Chapter 5
Nutritional Requirements
By:_ Dr.kedir.N
February ; 2020
1

What Is Body Composition?
• The ratio of fat tissue to lean body mass (muscle,
bone, and organs)
–Usually expressed as percent body fat
–Important for measuring health risks associated
with too much body fat
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PHN lecture notes

Most Body Fat Is Stored in Adipose Tissue
• Two types of fat make up total body fat
– Essential fat
• Found in bone marrow, heart, lungs, liver, spleen,
kidneys, intestines, muscles, and central nervous system
• Women have 4 times more essential fat than men
– Stored fat
• Found in adipose tissue
• Subcutaneous fat – located under the skin
• Visceral fat – stored around the organs in the abdominal
area
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Fat distribution in the body
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PHN lecture notes

Most Body Fat Is Stored in Adipose Tissue
 In negative energy balance, fatty acids are
released from adipose cells
◦ Used as fuel and cells shrink
 In positive energy balance, fat accumulates and
adipose cells expand
 Brown adipose tissue (BAT) is another type of
fat tissue made up of specialized fat cells
◦ Contain more mitochondria and rich in blood
◦ Function is to generate heat
◦ Found primarily in infants
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Body Fat Distribution Affects Health
 Storing excess fat around the waist versus the hips and
thighs increases risk of heart disease, diabetes, and
hypertension
 Central obesity (android obesity) ====apple shaped
obesity - from storing too much visceral fat in the
abdomen
 Gynoid obesity =Pear shaped obesity-from excess fat
around the thighs and buttocks
 Visceral fat releases fatty acids which travel to the liver
causing insulin resistance, increased LDL, decreased
HDL, and increased cholesterol
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9
Nutritional requirements
• An adequate supply of nutrients is needed to
– Maintain all the functions of the body and
– Daily activities at maximum efficiency, thus
ensuring healthy living.
• Health and nutrition are closely linked and to
ensure proper development and life quality
they must be adequate from early childhood on
and most vulnerable groups are
– Infants, young children,
– Pregnant women and lactating mothers.

• Good nutrition must meet the needs of varying
ages and activities and always with individual
differences.
• Therefore, the planning of food to meet
especial needs begins with:
– Pregnant women
– Nursing mothers
– Infants
– Adolescents and
– Adults
10

The energy requirements of individuals
depend on
♦ Physical activities
♦ Body size and composition
♦ Occupation status
♦ Age may affect requirements in two main ways
– the infant needs more energy because it is growing
– During old age, the energy need is less because
aged people are engaged with activities that requires
less energy.
♦ Climate: Both very cold and very hot climate restrict
outdoor activities.
11

• Predictive equation for energy (calorie) needs
• Harris Benedict uses
– Age,
– Height, and
– Weight to estimate Resting energy expenditure (REE), the
minimum amount of energy needed by the body at rest in
fasting state
• The REE is increased in patent suffering from burns,
fever, infections, fractures, trauma e.t.c
• Lowered in malnutrition
12
Estimation of Nutrient Needs

Harris Benedict equation
• In men:
– REE (kcal/day) = 66.5 + (13.8 X W) + (5.0 X H) –
(6.8 X A)
• In women:
– REE (kcal/day) = 55.1 + (9.6 X W) + (1.8 X H) –
(4.7 X A)
• Where W = weight in kilograms, H = height in
centimeters and A = age in years.
13

• REE is multiplied by
–An activity factor and
– Injury factor
• To predict total daily energy expenditure
–Confined to bed = 1.0-1.2
–Out of bed = 1.3
–Very light = 1.3
–Light = 1.5 -1.6
–Moderate = 1.6 -1.7
–Heavy = 1.9 -2.1
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Harris Benedict questions

Injury Categories
• Surgery
• Minor = 1.0-1.1
• Major = 1.1-1.2
• Infection
• Mild = 1.0-1.2
• Moderate = 1.2-1.4
• Severe = 1.4-1.8
• Trauma
• Burn factors
15

• For pregnant woman, the daily figure must be
increased by 150 calories for the first trimester
and 350 for the second and third trimester.
• For the nursing mother the daily figure must be
increased by 800 calorie.
18
Daily calorie requirements

• An unborn child needs a healthy and well-
nourished mother to grow properly.
• Therefore, a mother needs to gain weight
during pregnancy to help nourish her growing
baby.
• Women who do not gain enough weight often
have babies that weigh too little (low birth
weight).
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Nutrition during pregnancy and lactation

• Women’s nutrition during pregnancy and
lactation should focus on
–Vitamin A,
–Iron and
– Iodine
– Extra energy intake/reduction of energy expenditure
• Therefore the following are essential nutrition
actions related to maternal nutrition:
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During pregnancy and lactation

• In addition:
– Iodized salt in her diet
– At least one liter of water per day
– Vitamin A rich foods
– During lactation Increased requirements: vitamins A,
C, E, all B vitamins, and sodium
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Nutrition during lactation

Nutrition of infants and children.
• The common feature of infancy, childhood and
adolescence is that all these age groups are
undergoing rapid growth and development.
• This in turn poses a heavy demand on their
nutritional requirements.
• Small children and infants do not have a well
developed body nutrient store, and are more
vulnerable to infection.
– At risk of nutrient deficiency
22

Infant and young child feeding
 Optimal feeding of infants and young
children means exclusive breastfeeding from
birth to 6months
 followed by introduction of complementary
foods at 6 months of age and breastfeeding
should be sustained well into or beyond the 2nd
yr of life, with increasing amounts of
complementary foods.

Advantages of breast feeding
Infant benefits
• It’s best natural food for the babies. It contains
sufficient amount and the right mixture of fats,
sugars, proteins, minerals, and most vitamins
for growing baby.
• It’s easy to digest and nutrients are well
absorbed.

cont’
• Prevention of acute illnesses.
Breast milk contains immunoglobulin's IgA
and IgG, interluekin-10, polysaturated fatty
acids, and epidermal growth factor that helps
to enhance mucosal immunity. It also contains
WBCs ,which is 90% neutrophils and
macrophages, involved in antimicrobial
activities.

Cont’d
As a result, the incidence of gastroenteritis,
lower respiratory and ear infections is lower in
breast-fed infants.
 Stimulates GI growth and motility which
enhance maturity of GI tract.
 It’s always clean and available 24 hrs of a day.

Cont’d
• Enhance maternal-infant bonding which has a
positive impact on psychosocial behavior.
• Decreased risk of specific chronic disease
like, obesity, cancer, coronary heart disease,
inflammatory bowel disease, type 1 DM, and
allergies.
• It promotes normal growth and development.

Cont’d
Maternal benefits
• It reduces the risk of post-partum hemorrhage
by stimulating oxytocin secretion.
• It provides an efficient contraceptive method
during the 1st 6 months if breast feeding is
exclusive and frequent.
• It prevents breast engorgement and its
consequences

Cont’d
Economic benefits
• It doesn’t cost anything to the family.
• The cost from medical visits, medications,
procedures and hospitalizations will be
reduced.

Recommended breast feeding practices for
infants and young children
Optimal breast feeding practices from 0-
6months, which includes;
1. Initiating breast feeding within 1hr of birth.
The first milk (colostrum) is of particular
nutritional and health value to the infant b/c
of its high content of proteins and fat-soluble
vitamins and its anti- infective properties.

Cont’d
2. Establish good breastfeeding skills, proper positioning,
attachment and effective feeding
Proper attachment signs are;
 Infants mouth is open wide
 The lower lip is turned outward against the breast
 The chin touches the mother’s breast
 The nose is close to the breast
 The entire nipple and the good portion of the areola
are in infants mouth
 More areola is shown above than below
 Full cheeks

Figure showing; side by side positioning after cs delivery

Figure showing proper attachment

Cont’d
3. Exclusive breastfeeding for the first 6 months.
4. Frequent and on-demand breastfeeding,
including night feeds (as often as infant wants).
Feeding every 2-3hrs (8-12 times per 24hrs).
5. Offer second breast after infant empties the first,
so that the infant gets both ‘fore-milk’ (which
has high water content to quench the thirst) and
hind-milk (which is rich in fat and nutrients).

Cont’d
6. Mother continues breastfeeding more often
when the infant is ill.
7. A mother who will be away from her infant
for an extended period expresses her breast
milk and the caregiver feeds from a cup.

Cont’d
Recommended complementary feeding
practices;
1. introducing complementary feeding at 6
mon of age.
2. Continuing frequent and on-demand breast
feeding until 24months.
3. Increasing food quantity and frequency as the
child grows.

Cont’d
4. Gradually increasing food consistency and
variety as the child gets older.
5. Diversifying the diet to improve quality and
nutrient intake.
6. Practicing active feeding.
7. Frequent and active feeding during and after
illness.
8. Practicing good personal hygiene and proper
handling of foods

Cont’d
• The best complementary foods for children are
foods that are ;
– high in energy (calories) and protein
– good in variety
– easy to digest
– pure and clean
– easy and inexpensive to prepare

Cont’d
Additional measures and advice
• Give iron supplements daily (12.5mg/daily)to
infants 6mon-1yr of age, if daily vitamin-
mineral supplements or iron fortified foods are
not being given.
For LBW infants, start supplementation at
3mon.

Cont’d
• Give every 6 months, high-dose vitamin A
supplements after 6 months as follows;
Age vitamin A
 6-12months 100,000iu
 >12months 200,000iu

• Energy requirements decline thereafter and are
based on
– Weight, Height, And Physical Activity.
• Total water requirements (from beverages and
foods) are also higher in infants and children
than for adults.
• Increased requirements of energy, protein,
essential fatty acids, calcium and
phosphorus.
41
Nutrition of infants and children.

Specific nutrient requirements in old age
• An elderly person requires less energy than a
younger individual due to reductions in
muscle mass and physical activity
• They need fewer calories than younger people,
but about the same amount of protein and other
nutrients.
– But need micronutrients like zinc, iron, vitamins,
iodine
– Calcium and antioxidant vitamins
42

• In order to reduce the risk for age related
bone loss and fracture, the requirement
for vitamin D is increased
• Vitamin B9 and B 12 prevent chronic
illness risk
• Increase Vitamin A, C, E need
43
Specific nutrient requirements in old age

Infant Feeding in the context of
maternal HIV infection

The Problem: Breastfeeding Poses a Substantial Risk for MTCT
• While breast milk contains all of the elements needed
for perfect infant nutrition, it also can transmit HIV
infection
– When an HIV positive mother breastfeeds, her baby is
exposed to HIV
– HIV transmission risk continues the entire time an HIV
positive mother breastfeeds her child
• BF transmission may account for >35% of MTCT of
HIV
• Women with advanced disease are at highest risk for
transmitting HIV to their babies during BF

Breastfeeding can account for
35- 40% of all HIV transmission depending on
duration
• 1
Early Antenatal
(<36 wks)
Late
Antenatal
(36 wks to
labor)
Labor &
Delivery
Late
Postpartum
Early
Postpartum
Substantial Proportion of
infections occur during BF
1-6 mos
6-24 mos
Breastfeeding
35-40%
0-1
Pregnancy

Infant feeding and HIV: WHO 2001
recommendation
• “When replacement feeding is Acceptable,
Feasible, Affordable, Sustainable and Safe,
(AFASS) avoidance of all breastfeeding by HIV-
infected mothers is recommended.
• Otherwise, exclusive breastfeeding is
recommended during the first months of life.
• To minimize HIV transmission risk, breastfeeding
should be discontinued as soon as feasible,
taking into account local circumstances, the
individual woman’s situation and the risks of
replacement feeding (including infections other
than HIV and malnutrition).”

What are the risk factors for postnatal
transmission of HIV?
• Longer exposure to breast milk
– Transmission of HIV can occur at any point during
lactation.
– Transmission rates increase with duration of breast-feeding.
• Advanced maternal HIV disease
– High viral loads in blood or breast milk
– Low CD4 lymphocyte counts
• Mother with recently acquired infection
• Maternal Breast problems
– Mastitis
– Cracked nipples
• Mixed feeding

Can avoidance of breastfeeding decrease the risk of MTCT?
Complete avoidance of breast-feeding is the only
way to completely avoid MTCT through
breast milk.
Exclusive replacement feeding eliminates
transmission from breast-feeding
- Commercial infant formula
- Home-prepared formula with added nutrients
BUT……

Cont’d
However replacement feeding is
associated with a high risk of serious
diarrheal infections and malnutrition
– Formula is often unsafe having been diluted,
improperly mixed, given inconsistently or
prepared with unclean water
– Babies miss out on the general health benefits of
breast milk

Approaches that have been evaluated and/or
considered to decrease the risk of MTCT
associated with breastfeeding
o Complete avoidance of breastfeeding
• Shorten duration of breastfeeding
 Exclusive breastfeeding
• Antiretroviral therapy for the mother
and/or infant
• Improve breastfeeding practices
• Preventing acquisition of maternal HIV
infection

NUTRITIONAL DEFICIENCY DISEASES
• On global scale the five principal nutritional
deficiency diseases are:
1. Kwashiorkor
2. Marasmus
3. Xerophthalmia
4. Nutritional anemia
5. Endemic goiter
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Malnutrition
Malnutrition; is impaired nutritional status
• There are two types of malnutrition;
1. Under nutrition; due to inadequate intake of nutrients in
terms of the quantity and quality.
It takes two forms; PEM
Micronutrient deficiencies
2. Over nutrition (Obesity); due to excess intake of
nutrients

Cont’d
Epidemiology
 Under nutrition is most prevalent in
developing countries.
 In Ethiopia, 51%, 47%, and 11% of under 5
children are stunted, underweight and wasted
respectively.
 It accounts for 58%of under-5 mortality.
 The peak age for malnutrition is 12-24mon

Cont’d
• 27% of under-5 children suffer from
subclinical vit A deficiency.
• Vit A deficiency 17% of under 5 deaths
• Anemia and iodine deficiencies are also
common cause of morbidity and mortality.

Cont’d
Causes of malnutrition;
Immediate causes
• poor dietary intake
• Increased nutrient loss
• Increased nutrient demand

Cont’d
Underlying causes;
• household food insecurity
• inadequate care of women and children
• insufficient health care and unhealthy
environment
Basic causes;
• Inadequacies in educational, political and
economic systems

Clinical assessment of the child with malnutrition
It includes;
• Assessing the severity of malnutrition
• Distinguishing b/n marasmus and kwashiorkor
• Identifying acute life-threatening
complications
• Assessing for micronutrient deficiencies

Protein Energy Malnutrition(PEM)
Definition;
• It is a clinical syndrome mainly due to
deficiency macronutrients (protein and
calories)
• It may be associated with other micronutrient
deficiencies.

PROTEIN-ENERGY MALNUTRITION
• Protein– energy malnutrition usually manifests early, in
children between 6 months and 2 years of age
– Early weaning,
– delayed introduction of complementary foods,
– a low-protein diet and severe or frequent infections.
Types of PEM based on duration:
1. Chronic Malnutrition
– stunting (height for age)
– Underweight & stunting (weight for age)
– obesity
2. Acute malnutrition
• wasting (MUAC or weight for height)
60

Types of acute malnutrition
1. Severe acute malnutrition (SAM)
 All children with oedema;
 Weight-for-height below 70% or WFH Z score below -3
 Severe wasting
 MUAC below 11 cm for children
• It has three clinical forms
– Marasmus
– kwashiorkor
– Marasmic- kwashiorkor
2.Moderate acute malnutrition (MAM)
 Weight-for-height between 70-79%
 Moderate wasting
 WFH Z score between -2 and -3
 No edema
61

Cont’d
• Acute malnutrition can be classified into severe acute
malnutrition and moderate malnutrition according to
the following;
From 6mon to
18yrs
Severe acute
malnutrition
Moderate acute
malnutrition
Weight/height 70% 70-80%
MUAC( <11cm 11-12cm
Edema yes no

You must formally test for oedema with finger
pressure
you cannot tell by just looking

Kwashiorkor
• Is one of the serious forms of PEM.
• It is due to inadequate protein intake in the presence of fair or
good calorie intake.
• It is seen most frequently in children one to three years of age.
• It is found in children who have a diet that is usually
insufficient in energy and protein.
• There is edema together with failure to thrive, anorexia,
diarrhea and a generalized unhappiness or apathy.
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Signs and symptoms
• Failure of growth
• Edema and the presence of some subcutaneous fat
make the weight loss less striking than in marasmus.
• Edema in face, limb and body
• The characteristic dermatitis called 'flacky -paint
dermatosis‘
• The hair is sparse, soft and thin with color change.
• Watery diarrhea, enlarged liver
• Apathy is a characteristic feature and the child appears
constantly unhappy.
•
65

• Rounded prominence of the cheeks or ‘moon face’.
• Dry, dull, straight, sparse, hypopigmented hair that is
easily pulled out or plucked.
• Dry, atrophic, peeling skin with confluent areas of
hyperkeratosis and hyper pigmentation (flaky paint
dermatosis)
• Normal or nearly normal wt for age
• Bilateral pitting edema that starts in the lower
extremities and later involves the upper limb and the
face.
• Hepatomegally , fatty liver infiltrates.
• Distended abdomen with dilated intestinal loops
66

Cont…
KWASHIORKOR
67

Cont’d
Kwashiorkor dermatosis

Marasmus
• It is due to both protein and calorie deficiency,
predominantly calorie.
• It is well adapted to the deficiency due to the
high cortisol and GH level and depression of
insulin and TH.

Marasmus
• More prevalent than kwashiorkor.
• In marasmus the main deficiency is one of
food in general, and therefore also of energy.
• It may occur at any age, most commonly up to
about three and a half years, but in contrast to
kwashiorkor it is more common during the
first year of life.
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Cont’d
Clinical features;
• Wasting of muscle mass and depletion of body
fat stores.
• Reduced wt and ht for age
• Emaciated and weak appearance
• (have the face of an old man)
• Bradycardia, hypotension and hypothermia

Clinical features cont’d
• Thin and dry skin
• Redundant skin folds caused by loss of
subcutaneous fat
• Thin, sparse hair that is easily plucked.
• The child will usually have good apetite.
 Wasting of Subcutaneous fat and muscles (flabby
muscles)
 old man face (wizened (wrinkled)monkey)
 sunken eye balls
 Irritable always and has mild skin and hair change

Muscle wasting in a child with marasmus

Marasmic-Kwashiorkor
• It is b/c of inadequate dietary intake of all
nutrients
• The transition from marasmus to mixed
marasmus-kwashiorkor is associated with high
morbidity and mortality

MARASMUS
3. Marasmic kwashiorkor
Children with features of both nutritional marasmus and
kwashiorkor are diagnosed as having marasmic
kwashiorkor.
75

Community based management of Acute
malnutrition (CMAM)
• Has four areas
1. Community Mobilization
2. Outpatient supplementary feeding protocols for
those with moderate acute malnutrition and no
serious medical complications;
3. Outpatient therapeutic protocols for those with
severe acute malnutrition and no serious medical
complications; and
4. Inpatient therapeutic protocols for those with acute
malnutrition also suffering from serious medical
complications. 76

Treatment Include:
• Diet. Treatment is often based on dried skimmed milk
(DSM) powder.
– Formula Milk: F75 and F100
– Ready to use therapeutic foods (RUTF)
• Treatment of hypothermia.
• Medication like antibiotics and deworming
• Micronutrients: Vitamin A, folic acid, iron,
• Follow up
77

Complications of SAM
Hypoglycemia
• Due to impaired gluconeogenesis
• Often asymptomatic
• Clinical signs; eye-lid retraction, hypothermia,
lethargy, limpness or convulsion

Cont’d
Hypothermia
• Rectal T below 35.5c or axillary T <35c
• Due to impaired heat production and loss of
subcutaneous fat.

Cont’d
Infections
• Due to;
 impaired cellular immunity
 reduced secretary IgA
 low complement level
 impaired phagocytic function
 impaired acute phase response

Cont’d
• Common infections ; pneumonia,
gastroenteritis, UTI, sepsis
• Signs of infection; subtle
leukocytosis and fever is uncommon
hypothermia, apathy, lethargy…

Complications cont’d
Dehydration
• The main diagnosis comes from HISTORY
rather than examination
There need to be;
Definite HISTORY of RECENT FLUID LOSS
There should be a HISTORY of recent
CHANGE in child ‘s eye appearance
The child must not have any edema

Cont’d
Diagnosis of shock with dehydration;
When there is definite dehydration from
history and on examination;
Weak or absent pulses
Cold extremities
Disturbed consciousness

Cont’d
Heart failure
• Causes; over hydration
severe anemia
signs and symptoms
Clinical deterioration with wt gain
Increase in respiratory rate (acute increase in
RR of more than 5BPM, particularly during
rehydration treatment)

Cont’d
Crepitation or rales in lungs
Tachycardia, gallop rhythm
Prominent superficial neck veins
Sudden increase in liver size
Tenderness on the liver
Increase of edema or reappearance of edema
during the treatment
A fall in Hgb (dilutional anemia)

Cont’d
Severe anemia
• Hgb <4mg/dl or Hct <12%
Electrolyte abnormalities
• Increased ICF Na
• Decreased body K and magnesium (Mg)

Read on
• Vitamin A deficiency
• Iodine deficiency disorder
• Iron deficiency anemia
• Vitamin D deficiency disorders
87

THANK