Nutrition Notes PDF for BHMS | Vitamins, Minerals, BMI & Deficiency Diseases

1. Nutrients

Nutrients are Organic & Inorganic complexes contained in food.

Divided into:

1. Macronutrients

• Often called Proximate Principles because they form the main bulk of food.
• Total daily energy intake in a balanced diet should be in the proportion of:

Nutrient	Percentage	Energy Yield
Proteins	10–15%	4.2 kcal/g or 17 kJ/g
Fats	15–30%	9 kcal/g or 37 kJ/g
Carbohydrates	50–70%	4.1 kcal/g or 17 kJ/g

 

2. Micronutrients

• Called micronutrients because they are required in small amounts.
• These are Vitamins & Minerals.

Minerals

• Sodium, Potassium, Magnesium, Calcium, Phosphorus

Trace Elements

• Iron, Iodine, Fluorine, Zinc, Copper, Cobalt, Selenium, Chromium, Manganese, Molybdenum, Nickel
• Tin, Silicon, Vanadium

Trace Contaminants (No function in the body)

• Lead, Mercury, Barium, Boron, Aluminum

 

Sources of Nutrients

Rich Sources of Nutrients

Food	Richest Source
Halibut liver oil	Vitamin A & Vitamin D
Cod liver oil	Rich in Vitamin D (but richest is Halibut liver oil)
Gingelly (Sesame) seeds	Vitamin B₁ (Thiamine)
Sheep liver	Vitamin B₂ (Riboflavin)
Indian Gooseberry (Amla)	Vitamin C
Ragi (Millet)	Calcium
Dried Pumpkin Seeds > Pistachio	Iron

 

Poor Sources of Nutrients

Food	Poor Source Of
Meat	Calcium
Fish	Carbohydrate & Iodine (except some sea fish)
Egg	Carbohydrate & Vitamin C
Milk	Vitamin C & Iron
Butter	Iron
Rice	Calcium, Iron, Vitamins A, C, D & Vitamin B₁ (Thiamine)

 

Important Points

• Rice protein is better than other cereals because rice is rich in lysine.
• 60 g of egg contains:
• 6 g Protein
• 6 g Fat
• 30 mg Calcium
• Dates are rich in Iron > Calcium.
• Tomatoes are rich in Citric Acid.
• Banana is a good source of:
• Vitamin A, Vitamin B₆, Potassium, Phosphorus, Fiber, Carbohydrates, Energy
• Fermentation of pulses increases:
• Vitamin B₁, Vitamin B₂, Vitamin B₃, Vitamin B₇, Vitamin B₁₂
  (Thiamine, Riboflavin, Niacin, Biotin & Cyanocobalamin)
• White polished rice causes deficiency of Vitamin B₁ (Thiamine).
• Regular drinking of Cranberry juice helps prevent Urinary Tract Infection (UTI).
• Vegans are those who neither eat dairy products nor eggs.
• The trace element that cannot be adequately supplemented by diet during pregnancy is Iron (Fe).
• Alcohol yields 7 kcal/g (approximately 7 kcal/ml as noted in the page).

 

 

2. Dietary Fiber

• Remnants of edible part of plants & carbohydrates that are RESISTANT TO DIGESTION & ABSORPTION in the small intestine.
• Non-starch polysaccharide

Types

1. Insoluble fibers
• Cellulose
• Hemicellulose
• Lignin
2. Soluble fibers
• Pectin
• Gum
• Mucilage

Sources

Animal food does NOT contain fibers.

• Miller's Bran (richest source)
• Ragi > Cluster beans > Maize > Jowar (Sorghum) > Bajra (Pearl Millet)
• Oats

Functions

• Adds to the bulk of food & favors satiety
• Laxative action
• Reduces blood cholesterol & blood glucose
  (Gum in fenugreek seeds reduces post-prandial glucose level in blood.)
• Reduces incidence of:
• Coronary artery disease
• Colonic polyps
• Breast cancer
• Stomach cancer
• Prostate cancer
• Colon cancer
• Used in management of:
• Irritable bowel syndrome (IBS)
• Recurrent diverticulitis

Requirement

• Daily intake of 40 g is desirable (Indian diet provides about 50–100 g fiber/day).
• Intake of >60 g/day may cause bowel irritation.

 

3. Vitamins

Vitamin	Name	Deficiency Causes	Important Points
Vitamin A	Retinol	Xerophthalmia	Richest in whole grains
Vitamin B₁	Thiamine	Beri-beri, Wernicke's encephalopathy, Korsakoff psychosis, Lactic acidosis	Groundnut is rich in Vitamin B₁; RDA: 1–1.5 mg/day
Vitamin B₂	Riboflavin	Ariboflavinosis, Angular cheilitis, Glossitis, Corneal vascularization	Also called Warburg Yellow Enzyme
Vitamin B₃	Niacin	Pellagra	—
Vitamin B₅	Pantothenic acid	Burning feet (Burning sole syndrome)	Antistress vitamin
Vitamin B₆	Pyridoxine	Anemia, Peripheral neuropathy	Toxicity causes sensory neuropathy; deficiency seen in Isoniazid therapy; daily requirement is directly proportional to protein intake
Vitamin B₇	Biotin	Dermatitis	Raw egg contains Avidin, causing biotin deficiency (heat inhibits avidin)
Vitamin B₉	Folic acid	Megaloblastic anemia, Neural tube defects	Present in vegetables, spinach, paneer etc. Pregnancy: 500 mcg/day, Lactation: 300 mcg/day, Adults: 200 mcg/day, Children >5 years: 150 mcg/day, Children <5 years: 100 mcg/day
Vitamin B₁₂	Cobalamin	Megaloblastic anemia (especially in strict vegetarians)	Richest source: Liver
Vitamin C	Ascorbic acid	Scurvy	In Sitopaladi: >5 mg/100 g (as printed)
Vitamin D	Ergocalciferol (D₂), Cholecalciferol (D₃)	Rickets (children), Osteomalacia (adults)	5 min/day sunlight (UV-B) is sufficient; Calcitriol is the most active physiological form; stops therapy after recovery in rickets
Vitamin E	Tocopherol	Hemolytic anemia in newborns	Rich sources: Sunflower oil, Wheat germ oil, Soybean oil
Vitamin K	Phylloquinone, Menaquinone, Menadione	Hemorrhagic disease of newborn	Daily requirement 0.03 mg/kg; prolonged antibiotic use causes Vitamin K deficiency

4. Vitamin A

• Vitamin A covers both a Preformed Vitamin (Retinol) and a Pro-vitamin (Beta (β)-Carotene).

Functions

• Production of retinal pigment needed for vision in dim light.
• Maintains integrity and functioning of the epithelial lining of:
• Intestines
• Respiratory tract
• Urinary tract
• Skin
• Eyes

 

Sources

Form	Source	Foods
Retinol	Animal foods	Halibut fish liver oil (richest source), Liver, Egg, Meat, Milk, Cheese, Butter
Beta-carotene	Plant foods	Green leafy vegetables (Spinach), Yellow fruits (Papaya, Mango, Pumpkin), Roots (Carrot)

 

Daily Intake Recommended

Form	Adults	Pregnancy
Retinol	600 mcg	800 mcg
Beta-carotene	4800 mcg	6400 mcg

• RDA in infants: 350 mcg
• 1–9 years: 390–630 mcg

Assessment of Vitamin A Deficiency

• Serum Retinol <10 mcg/dL

Important Point

• Dehydration contributes to significant loss of β-carotene.

 

4.1 Vitamin A Deficiency / Xerophthalmia (Dry Eye)

Xerophthalmia (Dry Eye) refers to all ocular manifestations of Vitamin A deficiency in humans.

Epidemiology

• Most common in children 1–3 years of age and often related to weaning.
• Often associated with PEM (Protein Energy Malnutrition) and Measles.
• Occurs in food donation programmes using skimmed milk, which is devoid of Vitamin A.
• Common in rice-eating states because rice lacks carotene:
• Andhra Pradesh
• Tamil Nadu
• Karnataka
• West Bengal
• Bihar

 

Ocular Manifestations

Earliest manifestation

• Loss of vision to green light.

1. Night Blindness

• Due to impairment of dark adaptation.
• First clinical symptom.

2. Conjunctival Xerosis

• Conjunctiva becomes dry and wrinkled.
• First clinical sign.
• Appears like sand at receding tide (characteristic appearance).

3. Bitot's Spots

• Triangular, pearly white/yellowish foamy spots on bulbar conjunctiva on either side of the cornea.

Indicates:

• Children: Vitamin A deficiency.
• Adults: Inactive sequelae of earlier disease.

4. Corneal Xerosis

• Cornea becomes dry and opaque.
• Severe deficiency may lead to corneal ulcers.

5. Keratomalacia

• Liquefaction of the cornea.
• Cornea becomes soft and may burst open.

 

Extra Ocular Manifestations

• Follicular hyperkeratosis (Toad skin / Phrynoderma)
• Anorexia
• Growth retardation

 

Prevalence (%) Criteria for Determining Xerophthalmia in a Community

Prevalence	Indicator
>0.017%	Corneal xerosis
>0.017%	Corneal ulceration
>0.017%	Keratomalacia
>0.05%	Corneal scar
>0.5%	Bitot's spots
>1%	Night blindness
>5%	Low serum retinol

Note: Prevalence is measured in the at-risk population, i.e., preschool children aged 6 months–6 years.

 

 

 

 

WHO Classification of Xerophthalmia

Primary Signs

Code	Condition
X1A	Conjunctival Xerosis
X1B	Bitot's Spots
X2	Corneal Xerosis
X3A	Corneal Ulceration
X3B	Keratomalacia

Secondary Signs

Code	Condition
XN	Night Blindness
XF	Xerophthalmic Fundus
XS	Xerophthalmic Scarring

 

Treatment

Oral doses of Vitamin A

3 oral doses of Vitamin A are given on:

• Day 1 – Immediately
• Day 2 – After 24 hours
• Day 14 – After 2 weeks

Dose

• >12 months: 2 lakh IU
• 6–12 months: 1 lakh IU
• (Children >12 months weighing <8 kg are also given 1 lakh IU.)
• 0–6 months: 50,000 IU

 

Intramuscular (I/M) Vitamin A

• Water-based formulation (½ of oral dose)
• Given in:
• Very sick child
• Severe anorexia
• Edema with malnutrition
• Septic shock, etc.

 

Important Points

• Therapeutic doses of Vitamin A in pregnancy are TERATOGENIC.
• Mass Drug Administration (MDA) is NOT done for treatment of Vitamin A deficiency.

 

Vitamin A Toxicity

Excess Retinol intake

• Causes skin desquamation (Exfoliative dermatitis).

Excess Carotene intake

• May color plasma and skin but is not dangerous.

Hypervitaminosis A

• Carotenoderma – Yellow/orange pigmentation of face, palms, soles, and feet.
• Spares mucous membranes.
• In chronic hypervitaminosis A, pathological bone fractures may occur.

Acute Vitamin A Toxicity

• Pseudotumor cerebri

 

Prevention & Control

• Adequate intake of Vitamin A-rich foods.
• Reduce contributory factors such as:
• Protein Energy Malnutrition (PEM)
• Measles

 

WHO Recommended Strategy for Prevention of Xerophthalmia

Short-term Action

Vitamin A Prophylaxis to Vulnerable Groups

• Lactating women: 25,000 IU/day or 20,000 IU/week
• Postnatal women: 3 lakh IU within 1 month after delivery
• Newborn: 50,000 IU
• <1 year: 1 lakh IU every 6 months
• >1 year: 2 lakh IU every 6 months

 

Medium-term Action

• Fortification of foods with Vitamin A (2,500 IU)
• Dalda
• Vanaspati ghee

 

Long-term Action

• Health education and environmental modification
• Immunization against measles
• Treatment of diarrheal infections
• Promote breastfeeding as long as possible
• Increase consumption of:
• Green leafy vegetables (Spinach)
• Yellow fruits (Papaya, Mango)

 

National Programme for Prevention of Night Blindness / National Vitamin A Prophylaxis Programme

• Administration of massive doses of Vitamin A up to 5 years of age.
• Total 9 doses of 17 lakh IU are given under the National Immunization Schedule (NIS).

Schedule

• 1st dose: 1 lakh IU with MR vaccination at 9 months
• Subsequent doses: 2 lakh IU every 6 months up to 5 years of age

Administration

• Given with a 2 mL spoon having a 1 mL marking.
• Vitamin A solution contains 1 lakh IU per mL.

 

 

 

4.2 National Program for Prevention of Nutritional Blindness

Started: 1970

Beneficiaries

• 1970: Children 1–5 years (Preschool children)
• 1992: Children 9 months–3 years
• 2006: Children up to 5 years

 

Program Focuses On

1. Promoting Consumption of Vitamin A-Rich Foods

• In pregnant & lactating women
• In children up to 5 years

2. Administration of Massive Doses of Vitamin A in Children up to 5 Years

• First dose: 1 lakh IU with MR vaccination at 9 months
• Subsequent doses: 2 lakh IU every 6 months up to 5 years of age
• Total 9 doses (17 lakh IU) are given under the National Immunization Schedule (NIS)
• Administered using a 2 mL spoon with a 1 mL mark (1 lakh IU/mL)

 

For Sick Children

Children with Xerophthalmia

• Should be treated at health facilities

Children with Measles

• Give 1 dose of Vitamin A
• (If Vitamin A was not received during the previous 1 month)

Children with Severe Malnutrition

• Give 1 additional dose of Vitamin A

 

5. Vitamin B₃ (Niacin) Deficiency / Pellagra

Characterized by the 4 Ds

1. Diarrhea
2. Dementia
3. Dermatitis
4. Death

 

Skin Manifestations

• Rash appears on sun-exposed areas, especially around the neck.
• Characteristic lesion is called Casal's Necklace.

 

Important Points

• Vitamin B₃ deficiency is common in people consuming maize/sorghum (jowar)-based diets.
• Excess leucine in sorghum (jowar) interferes with the conversion of tryptophan to niacin.
• 60 mg tryptophan → 1 mg niacin.
• Tryptophan is the limiting amino acid in maize.
• Vitamin B₃ (Niacin) is contraindicated in diabetics because it may cause hyperglycemia.

 

 

 

6. Trace Elements

• Called Trace Elements because they are required by the body in very small amounts (less than a few milligrams per day).

Trace Elements

• Iron
• Iodine
• Fluorine
• Zinc
• Copper
• Cobalt
• Chromium
• Manganese
• Selenium
• Molybdenum

Important Point:

• The trace element which cannot be adequately supplemented by diet during pregnancy is Iron (Fe).

 

Copper

Hypocupremia (Copper Deficiency)

Occurs in:

• Wilson's disease
• Protein Energy Malnutrition (PEM)
• Infants fed exclusively on cow's milk for a prolonged period

Abnormalities Seen

• Neutropenia (best documented abnormality)
• Myelopathy
• Anemia
• Growth retardation
• Osteoporosis
• Defective elastin
• Hair defects

 

Hypercupremia (Excess Copper)

Causes

• Excessive intake of copper
• Eating food prepared in copper vessels

Associated with

• Leukemia
• Anemia
• Hyperthyroidism
• Hodgkin's disease
• Myocardial infarction (MI)
• Hepatotoxicity

 

Cobalt

• Constituent of Vitamin B₁₂ (Cyanocobalamin)
• Cobalt deficiency in soil results in Goiter
• Necessary for the first stage of hormone production

 

Chromium

• Plays an important role in:
• Carbohydrate metabolism
• Insulin function

 

Selenium

Deficiency occurs in

• Protein Energy Malnutrition (PEM)

Important Points

• Deficiency along with Vitamin E deficiency reduces antibody production
• Deficiency causes:
• Keshan cardiomyopathy
• Hypothyroidism (Sub-Himalayan region)
• Administration in Kwashiorkor results in significant weight gain

 

Molybdenum

Deficiency

• Associated with:
• Mouth cancer
• Esophageal cancer

Excess Absorption

• Causes bone deformity

 

6.1 Dietary Antioxidants

Dietary antioxidants are substances that include nutrients, non-nutrients, and some enzymes.

1. Nutrients (A.C.E.S.)

• Vitamin A (β-carotene)
• Vitamin C
• Vitamin E
• Selenium

 

2. Non-nutrients

• Plant phenols
• Flavonoids
• Coumarins
• Benzyl isothiocyanates
• Caffeic acid
• Ferulic acid
• Gallic acid
• Ellagic acid

 

3. Enzymes

• Superoxide dismutase (SOD)
• Catalase
• Superoxide mutase

 

Sources

• Vegetables
• Fruits
• Spices
• Tea
• Wine
• Cereals

 

Functions

• Reduce free radicals (produced during tissue damage)
• Reduce the adverse effects of:
• Reactive Oxygen Species (ROS)
• Reactive Nitrogen Species (RNS)

(These are generated during both physiological and pathological conditions.)

 

 

 

7. Iron (Fe)

Functions

• Formation of Hemoglobin (Each gram of Hb contains 3.34 mg of iron).
• Central function:
• Oxygen transport
• Cellular respiration
• Lack of iron directly affects the immune system.

 

Sources

Type	Origin	Sources	Bioavailability
Haem Iron	Animal origin	Liver, Meat, Poultry, Fish etc.	12–16%
Non-Haem Iron	Vegetable origin	Green leafy vegetables (Spinach), Jaggery (Poor man's iron source), Dry fruits, Dates, Soybean etc.	6–9%

Important: Dates contain approximately 39 mg Calcium, 6 mg Iron, β-Carotene & 280 kcal.

 

Absorption

• Iron absorbed from the Indian diet is <5%.
• Mostly absorbed from the duodenum & upper small intestine in the ferrous (Fe²⁺) state.
• Vitamin C promotes absorption.
  (Iron pills/injections should not be taken with high doses of Vitamin C.)

Inhibitors of Iron Absorption

• Disorders of duodenum & jejunum:
• Celiac disease
• Tropical sprue
• Phosphates
• Phytates
• Tannates
• Oxalates
• Fiber
• Calcium

 

Iron Losses

Physiological

• Menstruation
• Childbirth

Pathological

• Hookworm infestation
• Hemorrhoids
• Peptic ulcer
• Malaria

 

Iron Deficiency – Three Stages

Stage 1

• Decreased storage of iron.

Stage 2 (Intermediate Stage)

• Iron stores become exhausted.
• Latent iron deficiency.
• Serum ferritin & transferrin begin to fall.

Stage 3

• Decreased circulating hemoglobin.
• Results in Nutritional Iron Deficiency Anemia (IDA).

 

Evaluation of Iron Status & Diagnosis of Anemia

Hemoglobin Concentration

• 10–11 g/dL: Early anemia
• <10 g/dL: Marked anemia

Cut-off Values for Diagnosis of Anemia

Group	Hemoglobin
Adult pregnant female	11 g/dL
Adult non-pregnant female	12 g/dL
Adult male	13 g/dL

 

Serum Iron

• <0.5 mg/L
• Indicates iron deficiency.

 

Serum Ferritin

• <10 mcg/L
• Indicates absence of stored iron.
• Most sensitive test for iron status.
• Best indicator to detect iron deficiency in the community.

 

Serum Transferrin Saturation

• Should be >16%.
• Clinical indicator of iron status.

 

TIBC (Total Iron Binding Capacity)

• Most sensitive indicator for iron deficiency.

 

Recommended Dietary Allowance (RDA) of Iron

Group	RDA
Infant	5 mg/day
Adult male	17 mg/day
Adult female (Non-pregnant / Menstruating / Lactating)	21 mg/day
Pregnant woman	35 mg/day

Note: Additional iron required during pregnancy = 14 mg/day (21 + 14 = 35 mg/day).

 

 

 

7.1 Nutritional Anemia

Nutritional Anemia

• Condition in which hemoglobin content of blood is lower than normal as a result of deficiency of one or more essential nutrients.
• By far the most frequent cause of nutritional anemia is Iron deficiency, and less frequently Folate & Vitamin B₁₂ deficiency.

 

Problem Statement of Iron Deficiency Anemia

• Women of reproductive age (15–49 years) and children (6–35 months) are at higher risk.
• Prevalence is high in adolescent girls, as many of them get married at a younger age.

 

Causes of Iron Deficiency Anemia

• Poor bioavailability of iron
• Women lose considerable amounts of iron during menstruation
• Malaria & hookworm infestation

 

Detrimental Effects of Anemia

• Pregnancy: Abortion, Premature birth, PPH, LBW
• Infections: Anemia is aggravated by parasitic diseases (e.g., malaria, intestinal parasites)
• Work capacity: Significant decrease in work capacity

 

Interventions

If Anemia is Severe (Hb <10 g/dL)

• High doses of iron
• Blood transfusion

If Hb is 10–12 g/dL

• Iron + Folic Acid supplementation

 

Intensified Iron Plus Initiative (I-NIPI) / Anemia Mukt Bharat

Age Group	Elemental Iron	Folic Acid	Frequency	Form
6–59 months	20 mg	100 mcg	Biweekly	Syrup
5–9 years	45 mg	400 mcg	Weekly	Pink tablet
10–19 years	60 mg	500 mcg	Weekly	Blue tablet
Women of reproductive age	60 mg	500 mcg	Weekly	Red tablet
Pregnant women	60 mg	500 mcg	Daily	Red tablet

 

Important Points

• 1 tablet daily starting from the 4th month of pregnancy for a minimum of 180 days.
• Continue for another 180 days after delivery (postpartum).
• Biannual deworming through Albendazole is also done.
• Screening of target groups for moderate/severe anemia.
• Referral of these cases to appropriate health facilities.

 

Iron Fortification

• Double fortification of salt with iodine & iron.
• Addition of Ferric Orthophosphate or Ferrous Sulphate with Sodium Biphosphate.

 

Important Note

• In Iron Deficiency Anemia, after the hemoglobin level has returned to normal, iron tablets should be continued for 3 months to replenish iron stores.

 

 

 

8. Iodine (I)

Functions

• Required for synthesis of Thyroxine (T₄) and Triiodothyronine (T₃).
• T₄ is a more sensitive indicator than T₃.
• Adult human body contains 50 mg of iodine.

 

Requirement

Group	Requirement
Adult	150 mcg/day
Pregnancy	250 mcg/day
Lactation	290 mcg/day

 

Sources

• Richest source: Japanese seaweed
• Sea foods:
• Sea fish
• Sea salt
• Cod liver oil
• Vegetables:
• Onion
• Potato
• 90% of iodine comes from foods eaten (remaining from drinking water).

 

Deficiency

• The term Endemic Goiter has now been replaced by Iodine Deficiency Disorder (IDD).

 

Goitrogens

• Interfere with iodine utilization by the thyroid gland, leading to goiter.
• Found in Brassica group vegetables:
• Cabbage
• Cauliflower
• Important dietary goitrogens:
• Cyanoglycosides
• Thiocyanates

 

8.1 Iodine Deficiency Disorder (I.D.D.)

Prevalence of Iodine Deficiency in India

• 3–10%

 

Himalayan Goiter Belt

• Extends from Kashmir to Naga Hills.
• Length: 2400 km
• 263 districts are endemic where the prevalence of IDD is more than 10%.

 

Spectrum of Iodine Deficiency Disorder

(In order of increasing severity)

1. Goiter

• Grade I
• Grade II
• Grade III
• Multinodular

2. Hypothyroidism

3. Delayed Milestones

• Delayed development

4. Mental Deficiency

5. Hearing Defects

• Deafness

6. Speech Defects

7. Strabismus (Squint)

• Unilateral
• Bilateral

8. Nystagmus

9. Neuromuscular Weakness

• Spastic diplegia
• Spastic quadriplegia

10. Endemic Cretinism

(Occurs when iodine uptake is <20 mcg/day)

• Hypothyroid cretinism
• Neurological cretinism

 

 

8.1 Iodine Deficiency Disorder (I.D.D.)

Prevalence of Iodine Deficiency in India

• 3–10%

 

Himalayan Goiter Belt

• Stretches from Kashmir to Naga Hills
• 2400 km
• 263 districts are endemic (prevalence of IDD >10%)

 

Spectrum of Iodine Deficiency Disorder

(In order of increasing severity)

1. Goiter
• Grade I
• Grade II
• Grade III
• Multinodular
2. Hypothyroidism
3. Delayed Milestones (Delayed development)
4. Mental Deficiency
5. Hearing Defects (Deafness)
6. Speech Defects
7. Strabismus (Squint)
• Unilateral
• Bilateral
8. Nystagmus
9. Neuromuscular Weakness
• Spastic Diplegia
• Spastic Quadriplegia
10. Endemic Cretinism (when iodine intake is <20 mcg/day)

• Hypothyroid Cretinism
• Neurological Cretinism
• Stillbirth

 

Prevention of IDD

1. Iodized Salt

Level of Iodization in Salt (PFA Act, 1954)

• Production level: 30 ppm
• Consumer level: 15 ppm
• Process indicator to monitor success of the IDD Control Programme

Double Fortified / Twin Fortified Salt

• Contains Iodine & Iron
• Provides 40 mcg iodine & 1 mg iron per gram of salt
• Contains:
• Salt
• Potassium Iodate
• Ferrous Sulphate
• Sodium Hexa-Meta Phosphate
• Developed by National Institute of Nutrition (Hyderabad)

Hazards of Iodization

• Thyrotoxicosis
• Hashimoto's Disease

 

2. Iodized Oil

• Intramuscular (I/M): Iodized Oil (Poppy Seed Oil)
• Oral: Sodium Iodate tablets
• Provides protection for 3–4 years

 

 

 

9. Fluorine (Fl)

Functions

• Essential for:
• Mineralization of bones
• Formation of dental enamel
• 96% of fluorine is found in bones & teeth.

Major Source

• Drinking water

 

Sources

Drinking Water

• Recommended level (India): 0.5–0.8 mg/L (approximately 1 ppm)
• Maximum permitted level: 1.5 mg/L

Foods

• Sea fish
• Cheese
• Tea

 

Fluorine is a Double-Edged Sword

Deficiency

• Inadequate intake causes Dental Caries.

Excess

• Prolonged ingestion causes Dental Fluorosis and Skeletal Fluorosis.

Fluoride Level	Condition
>1.5 ppm	Dental Fluorosis (Mottling)
3–6 ppm	Skeletal Fluorosis
>10 ppm	Crippling Fluorosis

 

9.1 Endemic Fluorosis

• Endemic fluorosis is observed in areas where fluoride in drinking water is about 5 mg/L.
• It is an important public health problem in:
• Andhra Pradesh
• Nagaland
• Karnataka
• Kerala
• Tamil Nadu

 

Toxic Manifestations

1. Dental Fluorosis

• Occurs when excess fluoride is ingested during the first 7 years of life (period of tooth calcification).
• Reported when fluoride level is >1.5 mg/L in drinking water.
• Characterized by mottling of dental enamel.
• Best seen in:
• Central incisors
• First molars

 

2. Skeletal Fluorosis

• Associated with daily intake of 3–6 mg/L (or ppm).
• Causes heavy fluoride deposition in the skeleton.
• Crippling fluorosis occurs at 10 mg/L.

 

3. Genu Valgum

• Genu valgum with osteoporosis of the lower limbs.
• Observed among people whose staple diet is Sorghum (Jowar).

 

Intervention

1. Changing the Water Source

• Running surface water contains lower quantities of fluoride.

 

2. Chemical Treatment

Nalgonda Technique

For defluoridation of water

• Addition of:
• Lime
• Alum (major role)
• Bleaching powder
• Followed by:
• Flocculation
• Sedimentation
• Filtration

 

3. Household Defluoridation

• Nalgonda technique
• Alumina
• Phosphates

 

4. Other Measures

• Fluoride toothpaste is not recommended in endemic fluorosis areas.

 

 

 

 

10. Zinc (Zn)

• Antioxidant agent
• Required for synthesis of insulin by the pancreas.

 

Sources

• Animal foods: Fish, Meat, Milk
• Vegetables: Low bioavailability

 

Zinc Deficiency Causes

• Loss of taste (Ageusia)
• Acrodermatitis Enteropathica – inherited disorder of impaired uptake of zinc from the body
• Decreased insulin synthesis
• Growth failure
• Dwarfism & hypogonadism
• Sexual infantilism in adolescents
• Impaired cell-mediated immunity
• Delayed wound healing
• Pernicious anemia / Megaloblastic anemia (Macrocytic anemia)
• Thalassemia
• Myocardial infarction
• Hepatosplenomegaly

 

Zinc Deficiency in Pregnancy Causes

• Spontaneous abortion
• IUGR (Intrauterine Growth Restriction)
• Preterm delivery
• Low Birth Weight (LBW)
• Congenital malformations (Anencephaly)

 

Zinc Supplementation in Diarrhea

Zinc supplementation along with ORS reduces the duration and severity of diarrhea.

Dose

Age	Zinc Dose
< 6 months	10 mg/day
> 6 months	20 mg/day

Important: Zinc supplementation for a 12-month-old baby = 20 mg/day.

 

Toxicity

• Pulmonary fibrosis

 

 

 

 

 

11. Protein Assessment

Method for Assessment of Protein Quantity

 

Methods for Assessment of Protein Quality

1. Amino Acid Score (AAS)

• Measures indispensable (essential) amino acids in a protein and compares their values with a reference protein.

2. Protein Digestibility Corrected Amino Acid Score (PDCAAS)

• Amino Acid Score with an added digestibility component.

3. Digestible Indispensable Amino Acid Score (DIAAS)

• Best and most refined indicator of protein quality.
• FAO recommends DIAAS to replace PDCAAS as the preferred method of measuring protein quality.

4. Protein Efficiency Ratio (PER)

• Ratio of weight gain to the amount of protein consumed.

5. Biological Value (BV)

• Amount of nitrogen retained compared to the amount of nitrogen absorbed.

6. Net Protein Utilization (NPU)

• Ratio of nitrogen used for tissue formation to the amount of nitrogen digested.
• Better assessment of protein quality than Biological Value (NPU > BV).
• Both BV and NPU reflect availability and digestibility.

 

Limiting Amino Acids (LAA)

LAA are amino acids that are deficient in a food item's protein.

Food Item	Limiting Amino Acid	Other Limiting Amino Acid	Mnemonic
Cereals	Lysine	—	She Lies
Wheat	Threonine	Lysine	We Three Lies
Maize	Tryptophan	Lysine	Main Try-To Lie
Pulses	Methionine	Cysteine	Pulse Me Cyst

 

Supplementary Action of Proteins

• Consumption of only one type of food (e.g., cereals alone) leads to deficiency of its limiting amino acid.
• When two or more foods are eaten together (e.g., Cereals + Pulses), their proteins supplement each other, improving protein quality.

 

Essential Amino Acids (EAA)

• Essential amino acids are not synthesized in adequate amounts in the human body and must be supplied through diet.

10 Essential Amino Acids

1. Leucine
2. Threonine
3. Lysine
4. Histidine (semi-essential)
5. Arginine (semi-essential)
6. Isoleucine
7. Tryptophan
8. Phenylalanine
9. Valine
10. Methionine

Mnemonic:
"Lucifer Three Lies... His (Semi-Essential) Urge Is... Try Phenyl Wali Methi."

 

Conditionally Essential Amino Acids (CEAA)

• Non-essential amino acids become essential when their precursors are limited in the body.

Examples

• Tyrosine
• Cystine

Mnemonic: "Conditionally Tired Sis"

 

 

 

 

11.1 Net Protein Utilization (N.P.U.)

• Proportion of ingested protein that is retained in the body under specified conditions for growth & maintenance of tissues.
• NPU is the best indicator of Protein Quality (ICMR recommends it for determining dietary protein requirement).
• Better assessment of protein quality than Biological Value (NPU > BV).

 

Calculated By

• Ratio of amino acids converted into proteins to the amino acids supplied.
• Determining dietary protein intake and then measuring nitrogen excretion.
• Ratio of nitrogen used for tissue formation to the amount of nitrogen digested.

Note:
1 g of nitrogen = 6.25 g of protein

Relationship with Biological Value

 

NPU Range

• NPU ranges from 0 to 1.
• 0 → None of the supplied nitrogen is converted into protein.
• 1 → 100% utilization of dietary nitrogen as protein.

NPU of Foods

Food	NPU
Soybean	61%
Rice	65%
Milk	75%
Meat	80%
Egg	100% (Highest)

Important:

• Actual NPU of egg = 96 (maximum biological value).
• Since egg is taken as the reference protein, its NPU is considered 100 for comparison.

 

12. Essential Fatty Acids (EFA)

• Fatty acids that cannot be synthesized completely in the human body and therefore must be supplied through food.

Linoleic Acid

• Most important Essential Fatty Acid (EFA).
• Acts as the precursor for the synthesis of other EFAs.

 

Sources of Linoleic Acid

Safflower oil > Corn oil > Sunflower oil > Soybean oil > Sesame oil > Groundnut oil > Mustard oil > Palm oil > Coconut oil

 

Deficiency

• Phrynoderma (Toad Skin)

 

Important Point

• Essential fatty acids were previously known as Vitamin F.

 

Types of Fatty Acids

ω-3 Fatty Acids

• Derived from α-Linolenic acid
• Reduce the incidence of Coronary Heart Disease (CHD)

ω-6 Fatty Acids

• Derived from Linoleic acid

ω-9 Fatty Acids

• Derived from Oleic acid
• Non-essential in humans

 

Sources

Richest EFA Source

• Safflower oil
• Contains approximately:
• 10% Saturated Fatty Acids (SFA)
• 15% Monounsaturated Fatty Acids (MUFA)
• 75% Polyunsaturated Fatty Acids (PUFA)

PUFA-rich Oils

Safflower oil > Sunflower oil > Soybean oil > Margarine oil > Groundnut oil > Palm oil

SFA-rich Oils

Coconut oil > Butter > Palm oil > Groundnut oil > Margarine > Soybean oil > Sunflower oil > Safflower oil

 

Fat Content of Cereals

Bajra > Maize > Jowar > Wheat > Ragi > Rice

 

 

 

 

13. Balanced Diet

Balanced Diet

A balanced diet is a diet that contains a variety of foods in such quantity and proportion that the need for energy, amino acids, vitamins, minerals, fats, carbohydrates, and other nutrients is adequately met for maintaining health, vitality, and well-being, and also makes a small provision for extra nutrients to withstand a short duration of leanness.

 

Principles of Balanced Diet

• Protein requirement should be met with 15% of total daily energy intake.
• Fat intake should be limited to 15–30% of total daily energy intake.
• Carbohydrates rich in natural fiber should provide the remaining food energy.
• Requirements of micronutrients should also be met.

 

Balanced Diet for Moderately Active Adults (in grams)

Food Item	Man (Moderately Active)	Woman (Moderately Active)
Cereals	520 g	440 g
Pulses	50 g (40 g in sedentary)	45 g
Leafy Vegetables	40 g	100 g
Other Vegetables	70 g	40 g
Roots & Tubers	60 g	50 g
Milk	200 mL	150 mL
Oil & Fat	45 g	25 g
Sugar & Jaggery	35 g	20 g

 

14. Dietary Goals (Prudent Diet)

Prudent Diet

• It is a diet taken for the achievement of dietary goals.

Recommended by WHO

1. Protein should account for 10% of total daily energy intake.
2. Dietary fat should be limited to 20% of total energy intake.
• Saturated fat should contribute not more than 10% of total energy intake.
3. Carbohydrates rich in natural fiber should be consumed.
• Excessive consumption of refined carbohydrates should be avoided.
4. Cholesterol intake should be below 100 mg per 1000 kcal/day.
5. Fats and alcohol should be restricted.
6. Salt intake should not exceed 5 g/day.
7. Junk foods should be avoided.

 

 

 

 

15. Malnutrition

Malnutrition is defined as a pathological state resulting from deficiency or excess of nutrients.

 

Four Forms of Malnutrition

1. Undernutrition
• When insufficient food is eaten over an extended period of time.
2. Overnutrition
• Consumption of excessive quantity of food over an extended period of time.
3. Imbalance
• Disproportion among essential nutrients.
4. Specific Deficiency
• Lack of an individual nutrient.

 

Five Principal Nutritional Deficiency Diseases (Global Scale)

1. Kwashiorkor
2. Marasmus
3. Xerophthalmia
4. Nutritional Anemia
5. Endemic Goiter

 

Ecological Factors Related to Malnutrition

1. Conditional Influences

• Infectious diseases like:
• Intestinal parasites
• Measles
• Whooping cough
• Tuberculosis (TB)
• Malaria
• These diseases may contribute to malnutrition.

 

2. Cultural Influences

i. Food Habits, Customs, Beliefs, Traditions & Attitudes

• Papaya is avoided during pregnancy because it is believed to be abortifacient.
• A widespread belief is that if a pregnant woman eats more, the baby will become too big, leading to difficult delivery.

ii. Religion

• Some orthodox Hindus do not eat:
• Meat
• Fish
• Eggs
• Certain vegetables like onion and garlic
• These are known as Food Taboos.

iii. Food Fads

• Selection of foods according to personal likes and dislikes is called Food Fads.

iv. Cooking

• Draining away rice water and peeling vegetables influence the nutritive value of foods.

v. Child Rearing

• Premature curtailment of breastfeeding.
• Early adaptation of commercial refined foods.

 

3. Socio-economic Factors

• Poverty
• Large family size, etc.

 

4. Food Production

• Problem of uneven distribution of food.

 

5. Health Services

• Nutritional Rehabilitation Centre (NRC)

 

Preventive & Social Measures

At the Family Level

• Promotion of breastfeeding.
• Special attention to the nutritional needs of:
• Pregnant women
• Nursing mothers
• Children

 

At the Community Level

ICDS (Integrated Child Development Services) Programme

Provides:

• Supplementary nutrition
• Immunization
• Health check-ups
• Health education
• Nutrition education for mothers
• Non-formal education for preschool children

 

At the National Level

Rural Development

• Necessary to improve the living standards and purchasing power of the people.

Increasing Agricultural Production

• Modern farming practices
• Use of fertilizers
• Better quality seeds
• Efficient food distribution system

Stabilization of Population

• Birth spacing
• Small family norm

Nutrition Intervention Programmes

• Prevention and control of endemic goiter through iodized common salt.
• Control of anemia by distribution of Iron-Folic Acid (IFA) tablets to pregnant and nursing mothers.
• Control of night blindness through massive oral doses of Vitamin A to children.
• Supplementary feeding programme for preschool children.

 

At the International Level

World Food Programme (WFP)

International Agencies

• FAO
• UNICEF
• WHO
• UNDP
• CARE

 

 

 

 

 

15.1 Protein Energy Malnutrition (PEM)

• Occurs due to inadequate intake of food (food gap) in both quantity and quality, or as a result of infections such as:
• Measles
• Intestinal worm infestation
• Common in developing countries
• Incidence: ~2% in preschool children
• Hepatomegaly is an essential feature
• Hypothermia may be the cause of death

 

Vicious Cycle of PEM

• Inadequate dietary intake
  ↓
• Weight loss & lowered immunity
  ↓
• Disease
  ↓
• Appetite loss & malabsorption
  ↓
• Further inadequate dietary intake

 

Classification of PEM

I. Gomez Classification

Weight for Age (%)	Classification
90–110	Normal
75–89	Mild malnutrition
60–74	Moderate malnutrition
<60	Severe malnutrition

 

II. Waterlow's Classification

Height for Age	Weight for Height ≥ Mean −2 SD	Weight for Height < Mean −2 SD
Height/Age ≥ Mean −2 SD	Normal	Wasted
Height/Age < Mean −2 SD	Stunted	Wasted & Stunted

 

III. Mid Upper Arm Circumference (MUAC)

Shakir's Tape is used for children aged 6 months–5 years (MUAC remains almost constant during this age).

MUAC	Color	Nutritional Status
>12.5 cm	Green	Satisfactory nutritional status
12.5–11.5 cm	Yellow	Mild to moderate malnutrition
<11.5 cm	Red	Severe malnutrition

 

Clinical Features

Kwashiorkor	Marasmus
1. Edema present in lower legs, face & forearms	1. Muscle wasting
2. Child is irritable	2. Child is quiet
3. Poor appetite	3. Diarrhea is common
4. Flaky paint dermatosis	4. Severe loss of subcutaneous fat
5. Flag sign & easily pluckable hair	5. Weight for height is very low

 

Preventive Measures

1. Health Promotion

• Promotion of breastfeeding.
• Development of low-cost weaning foods.
• Nutritional education for pregnant & lactating mothers.
• Distribution of nutritional supplements.

2. Specific Protection

• Immunization.
• Food fortification.

3. Early Diagnosis & Treatment

• Early diagnosis and treatment of infections or any growth lag.
• Deworming and supplementary feeding programmes.

4. Rehabilitation

• Nutritional Rehabilitation Services at Nutritional Rehabilitation Centre (NRC).

 

 

 

 

 

16. Nutritional Rehabilitation Centres (NRC)

Nutritional Rehabilitation Centres (NRC)

• Facility-based units providing Medical & Nutritional Care to Severe Acute Malnutrition (SAM) children <5 years of age who have medical complications.

 

Services Provided

• Treatment of medical complications
• 24-hour care & monitoring of the child
• Therapeutic feeding
• Demonstration on preparation of energy-dense food using locally available affordable foods
• Counseling on appropriate feeding & hygiene
• Sensory stimulation & emotional care
• Social assessment of the family
• Follow-up of discharged children

 

Admission Criteria for NRC

• MUAC <11.5 cm with or without any grade of edema
• Weight-for-height < -3 SD with or without any grade of edema
• Bilateral pitting edema with:
• Loss of appetite, fever & hypothermia
• Persistent vomiting, hypoglycemia, severe dehydration, severe anemia & severe pneumonia
• Weak, apathetic & unconscious child

 

SAM Management (Therapeutic Feeding)

1. Stabilization Phase (1–2 days)

Starter Diet – F-75

• Given for nutritional & electrolyte balance

F-75 (per 1000 mL):

• 300 mL cow's milk or toned milk
• 100 g sugar
• 25 g vegetable oil
• Water

 

2. Transition Phase (2–3 days)

Catch-up Diet – F-100

• Started when:
• Edema begins to reduce
• Appetite returns
• Oral feeding is possible

F-100 (per 1000 mL):

• 900 mL cow's milk or toned milk
• 75 g sugar
• 20 g vegetable oil
• Water

 

3. Rehabilitation Phase

• Started when:
• Major loss of edema has occurred
• Appetite is adequate
• Child finishes >90% of the prescribed food

 

Micronutrient Supplementation

• Vitamin A: On days 1, 2, 14
• Vitamin B₂, C, D & E
• Folic acid: 5 mg on day 1, then 1 mg/day
• Iron: Only during the rehabilitation phase
• Zinc: 2 mg/day
• Copper

 

Discharge Criteria for NRC

• Edema has resolved
• >15% weight gain
• Child is eating an adequate amount of food
• All medical conditions have been treated

 

Follow-up

• Regular NRC visits
• Home visits by AWW (Anganwadi Worker) / ASHA
• Weekly for 1 month during the rehabilitation phase
• Every 15 days until the child is released from the program

 

 

 

 

17. Nutritional Factors in Cardiovascular Diseases

i. Cholesterol

• Mostly seen in foods of animal origin.

ii. Lipoproteins

• Low Density Lipoprotein (LDL):
• Dominated by its cholesterol content.
• Involved in the atherosclerotic process.
• Very Low Density Lipoprotein (VLDL):
• Dominated by its triglyceride content.
• Risk factor for Coronary Heart Disease (CHD).
• High Density Lipoprotein (HDL):
• Removes cholesterol from cells.
• Has a protective effect against CHD.

iii. Fatty Acids

• Saturated fatty acids increase plasma cholesterol.
• Unsaturated fatty acids lower plasma cholesterol.
• Polyunsaturated Fatty Acids (PUFA) inhibit platelet aggregation, thereby preventing thrombus formation.

iv. Triglycerides

• Blood triglyceride concentration is markedly increased in individuals with raised cholesterol levels.
• Acts as a risk factor for CHD.

v. Carbohydrates

• Dietary fiber intake decreases the risk of CHD.

vi. Salt

• Highest incidence of hypertension is seen in Japan (sodium intake >400 mmol/day).
• Hypertension can be treated with a low sodium diet (<10 mmol/day).

 

18. Nutritional Assessment Methods

Assessment of nutritional status is an assessment of dietary intake (Diet Survey).

1. Anthropometry

• Height/Length
• Infantometer
• Stadiometer
• Weight
• Salter scale
• Skinfold thickness
• Harpenden caliper
• Mid Upper Arm Circumference (MUAC)
• Shakir's tape

 

2. Biochemical & Laboratory Assessment

Biochemical Tests

• Vitamin A → Serum retinol
• Vitamin K → Prothrombin time
• Protein → Serum albumin

Laboratory Tests

• Hemoglobin estimation
• Stool examination (for intestinal parasites)
• Urine albumin & sugar

 

3. Clinical Examination

• Bitot's spots (Xerophthalmia)
• Absence of knee or ankle jerks (Beriberi)
• Enlargement of thyroid gland (Endemic goiter)

 

4. Dietary Intake Assessment

Weighment of Raw Foods

• Weighment of all food that is going to be cooked.
• Dietary cycle: Weighment of raw food done over a period of 7 days.

Weighment of Cooked Foods

• Foods are analyzed in the form in which they are normally consumed.

Oral Questionnaire Method

• Quantity of foods eaten during the previous 24 hours (24-hour recall method).

 

5. Ecological Factors Assessment

• Socioeconomic factors:
• Family size
• Income
• Cultural patterns
• Health services:
• Feeding programmes
• Immunization programmes
• Conditioning influences:
• Parasitic, bacterial & viral infections precipitating malnutrition
• Food balance sheet

 

6. Functional Indicators

• Capillary fragility → Vitamin C
• Prothrombin time → Vitamin K
• Sperm count → Zinc
• Nerve conduction → Vitamin B₁₂
• Dark adaptation → Vitamin A

 

7. Vital Statistics

• Mortality
• Morbidity, particularly in relation to:
• Protein Energy Malnutrition (PEM)
• Anemia
• Xerophthalmia
• Endemic goiter

 

 

 

 

 

19 – Nutritional Surveillance

Nutritional Surveillance – Keeping watch over Nutrition, to make decisions which will improve Community's Nutritional Status.

• Nutritional Survey (50–100 group size) is for detection of Malnutrition.
• Diagnostic Interventional Approach
• Objective: To provide input for Program Management (Policy Makers) and to give Timely Warnings.

Indicators of Nutritional Status

1. Maternal Nutrition

• Birth Weight

2. Infant & Preschool Children Nutrition

• Proportion being Breast Fed
• Proportion on Weaning Food

If Age is known

• Height for Age
• Weight for Age

If Age is unknown

• Weight for Height
• Mid Upper Arm Circumference (MUAC)

3. School Child Nutrition

• Height for Age
• Weight for Height

For assessment of Nutritional Status of Community:

• LBW (Low Birth Weight)
• Weight : Height in Preschool Children
• Mortality in 1–4 years

 

19.1 – Difference between Growth Monitoring & Nutritional Surveillance

Feature	Growth Monitoring	Nutritional Surveillance
1. Strategy	Preservation of growth	Detection of undernutrition
2. Approach	Educational	Diagnostic
3. Enrollment	All infants	Representative sample
4. Age	Starts before 6 months	Representative ages
5. Number	10–20	50–100
6. Weight recorder	Mothers	Trained workers
7. Weight card	Growth	Nutritional status
8. Response	Intervention	Rehabilitation
9. Intervention	ORS, Vaccines, Vitamin A, Deworming	Food subsidy
10. Referral	Health system	NRC (Nutritional Rehabilitation Centre)

 

 

 

 

 

 

 

 

 

 

20 – Milk Borne Diseases

1. Infection of ANIMALS that can be transmitted to man

• Anthrax
• Brucellosis & Salmonellosis
• Cow Pox & Q fever
• Foot & Mouth Diseases
• Tick Borne Encephalitis
• Streptococcal Infections & Staphylococcal Food Poisoning
• Leptospirosis & Listeriosis

2. Infections (primary to MAN) that can be transmitted through Milk

• Typhoid Fever & Para Typhoid Fever
• Cholera, Shigellosis, Enteropathogenic E. coli
• Streptococcal Infections & Staphylococcal Food Poisoning
• Non-diarrheal diseases – TB, Diphtheria, Hepatitis

Methylene Blue Reduction Test

• Indirect method for detection of Microorganism in milk
• Methylene blue is added to 10 ml of milk; sample is held at 37°C until the color disappears.
• Milk which remains blue for the longest time is considered to be the best quality.

 

21 – Pasteurization

Pasteurization: Heating of milk to a particular temperature for a specified period of time to destroy pathogens with minimum changes in its composition, flavor and nutritive value.

Methods of Pasteurization

I. Holder Method / VAT Method

(For small scale & rural communities)

• Milk is kept at 66°C for 30 min and then cooled to 5°C.
• Coxiella burnetii can survive the Holder method of pasteurization.

II. HTST Method (Flash Pasteurization)

(For very large quantities of milk)

• High temperature & short time method.
• Milk is rapidly heated to 72°C and held for 15 seconds, then rapidly cooled to 13°C.

III. UHT Method

• Ultra-high temperature method.
• Milk is rapidly heated (in two stages, second stage under high pressure) to 125°C for a few seconds, then rapidly cooled and bottled.

IV. HHST / Batch Pasteurization

• Milk is heated to 68°C for 30 min and then cooled.
• Pasteurization kills nearly 90% of bacteria in milk except thermoduric bacteria and bacterial spores.
• Pasteurized milk can be kept at 18°C for not more than 12 hours.

 

Tests of Pasteurized Milk

I. Phosphatase Test (Widely used test)

• Raw milk contains an enzyme called Phosphatase.
• At 60°C for 30 min, phosphatase is completely destroyed.
• Used to detect inadequate pasteurization or addition of raw milk.
• Used to test the quality of pasteurization.

II. Standard Plate Count

• To determine bacteriological quality of pasteurized milk.
• Limit is < 50,000 CFU/ml of pasteurized milk.

III. Coliform Count

• Coliform organisms should be absent in 1 ml of milk.
• Coliform organisms are completely destroyed by pasteurization; their presence in pasteurized milk indicates improper pasteurization or post-pasteurization contamination.

 

Quality Assessment of Milk

• Density – Lactometer
• Q₂ Chemical – SNF (Solid Non-Fat) test
• Gerber's Test – Fat content

 

 

 

 

 

22 – Food Borne Diseases

Food Borne Disease

• Disease either toxic or infectious in nature, whose infectious agent enters the body through ingestion of food.

1. Food Borne Intoxications

i. Naturally Occurring Toxins

• Lathyrism (Beta Oxalyl Amino Alanine – B.O.A.A.)
• Endemic Ascites (Pyrrolizidine Alkaloids)

ii. Toxins Produced by Bacteria

• Botulism (Clostridium botulinum)
• Staphylococcus Poisoning (Staphylococcus aureus)

iii. Toxins Produced by Fungi

• Aflatoxin (Aspergillus flavus)
• Ergot toxin (Claviceps purpurea)
• Fusarium toxin (Fusarium incarnatum)

iv. Food Borne Chemical Poisoning

Heavy Metals

• Mercury (Fish)
• Cadmium (Shellfish)
• Lead (Canned food)

 

2. Food Borne Infections

i. Bacterial

• Typhoid & Paratyphoid Fever
• Salmonellosis
• Shigellosis

ii. Viral

• Hepatitis
• Gastroenteritis

iii. Parasites

• Ascariasis
• Amoebiasis
• Taeniasis

 

 

 

 

 

23 – Food Toxicants

1. Lathyrism

• Paralyzing disease (Flaccid Paralysis)
• In Humans – referred as Neurolathyrism (Spastic Paraplegia)
• In Animals – referred as Osteolathyrism / Odoratism
• Once in Rewa & Satna districts of Madhya Pradesh, there were 25,000 & 32,000 cases respectively.
• Occurs mostly in adults (15–45 years).

Pulse

• Lathyrus sativus commonly known as Khesari Dhal (Teora Dal / Lak Dhal / Batra / Gharas / Matra).
• Looks similar to Red Gram Dhal or Bengal Gram Dhal.
• Diets containing 30% Khesari Dhal for 2–6 months result in Neurolathyrism.

Toxin

• Beta Oxalyl Amino Alanine (B.O.A.A.)

Five Stages

I. Latent Stage

• Individuals are apparently healthy but exhibit ungainly gait on physical stress.

II. No Stick Stage

• Patient walks with short, jerky steps without the aid of a stick.

III. One Stick Stage

• Patient walks with crossed gait, tends to walk on toes and uses one stick to maintain balance.

IV. Two Stick Stage

• Due to excessive bending of knees and crossed legs, patient needs two crutches for support.

V. Crawler Stage

• Knee joints cannot support body weight.
• Atrophy of thigh and leg muscles.
• Patient is reduced to crawling, throwing body weight on the hands.

 

Intervention

I. Vitamin C Prophylaxis

• Daily administration of 1000 mg Ascorbic Acid for 1 week.

II. Banning the Crop

• Prevention of Food Adulteration Act has banned Lathyrus in all forms.

III. Removal of Toxin

Steeping Method

• Water is boiled and pulse is soaked in hot water for 2 hours.
• Water is drained off and pulse is washed again with clean water.
• Water is again drained off.
• Pulses are dried under sunlight.

Parboiling Method

Hot Soaking Process

• Simple soaking in lime water (overnight) followed by boiling (partial cooking in steam).
• Vitamins and minerals in the outer layer are driven into the endosperm.
• Preserves nutritive value even during milling.

IV. Genetic Approach

• Certain strains of Lathyrus contain low levels of toxin.
• Selective cultivation of such strains is recommended.

V. Education

• Education regarding the dangers of consuming this pulse.

VI. Socioeconomic Changes

 

 

 

 

2. Aflatoxins

• Mycotoxin produced by fungi – Aspergillus flavus
• Fungus infests Groundnut, Maize, Sorghum, Wheat, Rice etc.
• Aflatoxins B₁ & G₁ are hepatotoxic and carcinogenic.
• Moisture level >16% and temperature between 11–37°C favor toxin formation.
• In 1975, about 400 cases of aflatoxin poisoning, including 100 deaths, were reported in Banswada (Rajasthan) and Panchmahal (Gujarat) districts.

Prevention

• Proper storage of food grains after drying.
• Moisture content should be kept below 10%.
• Health education on hazards of consuming contaminated food grains.

 

3. Ergotism

Also known as: Saint Anthony's Fire

• Frequent epidemics of ergotism during the Middle Ages were called Holy Fire/Saint Anthony's Fire because of the burning sensation resulting in gangrene of limbs.
• Caused by eating rye bread contaminated with the fungus.
• Named after the Monks of the Order of St. Anthony, who were successful in treating this ailment.
• Bajra, Rye, Sorghum & Wheat can become infected during the flowering stage.
• Caused by Ergot fungus (Claviceps purpurea / Fusiformis) producing Clavine alkaloids.
• Appears as blackish masses of seeds, becoming black and irregular.
• Outbreaks are reported from areas where Bajra is consumed as the staple food.

Symptoms

• Nausea
• Vomiting
• Giddiness
• Drowsiness
• Painful cramps in limbs
• Gangrene
• Upper safe limit: 0.05 mg/100 g of food material.

Removal of Ergot

• Float infested grains in 20% salt water.
• Hand picking.
• Air flotation.

 

4. Epidemic Dropsy

• Caused by toxic alkaloid Sanguinarine from Argemone oil.
• Contamination of mustard seeds/oil with Argemone mexicana (Prickly poppy) seeds, which closely resemble mustard seeds.

Symptoms

• Non-inflammatory bilateral edema of lower limbs.
• Diarrhea, dyspnea, cardiac failure, and even death.
• Glaucoma, GI bleed, and telangiectasia.

Prevention

• Remove Argemone weeds growing among mustard crops.

Tests for detection of Argemone oil contamination

• Nitric Acid Test
• Paper Chromatography (most sensitive for sanguinarine)
• Occurs in all age groups except breast-fed infants.

 

5. Endemic Ascites

• Outbreak occurred in Surguja district of Madhya Pradesh (1973) among the Nagesia tribe with about 40% mortality.
• Local population subsisted on millet Panicum miliaceum (Kodo/Kutki) contaminated with seeds of Crotalaria (Jhunjhunia).
• Jhunjhunia seeds contain Pyrrolizidine alkaloids (hepatotoxic).

Preventive Measures

• De-weeding of Jhunjhunia plants.
• Health education in affected areas.

 

6. Fusarium Toxins

• Field fungus
• Contaminates Sorghum or Rice.
• Toxin produced by Fusarium incarnatum.

 

 Food Adulteration

Food Adulteration

• Adulteration consists of mixing, substituting or misbranding the food products.

Disadvantages to the Consumer

• Paying more money for lower quality food stuff.
• Can be injurious to health.

Examples

Food Material	Adulterant
Dals	Kesari Dal
Dhania Powder	Cow Dung Powder
Black Pepper	Dried Seeds of Papaya
Chilli Powder	Brick Powder
Mustard Seeds	Argemone Seeds
Edible Oil	Argemone Oil
Milk	Water
Ghee	Vanaspati

 

Food Adulteration Act (1954)

• Minimum imprisonment of 6 months and minimum fine of ₹1000.
• Any adulteration causing grievous hurt or death:
• Comes under Section 320 IPC, resulting in life imprisonment and a fine of ₹5000 or more.
• 1986 Amendment:
• Consumer/Voluntary Organizations are empowered to take samples of suspicious food and send them to Food Laboratories (Kolkata, Mysore, Ghaziabad, Pune).

 

Food Standards

1. Codex Alimentarius

• Joint FAO/WHO standards for international markets.
• Food standards in India are based on Codex Alimentarius.

2. PFA Standards (Prevention of Food Adulteration)

• Laid under the Prevention of Food Adulteration Act, 1954.
• Food standards in India have to achieve the minimum level of quality under it.

3. AGMARK (Agricultural Mark)

• Purely voluntary.
• Expresses a degree of excellence above PFA standards.
• Food standardization by the Directorate of Marketing & Inspection (Government of India).

4. Bureau of Indian Standards (BIS)

• Purely voluntary.
• Expresses a degree of excellence above PFA standards.

5. ISI Mark

• Certification mark of the Bureau of Indian Standards (BIS).

FSSAI (Food Safety and Standards Authority of India)

• Follows the provisions of the PFA.
• Ensures the quality and safety of food products that are directly consumed.

 

 Food Fortification

Food Fortification

• Process where nutrients are added to food to improve the quality of diet.
• It is an example of Primary Level of Prevention (Specific Protection).

Examples

• Salt – Iodization of salt
• Twin fortification of salt with Iodine & Iron
• Water – Fluoridation of water
• Vanaspati Ghee – Vitamin A (2500 IU) & Vitamin D (175 IU) per 100 g Vanaspati Ghee

Criteria for Fortification

• Vehicle fortified must be consumed as a part of the regular daily diet.
• Addition of nutrient should NOT cause any noticeable change in taste, smell, appearance or consistency.
• Amount of nutrient added must NOT cause toxicity in consumers.
• Cost of fortification must NOT raise the price of the food.

Food Preservatives

• Substances added to food that inhibit, retard or arrest the process of fermentation, acidification or decomposition.

Types

Class I Preservatives

• Salt
• Sugar (Dextrose, Glucose)
• Spices
• Honey
• Vinegar
• Acetic acid

Class II Preservatives

• Benzoic acid
• Sulphuric acid
• Sorbic acid
• Lactic acid
• Nisin
• Propionic acid
• Irradiation & ionizing rays are also used in food preservation.

 

Hidden Hunger

Hidden Hunger

• Micronutrient deficiency (most common cause: Iron).
• A form of undernutrition that occurs when intake and absorption of vitamins and minerals (zinc, iodine, iron, etc.) are too low to sustain good health and development.

Factors Contributing to Hidden Hunger

• Poor diet
• Increased micronutrient needs during:
• Pregnancy & lactation
• Diseases, infections or parasitic infestations

Visible Effects (Clinical Signs)

• Night blindness (Vitamin A deficiency)
• Goiter (Iodine deficiency)

Invisible Effects

• Health and development of a population are affected by these less obvious effects; therefore micronutrient deficiency is known as Hidden Hunger.

Effects

• Affects 2 billion people (about one in three) globally.
• Leads to poor health, low productivity and even death.
• Adversely affects the health and survival of the first 1000 days of a child's life.
• Curtails socioeconomic development in low- and middle-income countries.

Triple Burden

• Developing countries are shifting from traditional minimally processed diets to highly processed, energy-dense but micronutrient-poor foods and drinks, leading to obesity and diet-related chronic diseases.
• This nutrition transition may result in Malnutrition + Micronutrient Deficiency + Obesity, collectively known as the Triple Burden.

 

Global Hunger Index (G.H.I)

• G.H.I measures & tracks the hunger globally.
• Agency involved: International Food Policy Research Institute (IFPRI).

G.H.I Calculation (Combination of 3 Indicators)

1. Undernourishment
2. Underweight Child (< 5 years)
• Child Wasting
• Child Stunting
3. Child Mortality (< 5 years)

Formula

G.H.I = (PUN + CUW + CM) / 3

Where:

• PUN = Proportion of Undernourished
• CUW = Underweight Children (< 5 years)
• CM = Children Dying (< 5 years)
• Value Range: 0–100

India

• G.H.I: 27.2
• Rank: 94

 

Glycemic Index

Glycemic Index (GI)

• Measure of how quickly 50 g of carbohydrate from a food is converted into sugar and affects blood sugar level over 2 hours.

Glycemic Response

• Food's ability to raise the blood sugar.

Glycemic Load

• Amount of carbohydrate per serving of food.

Types of Foods

1. Low Glycemic Index Foods

• Favor slow release of sugar into the small intestine and its absorption into blood.

2. High Glycemic Foods

• Foods with readily digestible and absorbable sugar.

Glycemic Index	GI Value	Examples
Low GI	< 55	Most fruits & vegetables (except potato/sweet potato), whole grains, beans, pasta, lentils
Medium GI	56–69	Sucrose, basmati rice, brown rice
High GI	> 70	Corn flakes, baked potato, white bread, candy bars, syrupy foods, jasmine rice

 

  

Nutritional Problems in India

Nutritional Problems in India

1. Protein Energy Malnutrition (PEM)
2. Low Birth Weight (LBW)
3. Xerophthalmia
4. Nutritional Anemia
5. Iodine Deficiency Disorder (IDD)
6. Endemic Fluorosis
7. Lathyrism

 

1. Protein Energy Malnutrition (PEM)

• Occurs due to inadequate intake of food (food gap) in both quantity and quality, or as a result of infections (Measles, intestinal worms, etc.).
• Common in developing countries.
• Incidence: 2% in preschool children.

Classification of PEM

1. Gomez Classification
2. Waterlow's Classification
3. Mid Upper Arm Circumference (MUAC)

Clinical Features

• Kwashiorkor
• Marasmus

 

2. Low Birth Weight (LBW)

Birth weight less than 2.5 kg irrespective of gestational age.

Birth Weight	Classification
< 2.5 kg	Low Birth Weight (LBW)
2.5–1.5 kg	Moderately Low Birth Weight (MLBW)
1.5–1.0 kg	Very Low Birth Weight (VLBW)
< 1 kg	Extremely Low Birth Weight (ELBW)

• Prevalence: 18% in India & 15% worldwide.
• Most common cause of LBW: Prematurity.
• Leading causes of death in LBW babies: Pneumonia, Atelectasis, Pulmonary hemorrhage, Intracranial bleeding.

LBW Babies Include

1. Preterm babies
2. Small-for-date babies

 

3. Xerophthalmia (Dry Eye)

• Refers to all ocular manifestations of Vitamin A deficiency in humans.
• Most common in children 1–3 years (often related to weaning).
• States predominantly affected are rice-eating states (Andhra Pradesh, Tamil Nadu, Karnataka, West Bengal & Bihar), as rice is deficient in carotene.

Ocular Manifestations

• Loss of vision in green light (earliest manifestation)
• Night blindness
• Conjunctival xerosis
• Bitot's spots
• Corneal xerosis
• Keratomalacia

Extra-Ocular Manifestations

• Follicular hyperkeratosis (Toad skin)
• Anorexia
• Growth retardation

WHO Classification of Xerophthalmia

Primary Signs

Code	Lesion
X1A	Conjunctival xerosis
X1B	Bitot's spots
X2	Corneal xerosis
X3A	Corneal ulceration
X3B	Keratomalacia

Secondary Signs

Code	Lesion
XN	Night blindness
XF	Xerophthalmic fundus
XS	Xerophthalmic scarring

 

 Nutritional Programs in India

Nutritional Programs in India

1. Vitamin A Prophylaxis Program (NPCBVI)
2. Prophylaxis against Nutritional Anemia (Anemia Mukt Bharat)
3. Control of Iodine Deficiency Disorder (NIDDCP)
4. Special Nutrition Program
5. Balwadi Nutrition Program
6. Mid-Day Meal Program (1961)
7. Integrated Child Development Services (ICDS) – 1975
8. Mid-Day Meal Scheme – 1995
9. National Nutrition Mission / POSHAN Abhiyan

 

1. Vitamin A Prophylaxis Program

• National Programme for Control of Blindness & Visual Impairment (NPCBVI).
• Single massive dose of Vitamin A (2 lakh IU) orally to all preschool children in the community every 6 months through Peripheral Health Workers.

 

2. Prophylaxis Against Nutritional Anemia (Anemia Mukt Bharat)

• Iron fortification of common salt along with iodine (Double Fortification).
• Intensified Iron Plus Initiative (IIPI) / Anemia Mukt Bharat.

Iron–Folic Acid Supplementation

Age Group	Elemental Iron	Folic Acid	Frequency	Form
6–59 months	20 mg	100 mcg	Biweekly	Syrup (1 ml)
5–9 years	45 mg	400 mcg	Weekly	Pink tablet
10–19 years (Adolescents)	60 mg	500 mcg	Weekly	Blue tablet
Women in Reproductive Age Group	60 mg	500 mcg	Weekly	Red tablet
Pregnant Women	60 mg	500 mcg	Daily	Red tablet

• Pregnant women: 1 tablet daily from the 4th month of pregnancy for at least 180 days, and continue for 180 days postpartum.

 

3. Control of Iodine Deficiency Disorder

• 1962: National Goiter Control Programme.
• 1986: National Iodine Deficiency Disorders Control Programme (NIDDCP).
• Replace all edible salt with iodized salt.

 

4. Special Nutrition Program

• During the 5th Five-Year Plan, it was a part of the Minimum Needs Programme.
• Later merged into ICDS.

 

5. Balwadi Nutrition Program

• Balwadis are being phased out because of the universalization of ICDS.

 

6. Mid-Day Meal Program (1961)

• Also called the School Lunch Program.
• Under the Ministry of Education.
• Aim: To attract more children to schools and retain them.
• Minimum number of feeding days in a year: 250 (recommended by the National Institute of Nutrition, Hyderabad).
• Became a part of the Minimum Needs Programme during the 5th Five-Year Plan.

 

 DIETARY ADVICE

ADVISING THE DIET

The most important advice the patient and the relatives seek from the Doctor—next of course to medicines—is the dietary advice. Unfortunately, we doctors usually tell the patients only what not to eat. The patient then goes home and ponders at every feed, as to what is allowed and what is not. Dietary advice is also about what to eat, and not just what not to eat.

This chapter is written in the format of the Doctor advising the patient, and we shall see what one can advise in commonly faced health problems.

These are the gross guidelines. Take into consideration the eating habits of the local people. (Advice to eat idli may be right in the Southern states, but may not go well in the North.) Also consider the eating habits of the person and his family. (Don't tell a poor man to eat pudding & cheese sandwich). And then using the guidelines given below, form your own menu.

For more interested Doctors, there is a Diet prescription at the end of the chapter, which may be xeroxed, or printed in local language on your letterhead. For selected patients, like Diabetes, Jaundice, Ulcer, IHD, Typhoid, etc., you may tick mark what to eat and what not to eat, and give this prescription.

 

Fever: Viral Fevers, Typhoid

Take soft foods:

• Ganji (Rice or Sago)
• Kheer (Payasam)
• Soft rice with milk/ghee/plain Dal
• Boiled vegetables (Cauliflower, Beet, Cabbage)

You may take a little lime pickle or papad for taste but no chillies.

Don't take any oily or fried foods.

Take plenty of water and fluids every 2–3 hours:

• Plain water
• Lime water
• Coconut water
• Electral water

Take milk with Horlicks or Bournvita.

With meals you may take:

• Soups
• Buttermilk

Avoid:

• Cold drinks
• Cold water
• Ice-cream

For snacks you can take:

• Plain Idli with butter
• Bread butter
• Toast with jam
• Gujarati plain Khakhra
• Cornflakes

Take fruits such as:

• Apple
• Bananas
• Pear
• Citrus fruits
• Watermelon

You may also take:

• Dry fruits
• Biscuits

 

Cough

Take warm or hot drinks often, such as:

• Hot tea
• Coffee
• Milk
• Soups

Take these 5–6 times a day.

Totally avoid fried foods such as:

• Wada
• Samosa
• Dosa
• Pakodas
• Papad
• Namkeens
• Potato chips

Avoid hotel food.

Do not take:

• Cold drinks
• Cold water
• Ice-cream
• Chilled food from the refrigerator

Avoid sour fruits such as:

• Citrus fruits
• Grapes

Take sweet fruits:

• Bananas
• Papaya
• Mango

Take mainly a soft diet:

• Rice
• Chapati or Phulka
• Non-spicy vegetables
• Boiled vegetables

  

Asthma

Avoid

• Deep fried foods such as Samosa, Dosa, Pakodas, Fried Papad, Namkeens, Potato chips, Hamburgers & Pizzas.
• Too cold foods such as Ice-cream, Kulfi, Cold drinks.
• Sour foods such as non-fresh curds, Sour Lassi, Srikhand, Raw Onion.
• Sour fruits such as Citrus fruits (Mosambi, Orange, Lemon), Sour grapes.

Important: By trial & error method and keen observation, identify the food that precipitates an attack of bronchospasm. Such foods must be totally avoided.

Take

• A glass of warm water early morning.
• Warm drinks often such as Tea, Coffee, Soups.

Breakfast & Snacks

• Bread sandwich
• Idli
• Sheera
• Cornflakes
• Khakhra
• Biscuits
• Sweet fruits such as Apple, Papaya, Mango
• Dry fruits

Meals

• Roti, Chapati, Rice
• Plenty of vegetables
• Black, Methi, Cabbage and salads such as Beet, Carrot, Cucumber
• Cooking should use minimum oil.
• Non-vegetarian foods may be taken only if tolerated.

General Advice

• Avoid heavy meals; eat small frequent meals.
• Avoid sleep for at least 2 hours after meals.
• Patients should have early dinner at 6 PM.

 

Acidity, Peptic Ulcer

Avoid

• Periods of starvation.
• Take small meals every 3 hours.
• Do not keep the stomach empty.
• Do not take heavy meals.
• Avoid tea & coffee on an empty stomach.
• Milk is good. Cold milk is preferred.
• Add Horlicks, Bournvita or Kesar for taste.
• For breakfast & snacks, take Bread or Toast with Jam, Cheese or Butter, Idli, Sheera, Cornflakes, Plain Khakhra.

Avoid

• Deep fried & hot foods such as Samosa, Pakoda, Masala Dosa, Hamburger.
• You may take sweets and cakes.
• All chillies.
• Chaat preparations.
• Sour fruits such as Citrus fruits, Imli, Grapes.

Take

• Sweet fruits.
• Dry fruits.

Meals

• Vegetables and other preparations should be non-spicy.
• Plenty of raw and boiled vegetables.
• Rice with plain dal or Roti.
• Jelly, Pudding or Ice-cream after meals may be taken.

During Acute Exacerbation

Take plenty of:

• Cold milk
• Chocolate milkshake
• Ice-cream

Take food without chillies, such as:

• Bread butter
• Rice with plain dal
• Boiled vegetables
• Khakhra
• Biscuits
• Sweet fruits
• Plain Idli

Continue until the acute phase is controlled.

 

Flatulence

Avoid

• Oily & fried foods such as Pakodas, Samosa, Namkeen, Potato chips, Puri, Bhaji.
• Tubers such as Potato, Sweet potato.
• Flatulence-producing foods such as Harbara (Chana), Chana dal, Peanuts, Brinjal.

Take

• Easily digestible foods.
• Wheat causes flatulence in many people, so Roti (Jowar) is preferred to Chapati (Wheat).
• Preparations should be less spicy.
• Vegetables rich in fibre should be taken in plenty.

General Advice

• Avoid aerated drinks.
• Avoid paan chewing and smoking.
• Avoid overeating.
• Do not sleep immediately after food.
• Have a small walk after each meal.

 

 

Chronic Constipation

Aim: Provide more roughage in the diet. Include fibrous vegetables such as Cabbage, Cauliflower, Palak, Cucumber, Lady’s finger, etc.

• Eat plenty of fruits with edible peels such as Apples, Pears (inner cover), Oranges (inner cover). Eat slightly ripe (slightly raw) bananas.
• Take 2 tsp of ghee with warm water early in the morning.
• For breakfast: Bread, Toast, Cornflakes.
• For meals: Plenty of salads and boiled vegetables, vegetable preparations, rice products/cereals and vegetables, with Roti.
• Avoid oily and fried foods. There is generally no restriction on any particular food.

 

Acute Diarrhoea

Principle: Take adequate quantities of water and electrolytes.

• Drink plenty of fluids:
• ORS (Electrolyte solutions)
• Lime water with salt and sugar
• Coconut water
• Black tea
• Buttermilk
• Soups
• Dal water
• Ganji
• Fruit juices
• Kokum syrup
• Avoid aerated drinks.
• Avoid milk.
• Avoid deep-fried foods.
• Avoid chillies.
• Prefer:
• Ripe bananas
• Bread
• Biscuits
• Once the acute phase is controlled, start a soft diet:
• Bread
• Toast
• Idli
• Sheera
• Cornflakes
• Soft rice
• Dry fruits
• Salads

 

Irritable Bowel Syndrome (IBS)

1. Eat small portions frequently and at leisure. Chew thoroughly.
2. Avoid hurried meals. If in a hurry, eat less.
3. The bulk of the diet should be food with soluble fibres:
• Rice & rice products (Idli, Pasta, Khakhra), Oatmeal, Cornflakes, Barley, White bread
• Potato, Sweet potato, Beet, Carrot, Pumpkin, Mushroom
• Ripe banana, Peeled apple
• Cook with minimum oil
4. Foods with insoluble fibres should be taken in small quantities, especially in IBS with constipation:
• Whole wheat flour (Chapati), Cereal bran, Beans, Seeds, Lentils, Popcorn
• Cabbage, Cauliflower, Broccoli, Peas, Sprouts, Grapes, Raisins, Cherry
5. Foods that may induce diarrhoea should be completely avoided:
• Milk & dairy products
• Fried foods (Pakodas, Namkeens, French fries), Spicy foods, Curry
• Oil, Butter, Chocolates, Artificial sweeteners
• Egg yolk, Red meat
• Coffee, Carbonated drinks, Alcohol

 

Jaundice

Principle: Fat-free diet.

• No oil, ghee, fried foods or alcohol.
• Plenty of sweets.
• Rice, Wheat, Jowar, Dals.
• Breakfast:
• Toast with jam
• Butter
• Plain Idli
• Tea with skimmed milk
• Meals:
• Rice
• Phulka
• Dal
• Kadhi
• Roti
• Tomato/vegetable soup
• Take all meals in small, frequent portions.

   

Ischemic Heart Disease (IHD)

Principle: Avoid fatty foods. If there is hypertension, avoid salt.

• Avoid:
• Unskimmed milk
• Butter
• Ghee
• Cheese
• Absolutely avoid saturated oils such as:
• Dalda
• Coconut oil
• Vanaspati oil
• Say NO to deep-fried foods:
• Puri
• Pakoda
• Samosa
• French fries
• Hamburger
• Cakes
• Avoid:
• Coconut
• Oilseed nuts (Groundnuts)
• Egg yolk
• Red meat
• Beef
• Duck
• Goose
• You may take a limited quantity of skimmed milk.
• Eat more:
• Vegetables
• Salads
• Sprouted pulses
• Fruits
• Soups
• Bhel
• Meals:
• Roti/Phulka without oil or ghee
• Vegetable preparations with no oil or minimum oil
• If oil is used, use polyunsaturated or unsaturated oil, alternately or in mixture.
• Onion and garlic are recommended.
• Non-vegetarian:
• Fish
• Limited quantity of egg white
• Lean meat with all visible fat removed.
• If hypertensive, avoid:
• Salt
• Pickles
• Papad
• Fast foods
• Tomato sauce
• Preserved/Tinned foods
• Salted biscuits

 

Tuberculosis

Principle: High-protein diet.

• Take milk with protein powder added 2–3 times daily.
• Eat more:
• Roti or Parathas
• Sprouted beans
• Pulses
• Non-vegetarians:
• One extra egg
• Meat

 

Osteoporosis

Principle: Diet rich in Calcium and Vitamin D.

For Calcium

• Take plenty of:
• Milk
• Curd
• Cheese
• Eat plenty of green leafy vegetables.
• Fruits:
• Guava
• Sitaphal (Custard apple)
• Seafood such as fish is rich in calcium.

Exercise

• Daily walk for 15–20 minutes.
• Weight-bearing exercises:
• Low-impact aerobic exercises
• Climbing stairs
• Running
• Do not perform muscle-building exercises such as:
• Weight lifting
• Bullworker
• Springs (not recommended in osteoporosis)

For Vitamin D

• Take:
• Eggs
• Liver
• Spend 15 minutes in sunlight, 2–3 times per week, to obtain natural Vitamin D.

 Gout

Avoid totally:

• Organ meat (Liver, Kidney, Brain, etc.)
• Fish
• Alcohol

Eat in moderation:

• Purine-rich vegetables:
• Cauliflower
• Spinach
• Mushroom
• High-fibre cereals with bran (e.g. Brown bread)
• Legumes
• Egg

No restriction:

• Refined grains
• White flour
• White bread
• Other vegetables
• Soups
• Coffee
• Fruit juices
• Sugar

Drink plenty of water and stay well hydrated.

 

Chronic Renal Failure

Principle: Take more proteins and calories. Restrict salt and potassium.

• Normal quantities of carbohydrates and fats are allowed:
• Rice
• Chapati
• Sugar
• Jaggery
• Potato
• Vegetables
• You may take:
• Oil
• Ghee
• Butter
• Milk products
• Meat
• If there is proteinuria, take plenty of:
• Dals
• Sprouted pulses
• Beans
• Soya bean
• Milk and milk products
• Meat
• Do not add salt while cooking or at the table.
• Avoid salt-rich foods:
• Pickles
• Papad
• Fast foods
• Pizza
• Sauce
• Salted biscuits

If serum potassium (K⁺) levels are high

Avoid:

• Chocolates
• Milk
• Potato
• Tomatoes
• Dry fruits
• Papaya
• Green leafy vegetables

Method to reduce potassium in vegetables:

• Cut vegetables into small pieces.
• Soak in water for 2 hours.
• Discard the water and cook in fresh water.

Allowed fruits:

• Apple
• Guava
• Papaya (small portions)

For Calcium

Take plenty of:

• Milk

Allowed fruits:

• Guava
• Sitaphal (Custard apple)
• Fish

If Serum Creatinine is High

Restrict protein intake.

If Phosphate Levels are High

Avoid:

• Chocolate
• Fudge
• Cake
• Nuts (Cashew, Peanut)
• Fish
• Meat

Eat less of:

• Dairy products
• Soya
• Yeast
• Eggs

If There is Weight Loss & Muscle Wasting

Increase calories:

• Butter
• Milk
• Ghee (if no IHD)

Take:

• Protein supplements
• Egg white (unless serum creatinine is very high)

 

Renal Stones

The most important advice is to drink plenty of fluids:

• 2–2.5 litres/day
• Drink enough to produce 250–300 mL urine every 3 hours.

Recommended fluids:

• Plain water
• Lemon water
• Barley water
• Coconut water
• ORS (Electrolyte solution)
• Black tea
• Soups

Avoid excess of:

• Milk and milk products
• Cheese (rich in calcium)

In Oxalate Stones

Reduce oxalate intake.

Avoid:

• Spinach (Palak)
• Chocolates
• Berries
• Brinjal
• Strawberries (small-seeded fruits)

 

Diet in Pregnancy

Principle: Diet should be rich in Iron, Protein, and Calcium to meet increased nutritional requirements.

• For Iron:
• Eat plenty of green leafy vegetables
• Pulses
• Meat

For Minerals

Eat fresh fruits regularly.

For Proteins

Take more of:

• Milk with protein powder
• Cereals
• Legumes
• Dal
• Rice
• Non-vegetarian foods: Egg, Meat

For Calcium

Take plenty of:

• Milk and milk products (Curd, Cheese)
• Green leafy vegetables

Among fruits:

• Guava
• Sitaphal (Custard Apple)

Also include:

• Dry fruits

During meals take:

• Soft rice or Ganji
• Salads
• Non-spicy vegetables
• Roti
• Chapati
• Fruits

Tea and coffee may be taken as tolerated.

Do not eat heavy meals. Chew cardamom.

 

Diet for Vomiting of Pregnancy

Principle: Eat small quantities at a time, mainly dry foods.

• Avoid all fried and oily foods.
• Avoid spicy and sour foods.
• Take small servings of:
• Fresh fruit juices
• Coconut water
• Cold milk
• Ice cream
• Take dry food every half to one hour, such as:
• Glucose biscuits
• Khakhra
• Bread sandwich
• Toast with jam
• Idli

 

Diet for Growing Children

Principle: Provide a well-balanced diet with more proteins, more calories, and good exercise.

Children in the growing age should increase the quantity of food by eating half to one extra roti and taking more milk in the diet. If needed, appetizers may be used to increase appetite.

For Proteins

Take more of:

• Milk with protein powder
• Cereals
• Legumes
• Dal
• Rice
• Non-vegetarian foods: Egg, Meat

For Minerals

Eat fresh fruits regularly.

  

DIET PRESCRIPTION

To be printed in Local Language

Legend:

·        Allowed = ✓

·        Not Allowed = ✗

·        Plenty = +++

·        Take Limited = L

 

Deep Fried Foods

☐ Samosa
☐ Dosa
☐ Udid Wada
☐ Pakodas
☐ Fried Papad
☐ Namkeens
☐ Potato Chips
☐ French Fries
☐ Puri

Sweets

☐ Sugar
☐ All Sweets
☐ Cakes
☐ Jam
☐ Honey
☐ Sweetened Biscuits
☐ Sweetened Drinks
☐ Fruit Shakes
☐ Sweet Fruits (Mango, Grapes)

Green Vegetables

☐ Cauliflower
☐ Cabbage
☐ Lady's Finger
☐ Tomato
☐ Brinjal
☐ Radish
☐ Pumpkin
☐ Cucumber

Tubers

☐ Potato
☐ Sweet Potato

 

Milk

☐ Milk
☐ Milk with Protein Powder
☐ Complan/Bournvita

Liquids

☐ Water
☐ Lime Water
☐ Coconut Water
☐ Electral Water
☐ Buttermilk

Hot Drinks

☐ Tea
☐ Coffee
☐ Herbal Tea
☐ Warm Milk
☐ Soups

Cold Drinks

☐ Aerated Drinks
☐ Ice Cream

Soft Foods (Breakfast Fast)

☐ Idli
☐ Sheera
☐ Bread
☐ Toast
☐ Khakhra

Soft Foods (Meals)

☐ Ganji (Rice/Sabu)
☐ Payasam
☐ Soft Rice with Milk/Ghee/Plain Dal
☐ Salads
☐ Boiled Vegetables

 

 

 

 

Regular Food (Breakfast)

☐ Upma
☐ Puri-Bhaji

Regular Food (Meals)

☐ Chapati
☐ Phulka
☐ Roti
☐ Spicy Vegetables

Fast Foods

☐ Hamburger
☐ Pizza

Fruits

☐ Banana
☐ Apple
☐ Pear
☐ Papaya
☐ Watermelon
☐ Mango

Sour Fruits

☐ Citrus Fruits (Orange, Lemon, Mosambi)

Dry Fruits

☐ Dates
☐ Manuka
☐ Pista
☐ Almond

Non-Veg

☐ Egg – White
☐ Yellow
☐ Omelet
☐ Boiled Egg

Meat

☐ Lean Meat

Sea Food

☐ Fish

Doctor's Signature: ____________________

  

Nutrition and Its Relation with Homoeopathy: Importance in Diet and Regimen

Introduction

Nutrition is the science of food and nutrients that are essential for the growth, maintenance, repair, and proper functioning of the human body. A balanced diet provides carbohydrates, proteins, fats, vitamins, minerals, water, and fiber in adequate amounts to maintain health and prevent disease.

Homoeopathy treats the patient as a whole, considering physical, mental, and emotional aspects. Along with the correct homoeopathic medicine, diet and regimen play a vital role in promoting recovery and maintaining health. Dr. Samuel Hahnemann emphasized that medicines alone cannot cure disease unless obstacles to recovery, including improper diet and unhealthy lifestyle, are removed.

 

Relation Between Nutrition and Homoeopathy

Homoeopathy and nutrition complement each other. While homoeopathic medicines stimulate the body's vital force to restore health, proper nutrition provides the necessary materials for healing and tissue repair.

The relationship includes:

1. Supports the Vital Force

Homoeopathic medicines act on the vital force, whereas good nutrition provides energy and nutrients that help maintain the body's natural healing capacity.

2. Promotes Faster Recovery

Adequate proteins, vitamins, and minerals help repair damaged tissues and strengthen immunity, allowing the homoeopathic remedy to act more effectively.

3. Prevents Nutritional Deficiencies

Deficiency of iron, calcium, vitamin A, vitamin D, vitamin B12, iodine, and other nutrients may delay recovery or aggravate disease. Correct nutrition prevents such deficiencies.

4. Improves Immune Function

Balanced nutrition enhances resistance to infections, reducing disease recurrence and improving long-term health.

5. Individualized Diet

Just as homoeopathic treatment is individualized, dietary advice should also be tailored according to:

• Age
• Constitution
• Disease condition
• Occupation
• Climate
• Digestive capacity
• Lifestyle

 

Importance of Nutrition in Homoeopathic Diet and Regimen

Diet and regimen are essential parts of homoeopathic treatment because they remove obstacles to cure and support the action of the indicated remedy.

1. Removes Obstacles to Cure

Improper food habits, alcohol, tobacco, excessive stimulants, and unhealthy lifestyles may interfere with recovery. Correct nutrition removes these obstacles.

2. Enhances the Action of Medicines

A wholesome, balanced diet allows homoeopathic remedies to act efficiently without unnecessary interference.

3. Maintains General Health

Good nutrition:

• Improves physical strength
• Maintains ideal body weight
• Increases stamina
• Supports mental well-being

4. Helps in Disease Prevention

Balanced nutrition reduces the risk of:

• Malnutrition
• Diabetes mellitus
• Hypertension
• Obesity
• Cardiovascular diseases
• Osteoporosis
• Nutritional deficiencies

5. Provides Disease-Specific Dietary Support

Examples include:

• High-protein diet in tuberculosis and protein-energy malnutrition.
• Low-fat diet in ischemic heart disease.
• Low-salt diet in hypertension.
• Low-purine diet in gout.
• High-calcium diet in osteoporosis.
• Iron-rich diet in anemia.
• High-fiber diet in constipation.

 

Hahnemann's View on Diet and Regimen

Dr. Samuel Hahnemann emphasized that the physician should regulate the patient's diet and lifestyle during treatment.

According to the Organon of Medicine, proper diet and regimen include:

• Pure and wholesome food.
• Regular meals.
• Adequate sleep and rest.
• Personal hygiene.
• Fresh air and sunlight.
• Moderate exercise.
• Mental tranquility.
• Avoidance of excesses in food and drink.
• Avoidance of alcohol, tobacco, and other harmful habits.

These measures help remove maintaining causes of disease and promote cure.

 

General Dietary Advice During Homoeopathic Treatment

• Eat a balanced diet rich in fruits and vegetables.
• Drink adequate clean water.
• Include whole grains and dietary fiber.
• Consume adequate protein.
• Limit refined sugar and processed foods.
• Avoid overeating.
• Reduce excessive tea, coffee, alcohol, and tobacco.
• Maintain regular meal timings.
• Exercise regularly.
• Ensure sufficient sleep and stress management.