranes by one or more of five mechanisms 1. Osmosis. 2. Diffusion 3. Active
transport 4. Filtration 5. Pinocytosis
1. Osmosis: by the process of osmosis through the semi-permeable membrane separating the two
solutions, water molecules pass from the more dilute solution , where water concentration is higher
and the solute concentration lower, to the more dense solution, where water concentration is
therefore lower and the solute concentration higher
2. Diffusion: in diffusion, particles in solution spread throughout the solution and across separating
membranes, from the place of highest solute concentration to all spaces of lesser solute
concentration. This movement may be simple passive diffusion or it may be carrier mediated.
3. Active transport: movement of solutes in solution such as glucose across a membrane against the
usual opposing forces. Such movement requires energy, which is supplied by the cell. Sometimes an
additional transporting substance is required, such as sodium, fro absorbing glucose.
4. Filtration: fluid is forced or filtered through membranes when there is a difference in pressure on
the two sides.
5. Pinocytosis: proteins and fats sometimes enter cells by the interesting process of pinocytosis. For
example larger protein and fat molecule may become attached to the cell's outer surface, causing
the cell membrane to form a pocket and encircle them. This creates an invagination , or incupping
on the cell surface, from which the engulfed material is eventually released into the cell cytoplasm.
Electrolyte in water balance:
The electrolytes play a prominent role in the control of water balance in the body.
Measurement of electrolytes in body fluids.
1. Chemical activity of solutions: the chemical activity of a solution is determined by the concentration
of electrolytes-charged particles-in a given volume of the solution. It is the number of particles in a
solution .
2. Miliequivalents: the unit of measure commonly used in an equivalent, with hydrogen as a reference
point. One equivalent of a substance is equal to the combining power of 1 g of hydrogen. One
milliequivalent (mEq) is equal to the chemical combining power of 1 mg of hydrogen.
3. Milliequivalents and milligrams: the relation of milliequivalents to milligrams of an ionized
substance in solution may be determined in the following manner. Equivalents of an ionized
substance in solution are calculated in terms of the molecular weight and valence of that substance.
One equivalent (Eq) is I mole; this is the gram molecular weight of the substance, that is the
molecular weight (mol weight) of the substance in grams divided by its valence. Thus :
1 Eq Na+ =

23 g (mol weight of sodium)

-------------------------------------- = 23 g
1 mEq Na + = 23 mg

40 g (mol wt of calcium)
-------------------------------- = 20 g
1 mEq Ca + + = 20 mg
Therefore the number of milliequivalents per liter equals the milligrams per liter divided by the
equivalent weight. Equivalent weight equals gram-molecular weight (atomic weight) divided by valence.
1 Eq Ca+ + =


Electrolyte components of ECF

1. Sodium: ionized sodium is the main cation of ECF.
2. Chloride: ionized chlorine ( Cl-) is the main anion in ECF. The chloride provides the balance to
sodium. It is present in particularly high concentration in gastric secretions, as a constituent of
hydrochloric acid.
3. Other anions: ECF also contains the variable anion bicarbonate (HCO3-) and phosphate (HPO4-)
4. Protein
Electrolyte components of ICF
1. Potassium ( K+) potassium is a main cation in ICF. Ionized potassium is concentrated within the
cells, where it provides a major osmotic force for maintaining the necessary water volume inside
the cell
2. Phosphate (HPO4= ) phosphate is the main anion in ICF
3. Cell protein: the quantity of protein in ICF is three or four times greater than that in extracellular
Electrolyte control of body hydration
1. Hypertonic dehydration: In ECF , when water loss exceeds electrolyte loss , the ECF becomes
hypertonic to the ICF. This means that the osmotic pressure of ECF is higher than that of ICF. The
imbalance in osmotic pressures causes water to shift from the cell into the ECF spaces. This
situation could occur from excess water loss or water restriction. Clinical signs include severe
thirst, a hot, dry body, especially tongue, vomiting, disorientation and scanty and concentrated
2. Hypotonic dehydration: when large amounts of water are added to ECF without addition of
sufficient electrolytes to maintain the normal density of the solutions, the ECF becomes
hypotonic to the ICF. This type of imbalance in osmotic pressures causes compensatory shift of
water from the ECF into the cell. The result is a dangerous shrinking of ECF, especially the blood
volume. Renal blood flow is impaired, and swelling of the cells, or cellular edema, occurs. Clinical
signs of hypotonic dehydration include progressive weakness without thirst or decreased urine i
Clinical applications of fluid and electrolyte imbalances
1. Gastrointestinal disorders, such as diarrhea.
2. Gastrointestinal surgery
3. Congestive heart failure: causing cardiac edema.
Nutritional deficiency diseases
Biologic and social problems
At Biologic level, malnutrition occurs. Malnutrition is inadequate supply of nutrients to the cell. It results
from a complex web of factors: personal, social, cultural, psycho logic, economic, political, and
educational. Each of these factors has relative importance as a cause of malnutrition at a given time and
place for a given individual. If these variables are adverse only temporarily, the malnutrition may be
acute and alleviated rapidly, leaving no long-standing effects or harm to life. But if they are continuously
adverse and unrelieved, malnutrition becomes chronic. Irreparable harm to life follows and if he
situation is prolonged and severe, death eventually occurs.

Levels of deficiency disease

On a biologic basis, nutritional deficiency disease may be classified at two levels, primary or secondary
according to the availability of the nutrients involved.
1. Primary deficiency diseases: disease that results directly from dietary lack of a specific essential
nutrient. For example , scurvy results if the diet is deficient in vitamin C, beriberi results if the diet is
deficient in thiamin.
2. Secondary deficiency disease: disease that results from the inability of the body to use a specific
nutrient properly: (1) failure to absorb the nutrient from the alimentary tract into the blood or (2)
failure to metabolize the nutrient normally after it has been absorbed.
Causes of malnutrition:
1. Poverty: on a global level , poverty is the main cause of malnutrition
2. Powerlessness: many of the world's underfed people are those without control over what is grown,
where it is grown and by whom and for whom it is grown. In many nations enough food is grown to
support the indigenous population but most of it is exported in an attempt to sustain the country's
cash economy.
3. Population:
4. Politics: those holding political power determine the economic, agricultural, and food distribution
The ecology of malnutrition
Ecology is the relations between the organisms and the environments. Many ecology factors work
together to produce malnutrition. For example, a common infectious disease of childhood such as
measles, which otherwise be mild, may cause death in a severely malnourished child. Infectious diarrhea
is a common complication of kwashiorkor and may be the irreversible factor that causes death. This
terminal diarrhea of kwashiorkor or marasmus is largely due to literally starved intestinal epithelium.
Some of the many related causes of malnutrition can be classified under the three factors:
1. Agent: the fundamental agent of a malnutrition disease is a lack of food. Because of this lack, certain
nutrients in food that are essential to maintaining cell activity are missing.
2. Host: the host is the person infants, child, or adult- who suffers from malnutrition. Various
characteristics in the host may influence the disease: presence of other disease, increased need as in
growth, pregnancies, or heavy labor, congenital defects or prematurity and personal factors such as
emotional problems.
3. Environment: many environmental factors influence malnutrition. These include sanitation, culture,
social problems, economic and political structure and agriculture.
Malnutrition Syndrome:
Kwashiorkor: protein deficiency
A deficiency of protein causes kwashiorkor. It develops in a child who is being weaned from the breast at
about 1 year of age because of the birth of the next baby. The weaning food consists largely of starchy
gruels or sugar water, its protein content is qualitatively and quatitatively inadequate.


General symptoms:

Retarded growth and development with mental apathy.

Muscular wasting
Depigmentation of hair and skin.
There are characteristic scaly changes in skin texture , a " flaky paint" dermatosis

Abnormal metabolism
1. Fluid and electrolyte: disturbances in water and electrolyte metabolism.
2. Protein metabolism: an extreme protein depletion reaches different degrees in different organs
and tissues
3. Fat metabolism: abnormality of blood lipid transport contributes to the extremely low levels of
vitamin A
4. Vitamins and minerals: blood levels of vitamins, especially vitamin A are low.
It results from protein deficiency. There is insufficient quantity and quality to meet the demands of
growth and cell repair.
Kwashiorkor is usually seen in children in the post weaning years , ages 1 to 4. It occurs in tropical and
subtropical areas , usually in regions where economic, social, and cultural factors combine to make
sufficient protein unavailable to the child. It continues to be a public health problem in 19 of the 21
countries of the America, Africa, middle and far east.
Immediate therapy and follow-up care : during the first 24 hours of therapy , correction of water and
potassium depletion takes priority, especially diarrhea. Such correction may prevent sudden death from
heart failure.
1. Education concerning improved available sources of dietary protein such as skimmed milk
poder, legumes, and fish meal.
2. Motivation to provide adequate food and means for procuring it.
Marasmus (protein-calorie malnutrition)
General symptoms: marasmus is characterized by gross underweight. Its victims appear almost
cadaverous, having a "living skeleton", skin-bones appearance. There is atrophy of both muscle mass
and subcutaneous fat, giving a shrunken, wizened, "old man" appearance to the face, which is in
contrast to the fat, rounded chicks of children with kwashiorkor. Diarrhea is common. The infant sleeps
restlessly and is fretful, apathetic, and withdrawn. Body temperature is subnormal. Heart is weak and
urine is scanty, prostration is common. Growth rate declines progressively, both physical stunting and
mental and emotional impairment are present.


It is caused by chronic undernutrition , both of kilocalories and protein. Gradual deterioration of body
function and atrophy of tissue result.
Marasmus is most common in infants 6 to 18 months of age. It occurs in slum conditions in any country
where socioeconomic deprivation breeds such disease.
Treatment and control
Same as in kwashiorkor.
Nutritional anemia
Iron-deficiency anemia:
General symptoms: weakness, pallor, extreme fatigue, headache, if the anemia becomes more severe ,
there may be increased shortness of breath and some degree of cardiac enlargement.
1. Nails: the fingernails of many patients become brittle and flat and develop longitudinal ridges.
2. Tongue and mouth: a papillary atrophy of the tongue is seen in about half of the patientsand
some have fissures at the corners of the mouth.
3. Gastrointestinal symptoms: gastritis, achlorhydria and gastric atrophy are common. Other
complaints include anorexia, flatulence, epigastric distress, the liver and spleen may be
4. Hand and feet: numbness and tingling of the hands and feet.
5. Laboratory findings: red-blood cells contain less than the normal amount of hemoglobin.
Etiology: because iron performs important physiologic functions in oxygen transport and cellular
respiration.. The total hemoglobin level is always below normal.
Infants and children: the body of a newborn infant contains about 500 mg of iron. When the normal
person has reached maturity, this amount has increased by about 2500 to 4500 mg. the infant is
vulnerable to iron deficiency because milk is a poor source of iron. The premature infant, especially one
born to a malnourished mother, is in even greater jeopardy. There is a lack of the normal quantity of
tissue stores present at a full-term birth.
Women in their reproductive years: during normal menses a women loses from 35 to 70 ml of blood
per menstruation period, representing a total loss of iron in hemoglobin of 15 mg to 25 mg .
Blood loss: acute hemorrhage is an evident emergency for which the patient usually receives immediate
blood replacement. Chronic blood loss, especially, occults gastrointestinal bleeding, may go uncounted
and drain the body reserves. Parasitic infections of the intestines may also cause a continuous blood
Poor absorption: diseases such as chronic diarrhea, infection, sprue, steatorhea or celiac disease hinder
absorption of iron.
Poor diet: a diet high in starch and deficient in animal protein and green vegetables is usually low in

Occurrence: iron-deficiency anemia is a world health problem of great magnitude. It occurs in all
Treatment and control: the enrichment of cereals by iron should be considered. Optimal diet and
supplementation of the diet with iron are important during periods of stress such as growth and
pregnancy. Treatment of iron-deficiency anemia consists of giving a ferrous salt, such as ferrous sulfate
or ferrous gluconate
Folic acid deficiency anemia: a deficiency of folic acid in human beings produces a macrocytic anemia
associated with megaloblastic arrest in red blood cell production. Production of white blood cells and
platelets is also hindered. Clinical manifestations include (1) the weakness and pallor usually associated
with anemia. (2) Degeneration of surface mucosal tissue, resulting in ulceration and secondary
infections, sore tongue, and gastrointestinal disturbances such as diarrhea and malabsorption.
Etiology: folic acid deficiency may be caused by (1) a primary dietary lack of the vitamin. (2) poor
intestinal absorption of the vitamin. (3) Increased metabolic demands such as during late pregnancy
and the rapid growth of early infancy and in concurrent ascorbic acid deficiency. The diets of person
with nutritional folic acid deficiency are particularly lacking in animal protein foods and green
vegetables. Chronic alcoholism also causes folate deficiency and megaloblastic anemia, because it
impairs both absorption of folate and cell metabolism of its coenzymes.
Occurrence: folic acid deficiency usually occurs in conjunction with general malnutrition.
Treatment and control: doses of 5 mg to 20 mg of folic acid may be given in cases of deficiency.
Vitamin B12- deficiency anemia:
Vitamin B 12 results in pernicious anemia. Clinical symptoms include anorexia, nausea, vomiting,
diarrhea, abdominal pain, and weight loss.
Etiology: the vitamin B12 deficiency of pernicious anemia is secondary to an inherent lack of intrinsic
factor in the gastric juice.
Occurrence: pernicious anemia occurs most often in middle-aged persons. Seldom is it seen in those less
than 30 years of age.
Treatment and control:
No means of preventing pernicious anemia is known. It may be treated effectively by injecting doses of
vitamin B12 to bypass the absorption defect.
Xeropthalmia: Vitamin A deficiency: a disease of the eye in which the cornea and conjunctiva become
General symptoms: early signs are drying, roughness and wrinkling of the conjunctiva, swelling and
redness of the eyelids. Pain and light sensitivity. Dry , lusterless patches may be seen on the conjunctiva
and triangular , whitish, foamy spots (Bitot's spots) occur. The cornea loses sensitivity and becomes
clouded and ulcers may form. If the disease is untreated , the cornea softens and perforation may
occur, resulting in total blindness.
Night blindness: inability to see in dim light may result from lack of vitamin A.


Endemic goiter
General symptoms: a deficiency of iodine causes goiter', in which the thyroid gland is greatly enlarged.
Etiology: simple goiter is the result of failure of the thyroid gland to receive sufficient iodine to maintain
the normal structure and function of producing the hormone thyroxine, which is 65 % iodine.
Occurrence: goiter may occur in persons of any age
Treatment and control: a sufficient supply of iodine in the diet prevents goiter. The most practical
means of ensuring adequate intake is the iodization of salt.
A deficiency of thiamin causes beriberi. Adult beriberi may be either a dry or wet form, according to the
presence or absent of edema. The symptoms usually result from involvement of the peripheral nerves
and related muscle function. First there may be tingling and numbness of the extremities, leg muscle
cramps and later involvement of muscles of the fore arms, thighs, and abdominal wall. Paralysis may
result. As the heart muscle becomes involved , cardiorespiratory symptoms follow quickly: palpitations,
tachycardia, dyspnea, cyanosis and circulatory collapse. Vomiting and constipation are usually present.
The edema in wet beriberi begins in the legs and progress upward.
Beriberi is caused by a deficiency of thiamin. Diets based principally on refined unenriched cereal grains
are deficient in thiamin and contribute to the development of the disease.
In children beriberi occurs mainly during the first of life. It is called infant beriberi. Both sexes are
affected. The disease is usually found among low-income groups or those ignorant of the need for an
adequate diet. It may occur in poverty stricken areas in conjunction with malnutrition.
Treatment and control
Prevention is based on improvement of economics and education, with the aim of supplying diets
adequate in thiamin.
General symptoms: a deficiency of riboflavin causes a general syndrome called ariboflavinosis.
Characteristics sebrrheic dermatitis is lacated in various skin folds of the body. Cheilosis lesions extend
from the corners of the mouth onto the facial skin.
Diets deficient in riboflavin causes these symptoms. Such diets are lacking in animal protein foods such
as milk , meat, or fish and leafy vegetables and legumes which are sources of riboflavin.
Riboflavin deficiency occurs in many underdeveloped areas.

Treatment and control

Adequate dietary supply of riboflavin is basic to prevention. Acute riboflavin deficiency is treated by the
oral administration of 10 to 20 mg of riboflavin daily.
A deficiency of niacin causes pellagra. It has been called " 3D's" of pellagra.
Diarrhea: gastrointestinal disturbance including diarrhea that is often severe, anorexia,
general indigestion, a swelling and redness of the tongue (stomatitis) and weight loss.
Dermatitis: skin lesions resembling burned areas that become infected if ruptured and are
much more painful on exposure to sunlight
Dementia: serious disorientation and confusion in extreme cases, preceded by general
neurologic changes such as mental apathy, depression, and anxiety.
Etiology: pellagra is caused by a deficiency of niacin and the amino acid tryptophan, a precursor of
niacin. The incidence of pellagra is high populations where staple food is corn because corn is deficient
in both niacin and tryptophan.
Treatment and control: pellagra is prevented by a diet adequate in tryptophan and niacin. Usually a
multivitamin preparation is also given , along with a balanced diet furnishing about 3000 kcal , adequate
amounts of good quality protein and foods rich in niacin.
Scurvy: a deficiency of vitamin C causes scurvy. Vitamin C performs many vital physiologic functions
related especially to connective tissue, collagen and integrity of capillary walls.
Skin: the skin becomes dry and rough and often has a dingy brown color, scaly raised areas, called
perifollicular hyperkeratotic papules, develop around the hair follicles in the skin. The follicular
hemorrghges develop around these hair follicles in the skin. Purpura ( hemorrhaging into the skin
producing the reddish purple discoloration of a bruise.
Muscles: deep hemorrhages in the muscle tissue produce brawny areas of induration , resulting from
hardening and thickening of the tissue. Phlebothrombosis (presence of clot in a vein) may follow.
Joints: scurvy may be manifested by hemarthrosis (hemorrhages in the joint cavaties, causing local
heat, painful swelling and immobility)
Gums: the gums are spongy , friable, and grossly swollen and bleed easily at the slightest touch. As
tissue hemorrhages continues, thromboses form in the blood vessels and infarcts occur, producing bluered discoloration. The teeth become loosened and may fall out. Infection is frequent.
Failure of wound healing: any trauma even small , produces an ulcerated area. New wounds fail to heal
or if they are apparently healed, they break open again under the slightest stress.
Anemia: hemorrhagic blood loss and faulty metabolic interrelationships of vitamin C with folic acid and
iron cause anemia.
Age variance: adult scurvy is characterized by general weakness , lassitude, irritability ad vague, dull,
aching pains in the muscles and joints of the lower extremities. There may be weight loss and dyspnea.

Etiology: scurvy results directly from a dietary lack of vitamin C. three groups of people most at risk: (1)
infants fed processed cow's milk.( 2) people living alone, preparing their own meals and subsisting on
little more than crereals, bread, and milk (3) individual eating unusual restricted diets, such as the
extreme macrobiotic regimen.
Occurrence: certain group of children may be at greater risk- for example , those in long-term care
settings or those fed the famill's strict macrobiotic diet. Among adults , scurvy occurs more frequently in
the aged because their diets are more likely to be insufficient.
Treatment and control: scurvy can be prevented by a well-balanced diet that includes some primary
sources of vitamin C such as citrus fruits or a wide variety of secondary sources in fruits and vegetables.
The disease responds quickly and dramatically to therapeutic doses of vitamin C of about 200 to 300 mg
or more daily, which will replenish the body's pool in as few days as 5 days. For example, all bleeding
ceases in 24 hours , gums heal in 3 or 4 days.
Rickets is caused mainly by a deficiency of vitamin C. it is directly related to impaired metabolism of
calcium and phosphorus and is manifested by defective bone growth and changes in the body
Etiology: in the full-term infants' rickets is most commonly produced by a deficiency of vitamin D. in
premature infants deficiencies of calcium and phosphorus contribute to the development of the disease,
because a large amount of the fetal skeleton is mineralized during the last trimester of pregnancy.
Occurrence: vitamin D deficiency rickets is observed most frequently in infants between the ages of 6
and 18 months.
Treatment and control: supplementation with vitamin D or a diet adequate in calcium and phosphorus
effectively controls rickets. Exposure to sunlight is also effective.
Osteomalacia and osteoporosis:
1. Osteomalacia: it is the adult form of rickets. It is caused by a deficiency of vitamin D, calcium or
phosphorus in the diet.
2. Osteoporosis: it is a metabolic disorder that usually occurs in persons older than 50 years,
especially women after menopause. It is believed to be caused by the age-related decline of
secretions of anabolic hormones by the ovaries and pituitary gland. Manifestations include
weakness, anorexia, hip and back pain, muscle tenderness and cramping, stooped posture,
decreased height because of shrinkage of the spine, and a tendency for the bones to fracture
Treatment and control: prevention of osteomalacia is based on adequate dietary provision of calcium ,
phosphorus, and vitamin D. osteoporosis is treated with a combined therapy of estrogen, vitamin D, ,
calcium, and exercise.


Methods of combating malnutrition:

Basic requirements to solve malnutrition problems
1. Medical care: a direct approach involving case findings, clinical diagnosis, and treatment is a primary
concern. All the resources of the medical team are needed for this aspect of the approach.
2. Health education: a balanced program must include nutritional rehabilitation, nutrition, and health
education and continuing personal support.
3. Responsibility: ultimately the success of any efforts must rest on a developed sense of responsibility
in the people involved. The responsibility of providing sound, relevant health care rests with
members of the health professions. The responsibility for helping provide a safe and adequate food
supply and exploring food enrichment laws, agricultural methods, marketing practices consolidation
of control programs, supporting reach, education and technical development rests with the persons
who form and administer the economic and political structure of the country.
4. Policy considerations: realistic approaches
Experienced workers in the field of international nutrition and involved nutrition scientists have
voiced some realistic policy considerations in the war on world hunger. No single program or
interventions by itself will eliminate hunger and malnutrition.
a. Food supply: for a country to have an adequate food supply there must be sufficient means for
those in need to obtain it, and there must be appropriate family distribution and use of these food
b. Infectious diseases: the means of preventing infectious disease, such as childhood immunization is
known and can help control killer diseases such as measles, whooping cough.
c. Food and agriculture: feasible, cost-effective and realistic measures of developing an agricultural
base for adequate food supply require attention to research, price policies, improved land
distribution and tenure, reduced social inequities, and alleviation of poverty.
d. Nutrition and health: improvement in nutrition and health requires basic attention to nutrition
education in the use of available foods
e. Social equity: political means within a community, state, or nation to achieve social equity include
exploration of possible and practical ways of ensuring adequate food for its entire people. This
involves such measures as access to agricultural land and services. , minimum wage laws and price
controls targeted to the poor , import and export policies, industrial development practices, food
subsidies and assistance programs, and income supplements.
Assessment of nutrition status
Diet is a vital determinant of health and nutritional status of people. The dietary habits of
individuals/families/communities/ vary according to socio-economic factors, regional customs and
traditions. Precise information on food consumption patterns of people through application of
appropriate methodology is often needed not only for assessing the nutritional status of people but also
for elucidating the relationship of nutrient intakes with deficiency as well as degenerative diseases.
Information on food consumption pattern is also essential for assessing the food needs of population
groups at national/regional level. No realistic policies on food production, procurement, and distribution
can be formulated without a thorough knowledge of food habits of the people.
Types of dietary surveys
Dietary enquiries are mainly of two types , one which concentrates on qualitative aspects of the foods
i.e. what kind of foods are eaten and the other which attempts to estimate the amount of food
consumed in quantitative terms i.e. how much of food is eaten.


1. Qualitative aspects: types of food people eat and frequency (habitual or occasional), their
opinion and attitudes towards food and the cultural significance they attach to special foods or
2. Quantitative enquiry: exact amount of foods consumed.
Methods of diet surveys

Food balance sheet method

Inventory method
Weighment method
Expenditure pattern method
Diet history
Oral questionnaire method
Chemical analysis method
Dietary score method
Recording method

Anthropometric assessment of nutritional status

Nutritional anthropometry is measurement of human body at various ages and levels of nutritional
Body weight
Body weight is the most widely used and the simplest anthropometric measurements for the evaluation
of nutritional status of young children. It indicates the body mass and is a composite of all body
constituents like water, minerals, fat, protein, bone etc.
Classification of nutritional status


Weight for age: various methods have been suggested to classify children into various nutritional
grades using the body weights. The most widely used classification is the Gomej classification in
which the children are classified as having first, second, or third degree malnutrition if their weight
for age is in the range of 75-90 %, 60-75 %, or less than 60 % of the reference median. All children
whose weight is 90 % and above are categorized as normal
Weight for height: the commonly used weight for age classification does not take into account any
variations in length. Length may differ widely among healthy children of the same age and weight is
related to length.
Assessment of duration of malnutrition: the index weight for height gives little information on
chronic malnutrition.
Wasting and stunting: Waterlow (1072) has recommended use of only weight for height and height
for age. In this classification children with low weight for height are considered as " wasted and
those with height deficit are considered as " stunted"
Classification by standard deviations: preschool children are classified according to standard
deviation classification as median-1 SD,median -1SD -2SD, median -2 SD to 3 SD, median -3 SD,
median + 1 SD, median + 1 to 2SD, median + 2 SD to -3SD and median + 3 SD
Mathematical indices based on weight and height: Many formulas have been proposed to describe
the way in which weight varies with height during growth. Rao and Singh (1970) found that Quetlet's
index - weight /height2 was independent of age in preschool children. Malnourished children have
lower values of weight/height 2

BMI in adults: after the cessation of linear growth around 21 years, weight for height indicates muscle
fat mass in the adult body. The ratio of weight (in kg)/ight2 (m) is referred to as Body Mass Index (BMI).
It provides reasonable indications of the nutritional status of adults. The BMI has good relation with
fatness. It may also be used as indicator of health risk. The following classification has been suggested by
James et al (1988) and Luizz et al (1992).
BMI class

presumptive diagnosis

< 16.0

chronic energy deficiency grade III severe.

16.0 -17.0

chronic energy deficiency grade II moderate.

17.0 18.5

chronic energy deficiency grade I mild.

18.5 -20.0

low weight normal




obese grade I

> 30.0

obese grade II

In other words BMI < 18.5 indicates malnutrition, while more than 25.0 is considered as an indicator of
Naturally occurring toxicants in foods
Toxicants or toxic substances in foods are generally those substances found in foods that produce
harmful effects on ingestion by humans or animals. Toxic substances present in foods can be natural or
due to accidental chemical contamination. Natural toxicants may be be inherently present in food or
arise due to abnormal environmental /improper storage conditions.
1. Toxic amino acids;
Certain leguminous plants contain toxic amino acids which are harmful to human and animal health.
These include beta-oxalyl amino alanine (BOAA) in Lathyrus sativus , neurotoxic cyanoalanine in vicia
sativa and mimosine in Leucana leucocephala.
Neurolathyrisim: the disease is associated with the consumption of the pulse Lathyrus sativus. The
affected persons have altered gait and show exaggerated knee and ankle jerks, ankle clonus. They
exhibit severe pain in the lumbar region and myospasm in calf muscle. The earlier symptoms of the
disease is spasmodic contraction in calf muscle. The symptoms at the time of onset include heaviness
and stiffness of the limbs, muscle cramps, tremors, and involuntary movement of upper extremity. The
unusual amino acid beta oxalyl amino-alanine (BOAA) is the causative agent. BOAA is a potent
neurotoxicant in a variety of animal species such as rat, mice, chicks, ducklings, pigeon, guinea pigs,
pups, monkeys, horses, sheep, and goat.
Toxic alkaloids
A number of weeds such as crotolaria senecio and Heliotropium grow along with cereals and millets in
the agricultural fields. The seeds of weeds contain toxic pyrrolizidine group of alkaloids. Outbreaks of
disease in human characterized by pain in the epigastrium and ascites due to consumption of weed
Potatoes that have been exposed to light, mechanical damage and sprouting may become green due to
rapid increase in the concentration of certain toxic steroidal glycoalkaloids such as solanine and
chacomine. These impart to the potatoes a bitter taste. Cases of human poisoning (even fatal) have

been reported. The symptoms of mild solanine poisoning are acute gastrointestinal upset with diarrhea,
vomiting, and severe abdominal pain. In more severe cases, neurological symptoms including
drowsiness, apathy, confusion, weakness, and vision disturbances, followed by unconsciousness, have
been observed. The vital signs include fever, rapid and weak pulse, low blood pressure and rapid
respiration. Symptoms appear within minutes to 2 days after ingestion of the toxic potatoes.
The toxic action of solanine has been attributed to inhibition of serum cholinesterase. These
alkaloids are not destroyed during the process of cooking, baking and frying.
Cyanogenic glycosides:
Cyanogenic glycosides occur in edible parts of plants used for human and animal consumption such as
cassava or tapioca and sorghum. Although over 25 cyanogenic glycosides are known to occur in 2000
plant species, important among them are linamarin and lotaustralin in cassava and lima beans
(Phaseolus lunatus), dhurin in sorghum, taxiphyllin in bamboo shoots and amygdalin in almonds.
Trypsin inhibitors:
Trypsin inhibitors are present in redgram, bengalgram, cowpea, double bean, fried bean, soybean ,
lathyrus sativus, potato, seeet potato, and sunflower. The trypsin inhibitors have been found to cause
growth retardation and hypertrophy of pancreas. The release of essential amino acids particularly
methionine is hampered by the presence of inhibitors. The trypsin inhibitors are heat labile and moist
treatment destroys them.
Some of the edible plant seeds belonging to leguminous and euphorbiaceae families contain globulin
type of protein component having the property of agglutinating red blood cells known as
phytohaemagglutinins. These heat labile agglutinins have been isolated from field bean (Dolichos
lablab) , white bean (Pisum spp.), double bean ( Phaseolus lunatus) and horse gram. The haemolytic
property is more in green seeds and diminishes as the seed matures. The agglutinins combine with the
cell lining of the intestinal wall and thus interfere with the absorption of essential nutrients.
Consumption of improperly processed beans have been reported to result in nausea, vomiting, and
diarrhea. The agglutinins at low levels lead to growth depression, reduction in food intake, and death.
Flatulence factors
Consumption of certain legumes such as bengalgram (Cicer auritinum), red gram (Cajanus cajan),
soybean ( Glycine max), lina bean, navy bean (Phaseolus vulgaris), black gram ( Phaseolus mungo), and
green gram ( Phaseolus aureus) in large quantities is associated with production of gases(flatulence)
which may lead to digestibility disorders. Much of the gas formed in the intestine is carbon dioxide.
Soaking the pulse overnight before cooking is known to decrease the flatulence producing factors.
Mycotoxins are secondary metabolites of certain fungi which are toxic to animals and humans.
Mycotoxins producing fungi are generally saprophytes and distributed widely in nature. They have been
broadly classified as field fungi and storage fungi. Claviceps which causes ergot contamination belong to
the category of field fungi and affects cereals like wheat and rye during the pre-harvest stages.
Contamination by fungi like fusarium generally occurs under field conditions and persists during early
storage. Species of Aspergillus and penicillium are typical storage fungi and infect agricultural
commodities due to improper storage.

Mycotoxicosis in humans
Ergotism due to consumption of bread made of ergot-infected rye grains , was common in Europe. The
disease with symptoms of gangrene of the extremities was popularly referred to as 'St. Anthony 's fire" ,
consumption of mouldy rice in Japan during the world war I had resulted in diseases like "cardiac beri
beri' and "yellow rice syndrome". "mouldy ragi poisoning"with symptoms of vomiting and diarrhoea has
resulted. Consumption of Rhizopus nigricans contaminated bajra was reported to cause a disease
termed polyuria, polydypsia. The main symptoms were thirst, anorexia, weakness, and fatigue.
In more recent times instances of human mycotoxicosis include outbreaks of aflatoxic hepatitis,
enteroergotism, and deoxynivalenol mycotoxicosis. An outbreak of aflatoxic hepatitis with symptoms of
jaundice, rapidly developing ascites and portal hypertension was reported due to consumption of
mouldy maize containing upto 15.6 ppm of aflatoxin.
Prevention and control of mycotoxicosis
Several preventive measures to minimize mycotoxin contamination in agricultural commodities has
been attempted. These approaches can be divided into three broad categories viz. plant breeding; good
agricultural practices during pre- and post-harvest period and detoxification. The problem of ergot
contamination of cereals and millets has been successfully minimized by cultivating varieties of rye,
wheat and pearl millet that are resistant to the disease. Good agricultural practices such as avoiding
water stress, minimizing insect infestation and reducing inoculums potential are effective in minimizing
aflatoxin contamination in groundnut and maize. Following good agricultural practices during the postharvest period can also minimize the problem of contamination by mycotoxins such as aflatoxins. These
include appropriate drying and storage to prevent entry of moisture and contamination during storage,
transport and marketing.
Risk assessment and risk management of food toxins
Risk assessment is the means of analyzing all available information on the safety of a particular
compound /food. For characterization, quantitation of risk in human populations, three types of
information have to be obtained. These are
1. Hazard evaluation: it is necessary to document all information on epidemiology and experimental
2. Dose response evaluation: the nature, severity, and risk of toxicity depend on dose. Dosage alone
determines toxicity is one of the basic principles of toxicology.
3. Human exposure evaluation: the risk of a particular toxin is only for the population group that
consumes it. For example, the risk of aflatoxins will mainly be to those who consume maize as staple
food. An even person who consumes groundnut is at risk.
4. Characterization of risk: the type of toxicity , neurotoxicity, or carcinogenicity caused by the
ingestion of the particular food containing the toxins has to be assessed.
Chemical contaminants in foods
The following chemical contaminants have been identified in foods.
1. Pesticide residues: any substance or mixture of substances introduced for preventing, destroying,
repelling, or mitigating any pest is called a pesticide. Pests can be insects, rodents, nematodes,
fungi, weeds or other forms of plant or animal life. Misuse or indiscriminate use of pesticides may
cause the following health hazards:


Enzyme imbalance.
Skin and allergic reactions.
Delayed neurotoxicity
Behavioral changes.
Effects on reproductive systems.
Respiratory failure.
Effects on immune systems.
Cataract formation.
Loss of memory.
Carcinogenic changes.
Polycyclic aromatic hydrocarbon ( PAHs) : burning of refuse, sewage sludges, forest fires, smoking,
coal combustion. Exposure to PAHs occurs principally by direct inhalation. They are mutagenic and
3. Polyhalogenated biphenyls: (PCBs): the most striking effects are hypersecretion in eyes,
pigmentation and acneform eruptions of the skin and disturbances of respiratory systems. Babies
born to affected mothers are less than normal size and initially showed skin pigmentation.
4. Polybrominated biphenyls ( PBBs): PBBs are the flame retardant chemicals.
5. Contaminants from plastics: normal plastics have 250 400 years of life.however, functional life is
much shorter. Plastics degrade in soil, landfills, and composting sites between 6 and 24 months.
Balanced diet:
Balanced diet is one which contains which contains different types of foods in such quantities and
proportions that the need for energy and protein, minerals, vitamins is not only met but a small
provision is made for extra nutrients to withstand short duration of leanness. Important factors that
need to be considered in the formulation of balanced diet are:

Food groups and nutrient contents.

Nutrient requirements of individuals.
Menu (meal) planning.
Socio-economic and cultural conditions of the people.

Food groups and nutrients

Food groups

Cereals and millets

Pulses, legumes, nuts, and oil seeds
Milk, egg, and flesh foods.
Vegetables and fruits

5. Fats and sugar

6. Condiments and spices

Major nutrients.
energy, iron, thiamin, niacin, folic acid.
protein, energy, calcium, iron, thiamin, niacin, folic acid.
Protein, calcium, vitamin A, riboflavin, vitamin B12.
calcium, iron, carotene, vitamin B- complex, ascorbic
energy, essential fatty acids,
flavoring agents for improving the palatability of food.

Nutrients requirements of individuals

Nutrient requirements vary according to age, sex, type of activity, body weight, and physiological status
(pregnancy, lactation) of individuals. Environmental temperature (climate) is also known to modify the
nutrient requirements.


The basic principles that should be kept in mind while formulating balanced diets are:
1. Include varieties of foods in the diet.
2. If cereals, millets, and pulses form the main stay of diet , protein requirement of individuals are
automatically met provided they are consumed in amounts sufficient to meet energy needs.
Hence, ensure inclusion of adequate quantities of mixed cereals and pulses in the diet. The ratio
of pulses to cereals should be 1:7 to 1 :8 in the diet.
3. Vegetable and fuits , being d sources of vitamin, minerals and fiber , their regular consumption
should be ensured.
4. Milk, besides containing good quality protein and certain vitamins, constitutes the only source
of vitamin B12 in vegetarian diets and hence its consumption is crucial for vegetarians .
5. Fats and oils besides containing essential fatty acids are calorie-dense foods hence their
judicious use helps in reducing the dietary bulk.
Menu planning
1. About one-third of day's nutrient requirement be ensured in each of the three main meals i.e.
breakfast, lunch, and dinner.
2. At each meal, inclusion of a variety of foods is desirable.
3. Preparations should not be very spicy.
4. Use of raw vegetables i.e. salad should be included in the meal.
5. Simple methods of cooking like boiling, roasting, baking, shallow frying should be preferred.
6. Socio-economic and cultural factors should be kept in mind.
7. The color, texture, and taste of the dishes should be such that they impart a sense of
pleasantness and satisfaction.
Balanced diets for different population groups
---------------------------------------------------------------------------------------------------------------------------------Food group
16-18 years
7-9 years
1-3 years
Boys girls
(g/day) (g/day)
Green leafy
Other vegetables
Roots and tubers
Sugar and jiggery
Fats and oils
Food processing and nutrition:
Food processing falls into two broad divisions, primary and secondary.
1. Primary processing: basic staple foods like rice, wheat, and pulses reach the market through
primary mechanical processing operations that convert the grain into an edible raw material.
2. Secondary processing: yields such popular products as bread and biscuits, jams, and squashes.

Post-harvest technology:

Losses in drying and storage: losses of about 10 % in cereals, pulses and oilseeds probably occur
even in the field during harvesting, handling, and threshing. Subsequent drying of the grain entails
further loss and storage results in both mechanical and nutrient loss.

Drying: kharif crops like paddy must be dried to a 13 % level for storage and rabi crops like wheat to 8-9
%.drying losses have been placed at 1-5 %.
Storage: a national figure of 2.5 % for loss of food grains by rodents and 2.25 %for loss by insects
appears to have now been accepted.
Deterioration on storage: heat and water are generated during respiration of living seeds held in
storage. Grains that are dry and held at low ambient temperature have a low respiration rate.
Biodeterioration during storage can occur through the agency of enzymes, either present naturally or
adventitious and is accelerated by heat and moisture. Amylases hydrolyse starch, proteases protein and
lipases fats while lipoxygenases oxidize unsaturated fats and fatty acids, eventually generating sharptasting aldehydes and ketones. Starch fermenting enzymes, present naturally or generated by moulds
and fungi, can yields alcohols and acetic acid of unpleasant taste and flavor.
The second risk in grain storage comes from the growth of moulds and fungi, which occur when the
moisture level is high. The grain becomes discolored and musty in odor, while certain moulds when they
grow elaborate mycotoxins which are highly toxic both to animals and human.
A third hazard of grain storage is infestation with weevils, beetles and borers. Insects cause physical
damage to the grain, and carry fungal infestation and microflora into it. They generate uric acid, fecal
matter body debris. Mites have a foul odor and carry allergens and pathogens
Nutritional consequences of food grain storage:
1. Physical losses: consumption of grains by rodents is a straight loss, and often a large one. Insect
infestation physically damages the grain and reduces the milling outturn, by as much as even 20 % in
2. Protein: actual farm storage for 9 months caused a 16 % loss of protein in bajra, jowar, and green
gram. The concomitant increase of 5 % in nitrogen content was attributed both to the presence of
insects excreta and to protein degradation. Insects preferentially consume the richest parts of the
grain such as the germ. The protein efficiency ratio of insect infested wheat dropped by 20-30 % in
just four weeks of storage and this was also the order of individual loss of lysine. , methionine, and
3. Vitamins: actual farm storage of several cereals and pulses for 5 months and 9 months led to the
following losses respectively.
Thiamin 13-25 %, and 21-38 %
Riboflavin 7-11 % and 14-23 %
Niacin 7-14 % and 20-24 %.
4. Cooking quality: storage of legumes leads to a "hard-to cook" phenomenon. Cooking times for black
gram, chick peas and pigeon peas increased by 30-50 % after 9 months of farm storage. Water
uptake when fully cooked was lowered, the yield of cooked product from a given weight of starting
material was less and digestibility was reduced. Changes in the seed coat on storage or in the nature
of the starch may be responsible. Alterations in the nature of the starch have been held responsible
for the firm cooking of aged rice.


Food fortification
Fortification refers to the process of addition of a nutrient to a food to improve its quality or as a means
of delivering the nutrient to a population to correct the existing nutritional deficiency among them.
Principles of fortification
Nutrients may be added to foods to:
1. Restore nutrients loss during processing of foods so that the nutrient content is restored to the
level originally present in the raw food.
2. Addition of nutrient to a staple to improve the nutritional quality of the food with a view to
ensuring an improvement in the nutrient intake of the population. This is referred to as
enrichment. Example lysine supplemented wheat flour , thiamin and other B-vitamins enriched
polished rice.
3. Nutrient added to a food to improve the quality of the diet of a group.
Food fortification program me
1. Iodization of salt
2. Vitamin A fortification.
3. Iron fortification program
Nutrition intervention programs
Nutrition interventions is aimed at provisions of food or nutrients directly to people who are at risk of
developing malnutrition.
The programs are:

Food supply and supplementary feeding programs.

School meal program or mid day meal program (MDM)
Food distribution through work programs
The public distribution systems (PDS): it is the major food subsidy /income transfer program.
Intervention against vitamin A and mineral deficiencies.
Iron and folic acid distribution program.
Integrated child development services (ICDS) program.

The specific objectives:

1. To improve the nutritional and health status of children in the age group of 0-6 years and
2. Lay the foundation for proper psychological, physical and social development of the child.
3. Reduce the incidence of mortality, morbidity, malnutrition, and school drop-out.
4. achieve effective coordination of policy and implementation amongst the various departments
to promote child development.
5. Enhance the capability of the mother to look after the health and nutritional needs of the child
through proper nutrition and health education.
Components of service activities of ICDS

The packages of services include periodic health check-ups, treatments of minor ailments and
monitoring and evaluation.
Monitoring: the process of keeping a careful watch on specific events.
Evaluation: evaluation is the process of reaching a judgment on the basis of well-defined criteria about
the success
Functional significance of nutrition
1. Energy metabolism and physical work performance: human beings require enough energy to
lead an active and healthy life. Energy fulfills the following functions:
a. Maintenance of basal body functions
b. Physical activity.
c. Growth and development in infants and children.
d. Maintenance of pregnancy and lactation in women.
Of the total energy derived from the food , nearly 50 % is used for basal functions and the other 50 % for
physical activity. An adequate and constant amount of energy must be made available to the body for
cell survival and maintaining the vital functions of brain and nervous system and transmission of nerve
impulses, pumping the heart and distribution of blood to supply oxygen, liver functions, and excretory
function of the kidney. Work output may be affected by low energy , and the nutritional status of the
individual. When energy intake is low there is a possible behavioural adaptation to adjust work output
to match te energy intake.
2. Malnutrition and psychosocial development: severe protein energy malnutrition might result in
long-lasting impairment in psychological development
3. Malnutrition and immune response: the response of a host to an infectious agent depends upon
several factors. Neutrophils impart innate immunity to the body and constitute the first line of
defense, by virtue of their phagocytic and bactericidal properties. These two functions of the
neutrophils are impaired in children with severe protein energy malnutrition. Hydrogen
peroxide , which is one of the important intracellular bactericidal systems of the phagocyte is
produced in less quantities due to decrease in the activity of the enzyme NADPH oxidase.
Humoral immune systems: the B cell number is unaltered in children with severe malnutrition. Total
immunoglobulin of various classes is normal or slightly elevated in malnourished children.
4. Nutrition in pregnancy and lactation:
Energy: calorie requirement during pregnancy is increased for maintaining the growth of the foetus,
placenta, and maternal tissues and for increased metabolic rate. The calorie needs are not evenly
distributed throughout pregnancy. In early pregnancy, it is minimal but rises sharply towards the end of
the first trimester and then remains more or less constant for the second and third trimesters. In the
first and second trimesters, the extra energy needs are directed towards the maternal tissues i.e.
expansion of blood volume, growth of tissues like breasts and uterus and laying down of storage fat. The
increased requirements in the third trimester are mainly for the growth of the fetus and placenta
besides some increase in maternal tissues as well.
The energy requirements during lactation is computed from the energy cost of lactation and would take
into account volume of milk secreted, its energy content and the efficiency of conversion of food
energy into milk energy.
Protein: the additional protein requirement during pregnancy is mainly due to secretion of protein by
the fetus which is around 1000 g for the entire pregnancy. WHO suggested an extra protein intake of
about 16 g per day. During the first six months of lactation, 12 g per day during the second six months

and 11 g per day thereafter. ICMR recommendation is 25 g day for first 6 months and 18 g per day from
6 -12 months.
Calcium: the additional calcium required during pregnancy is mainly that needed for the growth of the
fetus. The total pregnancy requirement is about 30 g of which the term fetus accrues 27.5 g, the
placenta 1 g and the maternal fluids and tissues about 1 g. since most of the fetal growth occurs in
third trimester.
Vitamin A: vitamin A requirement for a pregnant woman is not markedly different from that of a nonpregnant woman (600 micro gram /day ). During lactation, additional allowance has been suggested to
be about 350 micro gram of vitamin A.
Iron: additional iron requirement during pregnancy is computed from iron needs for foetal growth (250
mg) expansion of maternal tissue including the red cell mamm during pregnancy (400 mg), the iron
content of placental and the blood loss during parturition (250 mg) there is , however, saving (150 mg)
due to cessation of menstruation amenorrhoea. Based on these consideration during pregnancy
additional iron requirement for pregnancy is estimated to be 30 mg daily. No additional requirement has
been suggested during lactation since the saving due to amenorrhoea is belived to take care of the
secreted in milk.
Vitamin C: the recommended intake of ascorbic acid for an adult is 40 mg. during lactation the
requirement of vitamin C is doubled to compensate for the amounts secreted n milk.
B-complex vitamins: thiamin, riboflavin, niacin, pyridoxine: since, the requirements of B-complex
vitamins like thiamin, riboflavin, and niacin are related to calories, the additional amounts
recommended during pregnancy ad lactation are based on the additional calories. Thus the additional
amounts (mg) recommended during pregnancy are thiamin 0.2, riboflavin 0.2 mg and 2 niacin
equivalents. The corresponding values during the first six months of lactation are 0.3, 0.3 and 4 mg
respectively and during 6-12 months of lactation 0.2, 0.2 and 3 mg respectively.
Folate: during pregnancy there is considerable increase in the demand for folates which are required for
DNA synthesis in the rapidly growing tissues. Actually there is an increased absorption of folate during
pregnancy due to depleted maternal stores. The recommended daily intake of for adults is 100
microgram and for pregnant women 400 microgram. To reach this level, the consumption of green
vegetables should be encouraged and additional folate supplements given especially in the last 12-16
weeks of pregnancy.
During lactation the strain on maternal folate reserves is around 20 microgram per day. RDA for folacin
during lactation has been suggested as 500 microgram .
Vitamin B12 : the recommended intake of vitamin B12 for adults is 2 microgram per day . in pregnancy ,
additional amounts are required for haemopoiesis and liver storage for subsequent secretion in milk.
During the latter half of pregnancy , the requirements of vitamin B12 increase to 3.0 microgram per day
to provide the foetal storage of 50-100 microgram.
Weight gain during pregnancy:
A healthy woman gains on an average about 11-12 kg during pregnancy. The usual pattern of weight
gain consists of a minimal gain of 1-2 kg during the first trimester and a more or less , linear rate of 0.4
kg/week in the second and third trimester.low weight gain in pregnancy is associated with a higher
incidence of prematurity and low-birth weight, excess weight gain is associated with complications like

pregnancy induced hypertension- termed as toxaemia or preeclampsia, leading to perinatal deaths due
to prematurity. It would appear that best reproductive performance is associated with a weight gain of
about 9 kg in the second half of pregnancy.
Effects of maternal malnutrition in the foetus
1. Congenital malformation in the foetus: dietary deficiencies, single or multiple, are known to produce
congenital malformations.
2. Birth weight: the birth weight of infants is influenced by many factors such as maternal age, parity,
height, altitude, ethinic origin and socio-economic status. Low birth weight is an important cause of
high infant mortality rate.
3. Infant mortality: perinatal and infant mortality rates reflect the health of a society and its healthcare services. The major component of infant mortality i.e. perinatal (28 weeks of gestation to 7
days postnatal) and neonatal ( 7 days -1 month after birth) mortality, are directly related to the
health and nutritional status of the mother during pregnancy. Due to the high incidence of low birth
weight and prematurity in poor communities, perinatal and neonatal death rates are also higher and
contribute to almost 60 % of the infant deaths.
4. Nutrient stores in foetal liver: many of the nutrients are adequately stored in intrauterine life to
meet the immediate postnatal needs of the infant.
5. Development of brain and mental function: the peak period of human brain growth is in the last few
weeks of intrauterine and first six months of extra-uterine life. After this the brain growth slows
Intervention strategies during pregnancy and lactation:
Maternal under nutrition is a major factor in intrauterine growth retardation (IUGR). Simplest solution of
reducing the incidence of IUGR would be supplementing the mothers with extra calories to increase the
birth weight and thereby reduce the incidence of low birth and its unfortunate consequences.
The risk factors such as maternal weight below 40 kg , weight gain < 6 kg during pregnancy, hemoglobin
< 9 gms, maternal ages < 18 or above 35 years and also earlier history of still births and bad obstetric
history may be taken into consideration in identifying women at risk of giving birth to low birth weight
infants. The correction of anemia with proper distribution of iron/folic acid tablets would also reduce
the incidence of low birth weight due to anemia especially due to folic acid deficiency. Training of village
health workers and traditional birth attendants with respect to immunization against infectious
diseases, hygiene, and environmental sanitation, safe delivery and care of the new born may go a long
way in reducing maternal and child mortality and morbidity. The strengthening of existing traditional
birth attendants training with more emphasis on nutritional, health, and preventive strategies should be
the main thrust.
Nutrition for growth and development: Infancy, Childhood, and Adolescent
Nutritional requirements:
Energy: during childhood the demand for kilocalories is relatively great. However, there is much
variation in need with age and condition. For example, the total daily calorie intake of a 5-year old child
is spent in the following way: (1) about 50 % supplies basal metabolic requirements; (2) 5 % is involved
in the specific dynamic effect of food ingestion; (3) various physical activities require about 25 %; (4) 12
% is needed for tissue growth; (5) about 8 % is represented in fecal loss.
Protein: for the first 6 months of life an infant requires 2.2 kg /kg of body weight. This amount gradually
decreases until adulthood, when protein needs are only 0.8 g/kg of body weight.

Water: the infant's relative need for water is greater than that of the adult. The body content of water is
from 70 to 75 % of the total body weight, whereas in the adult water constitutes only about 60 to 65 %
of the total body weight. Generally, an infant drinks daily an amount of water equivalent to 10 % to 15 %
of the body weight, whereas the adult's daily amount equals 2 to 4 5 of the body weight.
Minerals and vitamins: calcium is necessary for rapid bone mineralization that takes place during
growth. Another mineral of concern is iron. It is essential for hemoglobin formation. The infant's fetal
store is diminished in 4-6 months after birth. Thus, infant needs solid food additions at about 4 to 6
months of age to help supply iron. Such initial foods are enriched cereal and egg and later meat
accomplish this.
Hypervitaminosis: excess amounts of two vitamins, A and D, are of concern in feeding children. Excess
intake of these may occur when they are given for prolonged periods. Parents must be instructed to use
only the amount directed and no more. These excess bring clear toxic symptoms.
Vitamin A: symptoms of toxicity from excess vitamin A include anorexia, slow growth, drying and
cracking of the skin, enlargement of the liver and the spleen, swelling and pain of long bones and bone
Vitamin D: symptoms of toxicity from excess vitamin D include nausea, diarrhea, weight loss, polyuria,
nocturia and eventual calcification of soft tissues including those of renal tubules, blood vessels,
bronchi, stomach, and heart.
Foods and feeding practices:
Infancy: birth to 1 year
The premature infant: premature infants vary in weight and development but are usually considered
premature if they are born at fewer than 270 days of gestation or weight less than 2500 g ( 5.5 lb).
Food and feeding: throughout the neonatal period and for many weeks afterward good nutrition is
crucial for optimal growth and development. Special consideration has to be given to the type of milk
and methods of feeding.
Method of feeding: Breast feeding is the ideal method of feeding during the first year of life. A diet of
breast milk alone is sufficient for the newborn and adequate for the infant's first 6 months of life.
However, attention needs to be given to several possible supplements:
1. Vitamin K: for the neonate parental administration of vitamin K is needed for two reasons: (1)
the content of vitamin K in human milk low compared with infant formula. (2) infants consume
relatively small amounts of human milk during the first few days of life.
2. Vitamin D: for infants with limited exposure to sunlight, supplementation with 400 IU vitamin D
per day is needed.
3. Iron: iron supplements for the breast-fed infant are controversial. Usually there is sufficient
fetal iron storage to meet needs during the first 4 to 6 months of life. In some cases, however,
7 mg of iron daily is recommended during the first 6 months.
Feeding technique:
1. Bottle feeding
2. Infants formulas
3. Commercial formulas


Note: infant should not be fed milk of reduced fat content during the first year of life.
There is no nutritional need to introduce solid foods to infants before 4 to 6 months of age. Two to
three cups of milk a day is sufficient for the child's needs: excess milk intake can lead to milk anemia
because excess milk intake, a habit carried over from infancy, may exclude some solids foods from the
diet. As a result, the child may be lacking iron and develop milk anemia.
Nutritional needs:
Toddlers: (ages 1 to 3 years): have lower energy needs because of a slower growth rate; although the
portion of kilocalories from protein should rise ensure muscular development. At the same time calcium
and phosphorus requirements rise to meet the need for bone growth that must accompany increased
muscular strength.
Preschoolers (ages 3 to 6 years): exhibit erratic growth rates and activity levels. Protein requirements
continue to be relatively high. They need about 24 g of good quality protein through milk, egg, meat
and fish. They continue to need calcium and iron for storage. Since vitamins A and C may be lacking in
diets of preschool and growing children, a variety of fruits and vegetables should be provided.
School age children (ages 6 to 12 years): the slowed rate of growth during this period results in a
gradual decline in the food requirement per unit of body weight.
Adolescent (12 to 18 years). calorie needs increase with the metabolic demands of growth and energy
expenditure. Individual needs vary, girl consume fewer kilocalories than boys from 1800 to 2500 kcal a
day ; boys need 2500 to 3500 kcal a day. They need 45 to 59 g of protein daily. Calcium and iron are
particularly needed. The B vitamins are needed in increased amounts.
Nutrition and stress management
Physiologic response to stress: the general adaptive syndrome: when any form of stress occurs, the body
automatically responds to defend itself from harm. Selye called this common physiologic response to
stress the general adaptive syndrome.
Stage I: the initial alarm reaction to stress
Brain signals: in response to a perceived threat, the brain instantly initiates a signaling ripple effect
throughout the body metabolism. It triggers the release of chemical messengers , neurotransmitters (
chemical substances that relay messages through the central nervous system), in the brain cortex,
which then relay impulses along neuron tracks in the brain's outer edge to the hypothalamus. It governs
the autonomic functions of the body, such as heart rate, blood pressure, peripheral temperature,
breathing, digestion, blood glucose level, hormonal balance and many other vital activities. The
hypothalamus has been called the "automatic pilot" or the "brain's brain". Upon instant receipt of the
brain's stress message, the hypothalamus triggers two responses: (1) it stimulates the release of the
neurohormone norepinephrine from the cells of the autonomic or sympathetic nervous system to act as
a chemical messenger: (2) with continuing stress it sends out another chemical messenger , corticoreleasing factor (CRF), to the pituitary gland, stimulating it to release its adrenocorticotropic hormone
Track 1: autonomic nervous system-adrenal medulla-catecholamines
At the brain's initial alarm, the controlling hypothalamus flashes electrochemical impulses down the
brain stem and spinal cord along autonomic nervous system, stimulating release of the neurohormone
norepinephrine from the cells of the sympathetic nervous system. In the fraction of seconds these
neurotransmitters reach their target adrenal glands. the adrenal glands lie on the top of the kidneys.

They have two different parts, an inner cor called the medulla and an outer layer of cells called the
cortex, which act as two separate glands, producing very different neurohormonal agents. In this instant
of stress , the penetrating chemical messengers trigger inner cells of the adrenal medulla to release a
Pair of powerful chemical compounds , epinephrine, commonly called adrenaline and norepinapharine ,
which are members of a group of substances called catecholamines.
These catecholamines are powerful compounds that go into immediate action to protect the body. They
bring about a large number of widespread effects throughout the body tissues:
Peripheral blood vessels: contract to reduce the loss of body heat and force more blood through the
vital organs of liver, kidneys, brain and major muscles.
Blood pressure: a more blood flows into the heart, blood pressure rises to force more blood out to
circulate through the vessels of the major organs.
Heart rate: blood pressure does not continue to rise because the heart rate also rises. This rate increase
is stimulated by the stretching of the heart muscles walls, providing a natural pacemaker. This reaction is
important to prevent rupture of the heart or its vessels from the increased volume of blood suddenly
flowing through the cardiovascular system.
Glycogenesis: in the liver, catecholamines initiate the conversion of stored glycogen to glucose to
provide an immediate source of fuel. This quick resource is especially important for cells of the nervous
system and brain that use only glucose as a metabolic fuel.
Digestion: epinephrine interrupts digestion , a process often of secondary urgency compared to the
need to focus on the perceived danger. Peristalsis is also inhibited and the anal sphincter is relaxed.
Urinary tract: epinephrine causes the bladder to contract and the urinary sphincter to relax , often
causing "accidents" of passing urine.
Bronchi: the catecholamines dilate the bronchi to facilitate a maximal exchange of oxygen and
Eyes: epinephrine also causes the pupils of the eyes to dilate. Evidently this adaptation to stress enables
the individuals to adjust better to dim light, which may have been an evolutionary advantage.
Spleen: the spleen contracts and adds its blood cells to the increased blood volume. This addition
increases blood pressure, adds hemoglobin for enhanced oxygen transport and adds white cells that
fight pathogens.
Blood coagulation: the coagulation process is regulated so that it prevents excess loss of blood in an
wounded area but prevents coagulation in the peripheral parts of the body, thus guarding against the
formation of blood clots, which could then be carried to the heart.
Muscle tone: the catecholamines increase the tone of voluntary muscles. This is evident in the tremor of
the hands after a frightening experience.
Tract 2: hypothalamus CRF-pituary ACTH-adrenal cortex
The hypothalamus also defends the body against stress via the pituitary gland or the hypophysis. This
pea-sized gland hanging in a central space at the base of the brain has been called the "master gland"
because it produces hormones that regulate other glands and many body functions. It is also a dual
gland, with two separate parts or lobes arising from different embryonic tissues, each having distinct

functions. The larger anterior lobe, the adenohypophysis, secrete stimulating hormones that control
other body glands. The smaller posterior gland, together with its stalk, is continuous with the
hypothalamus and is called neurohypophysis. Here in the additional tract that instantly relays the initial
brain stress signals, the corticotrophin releasing factor (CRF) of the hypothalamus flashes its warning to
the larger anterior lobe of the pituitary, triggering the immediate release of one of its major control
agents, adrenocorticotropic hormone (ACTH) . ACTH act selectively on the adrenal glands cortex or outer
layer , stimulating the immediate release of its powerful hormones, the corticoids.
Two groups of adrenocortical hormones , the corticoids , are named according to their functions: (1)
glucocorticoids including cortisol and hydroxycortisone and (2) mineralocorticoids.
Glucocorticoids: they mobilize fatty acids triglycerides for emergency fuel. They also mobilize free amino
acids from protein which can thus serve not only for fuel but also as an important source of nitrogen for
new protein synthesis. they also trigger glycogenolysis and gluconeogenesis, which help maintain liver
and muscle glycogen as a readily available fuel source. The glucocorticoids along with epinephrine ,
suppress the action of insulin. Insulin is the body's key anabolic hormone , promoting storage of
metabolic fuels inside cells. Suppressing this action of insulin to remove glucose from circulation sustains
an elevated blood glucose level, thus keeping metabolic fuel mobilized.
Mineralocorticoids: also called aldosterone , causes the resorption of sodium by the nephrone tubules
and with it water, thus helping to protect the body,s vital water and electrolyte balance.
Some nutritional factors play lead roles in this overall process.
1. Energy: stress may increase the body's basal caloric need as much as 200 %. The stress hormones
act to increase body heat production and when the heat is released it is not available to the body as
chemical energy for cell metabolism.
2. Protein: stress may increase the body's protein need from 60 % to as much as 500 %. The integrity of
body tissues involved in the body's immune system such as the skin and mucosal tissue depends on
the adequate protein.
3. Fat: dietary fatty acids, notably linoleic and arachidonic acids , influence prostaglandin synthesis by
macrophages. In turn these can stimulate and suppress other cellular and humoral immune
functions as needed.
4. Vitamins: requirements are increased.
5. Minerals: requirements are increased. Deficiency of zinc impairs T cell proliferation and
responsiveness. Iron deficiency affects humoral immunity.
Diet, Nutrition and Degenerative diseases
1. Diet and coronary heart disease: atherosclerosis is defined as arterial lesions characterized by
patchy thickening of intima, the thickening being due to the accumulation of fat and layers of
collagen like fibers. It leads to serious life threatening clinical situations such as unstable angina,
myocardial infarction, or arrthmias, or rupture of aneurysm, stroke, etc. these abnormalities can
start at a young age of 10-15 years and progress as age advances.
Risk factors for coronary artery disease and related disorder
Non modifiable: heredity, sex, age, personality.
1. Behavioural: smoking, sedentary habits, stress, alcoholism, diet
Diet: Increased: energy, fats, saturated fatty acids, cholesterol, animal proteins, alcohol, salt, sugar.
Decreased: fiber, antioxidants, trace metals, and minerals.

2. Physiological, metabolic
Increased: hypertension, obesity, high serum lipids, diabetes, fibrinogen, platelet aggregation,
Decreased: antioxidants, trace metals, and minerals, HDL-cholesterol
Food guide for a healthy heart





wheat, rice, kodo, bajra

Maize and jowar

food prepared with refined

cakes, pastries
wheat flour like bread and biscuits nann roti, fast


whole and sprouted



green leafy vegetables,

Roots, tubers.

fried vegetables
Potato and
Banana chips
Canned vegetables.

Dairy products

low fat milk, and its curd. Whole milk.

Cheese, butter, khoa

Cream, condensed milk.


egg white


more than one type

egg yolk, oily dishes,

Butter, ghee, coconut
oil, hydrogenated oils
deep fried foods.

Of vegetables oil but limit

Total intake.
Total fat intake

Sugar and sugar products

oily dishes, butter,

Ghee, coconut oil,
Deep fried foods.

sugar in any homemade

sweets, chocolate

Nuts and oil seeds

all nuts and oil seeds.

ice-cream, purchased
Sweets ( Mithai),
Chocolate, sweets


coffee, soft drinks.



fresh fruit juice

Light tea.

Salt in preparations

pickles, papads, sauces,

salted biscuits, fried


Diet and diabetes mellitus

1. Insulin-dependent diabetes mellitus (IDDM): it accounts for only 2-5 % of all cases of diabetes and
usually develop during childhood or adolescence.
2. Non-insulin dependent diabetes mellitus ( NIDDM): this is the most common type of diabetes and
nearly 90-95 % of all patients with diabetes belong to this category. This types occurs usually after
40 years of age and affects over-weight or obese persons.
3. Malnutrition-related diabetes mellitus (MRDM):

Increased thirst ( polydipsia)

Increased urination (polyuria)
Increased hunger ( polyphagia)
Weight loss ( IDDM) or obesity ( NIDDM)

Clinical laboratory test data reveal the following:

1. Glycosuria (sugar in the urine)
2. Hyperglycemia (elevated blood sugar)
3. Abnormal glucose tolerance tests
Other possible symptoms occur as the uncontrolled condition becomes more serious:
1. Blurred vision.
2. Skin irritation or infection.
3. Weakness, loss of strength.
Continued metabolic consequences may occur as the uncontrolled condition becomes more serious:
1. Fluid and electrolyte imbalance.
2. Acidosis (ketoacidosis)
3. Coma
Normal blood sugar controls
Control of the blood sugar within its normal range of 70 to 120 mg /DL ( 3.9 to 6.7 mmol/L) is vital to life.
The cells can starve and die for want of enough of their major energy fuel. With too much, as in
uncontrolled diabetes, the body's life sustaning water electrolyte and acid-base balances no longer
Role of insulin
1. It facilitates the transport of glucose through the cell membrane by way of specialized insulin
receptors. These receptors are located on the membrane of various insulin-sensitive cells. A
chemical linkage is formed between the insulin and another chemical compound on the target cells,
causing an alterations of the cell membrane ad allowing the insulin coupled with the receptor and
allowing the insulin coupled with receptor to enter the cell.
2. It enhances the conversion of glucose or glycogen and its storage in the liver (Glycogenesis)


It enhances the conversion of glucose to fat (lipgenesis)

It inhibits fat breakdown (lipolysis) and the breakdown of protein .
It promotes the uptake of amino acids and increase protein synthesis.
It influences glucose oxidation through the main glycolytic pathway by aiding the necessary initial
phosphorylation reaction catalyzed by the enzyme glucokinase.

General management of diabete

1. Diagnosis:
Glucose tolerance: a 75 g dose of glucose is given and followed by two blood glucose tests: fasting and a
2-hour plasma glucose. A 2- hour plasma glucose value of 200 mg /dL (11.0 mmol/L) or above indicates
diabetes and 140 mg/dL (7.8 mmol/L) is the upper limit of normal. Those values falling between 140 and
200 mg/dL (7.8 and 11.0 mmol/L) are labeled impaired glucose tolerance.
Glycosylated hemoglobin AIc: glycohemoglobin are relatively stable molecules within the red blood cells.
During the life of the cell, about 120 days, glucose molecules attach themselves to the hemoglobin. This
seemingly irreversible glycosylation of hemoglobin depends on the concentration of blood glucose. The
higher the level of circulating glucose over the life of the red blood cells, the higher the concentration of
glycohemoglobin. Thus this measurement of Hb AIc relates to the level of blood glucose over a period of
2. Treatment objectives: the health team has three basic objectives in the care of of the persons with
a. To maintain optimal nutrition
b. To avoid symptoms
c. To prevent complications such as retinopathy, neuropathy, nephropathy, and vascular disease.
Diet, nutrition and cancer
Carcinogenic process: cancer, in simple terms, is an uncontrolled growth of cells.
Naturally occurring carcinogens and contaminants
Plant constituents and their metabolites such as pyrrolizidine alkaloids in Senecio, Crotalaria, and
Heliotropium in amounts ranging from traces to as much as 5 % of dry weight are known carcinogens.
Plants containing pyrrolizidine alkaloids may contaminate forages and food grains. Alycyclic and
propenylic benzene derivatives present in essential oils of a wide variety of plants induce tumours and
are mutagenic. A significantly higher risk of oesophageal cancer is associated with a hot gruel of bracken
fern in Japan. Plant oestrogens , methylxanthines, cycasin, tannins, coumarins, and hydrazines are
putative carcinogens. Grilling, and broiling of foods result in the formation of heterocyclic aromatic
amines and polycyclic aromatic hydrocarbons are carcinogenic in animals.
Coffee and tea
Certain substances present in coffee and tea ( methyl xanthenes) are capable of either directly initiating
or enhancing mutagenic effects. A positive association between coffee drinking and higher risk of
pancreatic cancer has been consistently observed. Steaming of beverages in general has been related to
oesophageal cancers. Chinese tea has been shown to protect against nitrosation. The active factor in tea
is suspected to be polyphenols which can act as scavengers of nitrite. Therefore wheather tea is
causative or protective depends on the type of tea consumed and method of preparation. Recent
evidence indicates that a specific type of salted tea consumed in Kashmir can lead to the formation of Nnitrosamine related compounds.

Alcoholic beverages are a risk factor for cancer at many sites. Smoking appears to have a synergistic
effect with alcohol. Malnutrition due to alcohol further complicates the issue by precipitating
micronutrient deficiencies. Excess bear drinking has been associated with increased risk of colorectal
cancers. Alcohol acts synergistically with smoking to increase the risk for respiratory tract cancer. It can
produce hepatic injury and cirrhosis and lead to formation of hepatomas. There is moderate and
positive association between alcohol consumption and breast cancer. Nitrosamine in alcoholic
beverages have been implicated as putative carcinogens. Other putative carcinogens are polycyclic
aromatic hydrocarbon (PAH). Alcohol per se can act as a carcinogen, co-carcinogen or promoter and
facilitate transport of other carcinogens , induce enzymes, which bioactivate carcinogens and produce
nutrient deficiencies and immunosuppression which may enhance carcinogenesis.
Among the various dietary or food contaminants , aflatoxins have received considerable attention and
have been linked with liver cancers. The major plant foods which are contaminated are groundnuts,
corn, coconut, and pepper which are stored under improper conditions of temperature and humidity.
Nitrite, nitrate, and nitrosamines
Nitrates are non-toxic, they can be reduced to nitrites under certain circumstances both in the food and
in the body. Nitrite is also directly to foods particularly in the curing of meat and fish. Nitrite is
intrinsically toxic but it is as precursor of N-nitroso compounds that more serious problems are
encountered. Cooking practices like smoking, grilling, and frying seem to increase the N-nitroso
compounds (NOC). Oral microflora can reduce the nitrate to nitrite , which can then combine nonenzymatically with the amine present in the diet to yield to the potentially hazardous nitrosamines.
Microbes can play a role in the formation of nitrosatable compounds through fermentation or
decarboxylation of amino acids.
Food additives:
The use of permitted food additives such as colors, flavors, and preservatives except nitrates contribute
significantly to the overall risk of cancer in humans.
Non-nutrient inhibitors of carcinogenesis
Benzyl isothiocyanate, cafesteral palmitate, kahweol palmitate, limonine dialytrisulfide, coumarine,
isoflavones, quercetin, pectins, gums, cellulose, piperine apigenin, ellagic acid, indole-3 carbinol,
curcumin in turmeric, protease inhibitors, beta- sitosterol, caretenoids. Rich sources of these
compounds are fruits, vegetables, whole grains, cereals, legumes.
Other anti-carcinogenic substances
Several chemical compounds which are natural components of vegetables, fruits, legumes, and nuts,
and cereal grains are known to protect against cancers. These minor dietary components act as
modulators of carcinogenic process. Among vegetables, brassica family and allium species (onion and
garlic) are known to be more protective. They can prevent formation of highly electrophilic substances
from precursors or detoxify these substances and prevent their interaction with the target molecules
such as DNA or act as nucleophiles and scavenge potentially toxic substances. some of them act as

Dietary guidelines for cancer prevention

1. To maintain appropriate body weight for height.
2. Wholegrain cereals/pulses should be used as source of energy.
3. Fat intake to be between 20-25 % of total calories.
4. Fresh vegetables / fruits to be used in plenty after through washing.
5. Intake of processed and preserved foods to be in moderation.
6. Fried, burnt, smoked, fermented, salted, and pickled foods to be limited.
7. Fungal and contaminated foods to be avoided.
8. Beverages to be used in moderation.
9. A variety of foods to be used routinely.
Dietary management of renal disorder
Chronic renal failure
Chronic renal failure (CRF) is a progressive disorder with several factors influencing the rate of
progression of the disease. Age, sex, genetic profile, underlying renal pathology, immune status of the
host is some of the factors that determine the progress of the disease.
Dietary management:
1. Low protein diets (LPD) proving 0.55 -0.6 protein /kg/day
2. Diet providing 16-20 g/day mixed quality protein supplemented with 14-20 g of nineL-essential
amino acids
3. Diets containing 16-20 g/day of mixed quality protein supplemented with four essential amino acids
( histidine, lysine, threonine, and tryptophan).
Energy requirement:
35 kcal/kg/day
4. Other nutritional factors:
Lipids: low protein diet with elevated polyunsaturated fatty acids/saturated fatty acids ratio is able to
counteract lipid abnormalities in CRF.
Carbohydrate: diets high in carbohydrates accelerate the development of age related glomerular
sclerosis. Complex rather than purified sugars reduce triglycerides synthesis and improve glucose
Phosphorus: high phosphorus diet has deleterious effect on the progress of renal insufficiency.
Calcium: have an increased dietary requirement of calcium.
Magnesium: diets low in magnesium is preferred.
Sodium and water: as renal insufficiency progresses both the glomerular filtration and fractional
reabsorprion of sodium fall and therefore , patients with CRFare able to maintain sodium balance with a
normal sodium intake.
Potassium: kidney is the major vehicle for potassium excretion and therefore in CRF potassium retention
may occur causing fatal hyperkalaemia. Patients with CRF should receive no more than 70 mEq of
potassium /day.
Fiber: fiber helps to prevent constipation, irritable bowl, diverticulitis, and neoplasia of colon. At least
20-25 g of fiber should be taken /day. Fiber also reduces blood urea nitrogen (BUN) by increasing fecal
ammonia excretion.


Course breakdown:

Nutrition and human health, human health needs, major Nepalese health problems.
Nutritional guide for health promotion: cancer and heart disease.
Foods and its classification.
Relation of food and nutrition to health : nutrition and aging; nutrition and mental function;
weight control; nutrition cancer; heart disease; and diabetes mellitus.
Bioactive phytochemicals in foods and their mechanism to promote health.
Carbohydrates : classification; dietary fiber and its role; physiologic effects of dietary fiber;
dietary fiber recommendation; special function of carbohydrates in body tissues.
Lipids: classification, functions; requirements; and food sources ; cholesterol and its role to
promote human health; cholesterol and health concern.
Proteins: essential amino acids ; functions of proteins; proteins requirements; factors affecting
protein requirements; protein turn over; functions of dietary protein; measure of protein
requirements; deficiency symptoms of proteins.
Minerals: major and minor minerals; functions of minerals in human body; deficiency symptoms
of minerals; mineral requirements ; food sources of minerals.
Water ; electrolyte; and mineral balance.
Energy metabolism and physical work performance; factors influencing basal metabolism;
energy requirements for various physiological functions.
Nutritional deficiency disorders; protein-energy malnutrition; causes of malnutrition; methods
to solve malnutrition; governments strategy to solve malnutrition.
Food toxicities: naturally occuring toxicants in food; chemical contaminants in foods.
Food processing: effect of food processing on nutritional status.
Diet, nutrition and degenerative disease; coronary heart disease; diabetes mellitus; cancer;
gastrointestinal problems; renal disorder; urolithiasis; food factor and cataract.


Mahatab. S. Bamji; Pralhad Rao, and Reddy , Vinodini 1996 : Text Book of Human Nutritio :
Oxford and IBH Publishing CO. PVT . LTD, NewDelhi.
2. Sue Rod Well Wiliams 1989. Nutrition and Diet Therapy. Times Mirror/ Mobby College
Publishing , ST. Lous, Toronto