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Section 6 : Nutrition in Public Health127 Introduction to Nutrition in Public health Rajul K Gupta 712

128 The Proximate Principles and Energy Rajul K Gupta 717

129 Micronutrients : The Vitamins Rajul K Gupta 725

130 The Micronutrients : Minerals Rajul K Gupta 734

131 Major Foods and their Nutritive Value Rajul K Gupta 741

132Nutritional Requirements of Special Groups: Mothers, Children and the Elderly

Rajul K Gupta 750

133 Nutritional Deficiency Diseases of Public Health Importance Rajul K Gupta 758

134Public Health Aspects of Food Hygiene & Sanitary Regulation of Eating Establishments

Rajul K Gupta 771

135 Nutritional Programmes in India Rajul K Gupta 778

136 Nutritional Assessment and Surveillance of a Community Rajul K Gupta 783

137Food Processing, Food Adulteration, Food Additives, Preservatives, Food Toxicants and Food Fortification

Rajul K Gupta 791

138Nutrition during Special Situations : Disasters, Fairs and Festivals, Community Feeding of Children

Rajul K Gupta 798

139 Nutrition Tables Rajul K Gupta 804

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127 Introduction to Nutrition in Public health

Rajul K Gupta

The term ‘Nutrition’ is derived from a Latin word nutritic, meaning nourishment (1). Nutrition can be considered to be the foundation of good health and freedom from disease. ‘Nutrition science’ has been comprehensively defined by Robinson as ‘The science of foods, nutrients and other substances therein; their action, interaction and balance in relationship to health and disease; the processes by which the organism ingests, digests, absorbs, transports and utilizes nutrients and disposes off their end products…” (2). Simply put the word nutrition is used to refer to the processes of the intake, digestion and assimilation of nutrients and the application of this knowledge to maintain health and combat disease. See Box - 1.

Box - 1 : Significance of nutrition

Adequate nutrition is required for growth, development and maintenance of normal functions

Under nutrition contributes to 60% deaths amongst under five children (WHO, 2002)

More than 85% children in India suffer from malnutrition (44% Mild malnutrition, 38% moderate malnutrition and 4.6% severe malnutrition) (Gomez classification, NNMB 2007)

About 55% men and 75% non pregnant non lactating women are anaemic

Epidemiological data shows strong association between under nutrition and morbidity / mortality

Chronic degenerative disorders such as coronary artery disease, hypertension, type 2 diabetes, certain cancers, etc are related to diet and nutritional status

Obesity is associated with higher risk of developing cancer breast, colon, endometrium, gallbladder, esophagus, pancreas, etc.

Consumption of foods rich in dietary fibre and antioxidants is associated with reduced risk of certain cancers

Under nutrition during foetal and early childhood is known to be associated with chronic degenerative disorders in later life

Good nutrition is a fundamental requirement for positive health, functional efficiency and productivity. Nutritional status is internationally recognized as an indicator of national development. Nutrition is both an input into and an output of, the developmental process (3).

Nutrition is an extremely dynamic subject that changes every day. Continuous research and a constant study into nutrition therefore remains a subject of contemporary interest.

HistoryIt is believed that Hippocrates, the Father of Medicine, paid strict attention to the diet of his patients as a feature of his

therapeutic regimens. For instance, his dietetic prescriptions reveal a close relationship of effects of individual foods on both sick and the well. Pulses, he said, should be eaten with cereals. The obese should be advised to labour much, drink little…. Remedial foods have been suggested for fever, ‘hot intestines’, dysentery, melancholic disorders etc. (4, 5). Ancient Indian texts give adequate indication of the importance that diet and nutrition were accorded during ancient times (Box - 2).

Box - 2 : Aahara, Vichara, Yoga and Ayurveda : The Ancient Indian wisdom

Aahara or the dietary philosophy has been central to the concept of ancient Indian system of medicine, Ayurveda. Prudent food with a strict dietary discipline was the hallmark of ancient Indian lifestyle and one of the secrets of a long and healthy life which the Indians enjoyed in the Vedic times. As per the principles of Ayurveda, the diet is supposed to change with the time of the day and seasons. ‘Hot’ and ‘cold’ temperaments of the food are supposed to be balanced with the weather, seasons and climate. These dictums were ingrained in the lifestyle along with good and noble thoughts (vichara) and the discipline of life (Yoga) for a long lasting good health and the ultimate union with the supreme power. Can we learn something from this traditional Indian wisdom!

The phrase ‘science of nutrition’ was first used probably by Count Rumond in an essay on feeding poor people in 1795 (6). During the same period Lavoisier who was working on combustion and respiratory metabolism, is said to have established nutrition as a science (7). In 1753 James Lind published the first edition of A Treatise on the Scurvy which elaborated how 110 men were disabled by scurvy and were miraculously cured by an Indian remedy (the infusion of the needles of an evergreen tree). Lind was also the first one to study experimentally the value of different substances in the treatment of scurvy, and proved that dietary lemons and oranges cured scurvy (5).

In 1839, a Dutch physician Gerrit Mulder claimed that complex nitrogen compounds like egg albumin, serum albumin, fibrin and wheat gluten all contained a common radical, ‘protein’ (8). Marasmus was described in the year 1877 by Jules Poirot from France under the term “athrepesie”.

The science of nutrition bloomed during the 20th century. Vitamins and amino acids were discovered, human nutritional requirements were established and the relationship between diet, nutrition and the human body in health and disease were recognized. These scientific advances evolved through several phases. Lafayette B. Mender (USA) identified the nutritive value of proteins during 1909-1928. In due course, various experiments and observations by different workers pointed towards some unknown food factors that were vital for the very sustenance of life. JBA Dumas (1871) was the earliest man of science to question the adequacy of diet composed only of proteins, carbohydrates, fats and salts. He had published his observations on the health of infants of Paris made during the siege by the Germans. Pekelharing demonstrated in 1905 the existence of unidentified nutrients in milk and why they were absolutely essential for survival of mice in minute quantities.

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In 1912 Casimir Funk (Poland) propounded the theory that beriberi, scurvy, pellagra and possibly rickets were caused by deficiency of “special substances which are of the nature of organic bases” and coined the term ‘vitamine’. Thus the new concept of dietary deficiency diseases was born. In 1926 Goldberger and Lillie described malnutrition in rats also featuring growth arrest, ‘ophthalmia’, hair loss on ears, neck, chest and forearms etc. Fur became matted and fell exposing denuded pale pink skin. Oral and lingual ulcers and fissuring were also noticed. Diarrhoea was also seen in some rats. The condition was diagnosed as rat pellagra. Lean meat and yeast cured it. The curative agent was designated by Goldberger and Lillie as pellagra-preventive (P-P) factor. However, later it was found that this condition (in rats) was not analogous to human pellagra, but was caused due to the deficiency of riboflavin.

The dangerous disease Pellagra was earlier described in Northern Spain in 1735 by Casal. However, scientific world had to wait till Goldberger undertook a study in 1915. He studied the diets of patients and medical staff in State Asylums in South Carolina, Georgia and Mississipi. This study proved that the disease was caused by a deficiency rather than a poison or infection. The search for the pellagra preventing factor travelled through high proteins, yeast and liver and ended with the isolation of nicotinic acid from rice polishings by Funk in 1912. Many other workers also isolated this chemical from other food stuffs (5).

Verner McCollum (USA) discovered a fat soluble soluble factor that was essential for growth (Vitamin A) in l916 (6). Chick, Windaus and Hess worked on Vitamin D, Evans and Bishop on Vitamin E, King and Gyorgy on Vitamin C, Dam on Vitamin K, Mitchell, Snell and Williams on folic acid and Hodjkin on Vitamin B.

McCance, Mac Kay, Widdowson, McLaren and Woodruff did pioneering work on iron deficiency. Ciceley Williams (England) described Kwashiorkar in 1933. Kerpel Fronuis, Gomez and Cravioto also worked on protein calorie deficiency.

Great debate started in the sixties and seventies on the causation and relationship between marasmus and kwashiorkor where eminent nutritional scientists, Waterlow, Gopalan, Scrimshaw, McLaren and others participated. Various studies on protein and energy requirements, the role of infection, metabolic and endocrine changes, and adaptation were carried out. Derrick Jelliffe, a pioneer in nutrition introduced the term ‘protein- calorie’ malnutrition, which was later modified to protein energy malnutrition and adopted by the FAO/WHO committee in 1971 to describe both kwashiorkor and marasmus.

Into the 21st century : The era of interdisciplinary coordinationAgriculture cannot be kept away from nutrition. Great advances in agriculture were achieved with the green revolution in India. The introduction of genetically engineered food during the last decades of the twentieth century was followed by an ongoing international scientific debate. Parallel advances were achieved in animal nutrition and veterinary medicine, which increased animal food production. The relationship between mad cow disease and animal food as well as its relationship to Cruetzfeld Jacob disease in the humans is stimulating further

research on animal nutrition, communicable disease and food safety. The bird flu endemic has once again opened the Pandora’s Box : ‘Are the non-vegetarian foods safe enough?’ (9). Fierce research is on, to answer these questions through the integrated effort of multidisciplinary forces… medicine, virology, veterinary medicine, nutrition, food technology, public health, epidemiology, genetics, biotechnology, mathematical modelling, information technology…. These and many other advances in nutritional sciences represent the ceaseless effort, genuine initiative and devotion of many pioneer scientists all over the world through out the ages.

Food and Nutrients : Major Categories of Foods and NutrientsFood : Food is a substance eaten or drunk to maintain life and growth. The foods are generally classified into cereals (wheat, rice, maize etc.), legumes (pulses and peas), nuts and oilseeds, vegetables, fruits, milk and milk products and flesh foods (fish, meat and chicken and egg). Diet, on the other hand is what a person habitually eats and drinks.

Nutrients : The nutrients are chemical substances that are present in the food we eat. The important nutrients are proteins, fats, carbohydrates, vitamins and minerals. Foods contain various nutrients in different proportions. Depending on the relative concentration of various nutrients foods can be classified into protein, carbohydrate or fat rich foods.

Why do we eat food? - Functions of food : We eat to satisfy hunger (satiety) and to get energy for our day to day functioning. Food serves many functions in the body :

a) Food builds body tissues : The structural materials of food, proteins, minerals, vitamins and water are needed for growth and development. The food is also needed for the maintenance of the cells and tissues.

b) Food regulates body processes : Many a body processes are regulated by the ‘fuel’ supplied through food e.g. temperature control of the body (calories), control of osmotic pressure (proteins and electrolytes), maintenance of hydrogen ion concentration (pH through electrolytes), solvent power of fluids (proteins and water), nerve conduction (minerals), muscle elasticity (minerals), innumerable metabolic processes (vitamins and minerals).

c) Food supplies energy : The macronutrients (carbohydrates, proteins and fats) supply energy. These provide constant source of fuel to the body. It is measured in terms of a kilo calorie.

d) Food gives us enjoyment : We want to enjoy food and entertain our guests with tasty food.

These requirements may be met by various combinations of the three major food constituents : carbohydrates, proteins & fats, taken in different proportions. Although the actual distribution of each one of these nutrients in our daily diet is vital for good health, one hardly considers their proportion, as long as he enjoys the food. It must be appreciated that our lifestyle governs all facets of our life including our eating habits.

The community faces major nutritional problems from the consumption of inadequate or imbalanced diet. This is true for both healthy and sick. Economic prosperity and affluence, at least in a section of the society, are now threatening the

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community through over nutrition and its related hazards.

From Under-Nutrition to Over-NutritionWithin the past few decades, there has been a significant reduction in cases of nutritional deficiencies. Classical nutritional deficiency syndromes of florid pellagra, beriberi, scurvy or kwashiorkor have almost disappeared. We do not come across the famines any more. This improved scenario is a result of multiple inputs namely, smaller families, better food security, economic development, improved health systems, conquest of infections, better health awareness and accountable governance. It is seen that malnutrition among preschoolers has reduced appreciably and nutritional status of adults too has improved significantly. There is not only a major reduction in malnutrition, but over the past decade or so we have stepped into the realm of over nutrition. The number of overweight and obese is steadily and alarmingly rising in India. This is owing to the rapid lifestyle changes that have swept India. Mechanization, motorization, static entertainment (television and computers), sedentary life, low physical activity and the fast food culture has taken its toll. The situation is so alarming that there is a recommendation to redrawn BMI standards with a more stringent ‘pen’, in a hope to stall the rapid progression of lifestyle diseases - diabetes, hypertension and the coronary artery disease.

The Interplay between Malnutrition and InfectionThere has been a close association between malnutrition and infections (Fig. - 1). It is a vicious cycle that is difficult to break in the setting of poverty, ignorance and lack of health services.

Fig. - 1 : The vicious cycle of malnutrition and infections

Increasedmetabolic rate & tissue

damage.Low immunity

Nutrients:Extra need &Poor supply

SevereMalnourishment

Need for extranutrients andalso reduced

appetite

In GI infectionsnutrient absorption

diminished

Let’s take fever as an example. The raised temperature escalates the metabolic rate and thus increases the nutritional demand; it also increases the tissue breakdown further putting an extra nutritional load on the system. In almost all infections the appetite goes down and the absorption and assimilation is also hampered. The requirement of nutrients is increased and to make matters worse, the supply is diminished and the absorption is reduced. The body can cope up with this situation for few days but subsequently acute severe malnutrition develops. Repeated

attacks of acute respiratory or acute diarrhoeal infections are notorious to lead to a malnourished state. Measles is another dangerous condition that has a lasting negative effect on the system through compromised immunity, micronutrient deficiency and severe malnutrition.

Malnutrition in childhood diminishes the proper development of the immune response mechanism. The cellular immune responses are markedly impaired leading to a higher mortality from the seemingly common infections.

Variability in Nutritional RequirementsEven though there is a concept of standard requirements and intakes, it must not be forgotten that each person has unique nutritional requirements. This is because each one of us has a unique genetic make up and body biochemistry. A nutrient intake sufficient for one person may be inadequate for other. There are many references in literature where it is quoted that where 2 mg Vitamin B6 is normally adequate for most but there are individuals with inherited defects in B6 metabolism and need 30 to 100 times that amount. Similarly the absorption and daily requirements of Calcium varies 3 to 5 folds in various normal individuals. The same can be said for Vitamin D and Iron where metabolic differences in handling these nutrients alter their requirement.

Besides these genetic differences, many other factors can also alter daily requirements, including age, environment and life style choices. Factors as diverse as pregnancy, lactation, sports training, smoking and pollutants can cause nutritional needs to vary. Some of these factors are summarized in the Box - 3.

Box - 3 : Factors altering the daily requirement of nutrients

Biochemical individuality Genetic differences

Gender Pregnancy

Lactation Growth

Infections Other diseases

Surgery Drug-Nutrient interaction

Smoking Alcohol

Caffeine Environmental pollutants

Activity Exercise levelDiet factors e.g. intake of : Carbohydrates; Fat; Fibre; Proteins

Dietary Standards : Concept of Recommended Dietary Allowance (RDA)It is extremely important to plan the rations and food supplies for various groups, may it be the general community or a specialized group like the armed forces, a school or a prison.

For such a planning we must have a set of standard allowances that are universally acceptable and followed. The first such example (for cereals) can be traced back to ancient Rome (see Box - 4). The concept of various macro-nutrients first evolved in the nineteenth century. At that time the dietary requirements were stated in terms of nutrients rather than foods. In the early twentieth century vitamins came on the landscape and their requirements were also worked out and stated (10).

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Box - 4 : The Roman Pound of Wheat

The concept of recommended allowance for the day probably came from the Romans. The Romans gave their legionaries a ration of one ‘librum’ of wheat per day and that was supposed to meet their caloric requirement for the day. The ‘librum’ became the British Pound (abbreviated to and still used as ‘lb’). One pound of cereal is now known to be good enough to provide energy needed for an adult man for resting metabolism.

Recommended Dietary Allowances or Intakes (RDA or RDI) The RDA of a nutrient is the amount (of that nutrient) sufficient for the maintenance of health in nearly all people (11). In other words these are the estimates of nutrient intakes which individuals in a population group need to consume to ensure that the physiological needs of all subjects in that population are met. It is an estimate that corresponds to mean intake of the given nutrient + 2 Standard Deviation (that is about 25% of the mean has been added). It covers the requirement of 97.5% of the population. This is the safe level of intake and the chances of this level being inadequate is not more than 2.5%. This ‘safe level’ approach is however not used for defining the energy requirement, as any excess of energy intake is as undesirable as its inadequate intake. Hence for defining the RDA of energy only the average requirement is considered. The recommended dietary allowances for Indians are summarized in Table - 1 in ‘Chapter on Nutritional Tables’.

Can the RDA be Applied to Individuals?It must be appreciated that the RDA is the mean requirement figure for a nutrient (except energy), to which an allowance corresponding to 2 SD has been added. There are several individuals in a population whose requirement is actually well below or above the RDA. If all the students in a class of 100 were to eat food exactly as per their RDA about half would loose and the other half would gain weight, to the extent of being seriously undernourished or obese after a year! It is because the RDA for energy is a catering average; individuals however consume as per their appetite, which follows their energy expenditure. The RDA can therefore, not be used as standard to determine whether or not a given individual’s requirement of a nutrient has been met. It is therefore important to keep the principles of probability in mind and be cautious, when applying RDA at an individual level (10).

RDAs provide a standard against which the nutrients in the food eaten by a section of the community /country can be assessed. It is thus possible to find out a group with a low intake of a particular nutrient. Further nutritional investigations are then mounted to go into the details and suitable measures can be recommended. As discussed earlier, RDAs should not be used to assess the diet of an individual patient as they are designed to be on the higher side than the average individual requirement. Whenever diets are required to be planned for a group like the armed forces, a school, hostel etc., the diet should meet the RDA. Similarly, RDAs are the starting point for the food and economic planning for the agricultural, economic and food sectors. The national level food balance sheets are prepared

keeping the RDAs in mind.

Reference Man and WomanThe final goal of all nutritional policies and recommendations at a national level is to provide adequate nutrition to its population in order to attain their full genetic potential of growth and development. It is important that the ideal/desirable weights and heights are considered to recommend nutrient intakes. For this purpose the ICMR expert committee recommended reference weights for adult men and women to be 60 Kg and 50 Kg respectively.

Reference Indian Adult Man : Reference Indian adult man is between 20-39 years of age and weighs 60 Kg. He is free from disease and physically fit for work. On each working day he is employed for 8 hours in occupation that usually involves moderate activity. While not at work he spends 8 hours in bed, 4-6 hours sitting and moving about and 2 hours in walking and in active recreation or household duties.

Reference Indian Adult Woman : Reference Indian adult woman is between 20-39 years of age and healthy; she weighs 50 Kg. She may be engaged in general household work, in light industry or in any other moderately active work for 8 hours. While not at work she spends 8 hours in bed, 4-6 hours sitting and moving about in light activity and 2 hours in walking or active household chores.Energy requirements for sedentary, moderate and hard work (12) : Energy requirements of an individual vary over a wide range depending upon the sex, age, body size, BMR and degree of physical activity. As it has been discussed earlier, energy requirements are given in terms of a Reference man/woman. Energy requirements for other individuals with different weights and age have to be calculated.

The classification of physical activity as sedentary, moderate and heavy is essentially based on the occupational activity. Some more examples are given in the Box - 5. The energy requirements for these three categories are summarized in Table 1.

Box - 5 : Some examples : Sedentary, moderate and hard workers

Sedentary worker : Teacher, tailor, barber, priest, executive, peon, retired personnel, shoe maker, housewife, maid, nurse, doctor, clerk, shopkeeper, manager, goldsmith etc.

Moderate worker : Potter, basket maker, carpenter, mason, electrician, fitter, turner, driver, welder, fisherman, coolie, site supervisor, post man etc.

Heavy worker : Stone cutter, blacksmith, mine worker, wood cutter, farm labourer, army soldier etc.

Table - 1 : Energy Requirements of Reference Indian Man and Woman

Sex Body weight (Kg) Activity levels

Sedentary Moderate Heavy

Male 60 2425 2875 3800

Female 50 1875 2225 2925

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Prevention of Nutritional Disease and Upkeep of Nutrition in the Community - Role of Individuals, Family, Communities and GovernmentsIt can be well appreciated that it is not merely the ‘nutritional’ factors that are responsible for nutritional disease. These conditions are truly multi-factorial in origin and progression. The scarcity of food, its nutritional value, distribution, balance in diet, cultural, local and religious factors and beliefs, other social factors like ignorance, poverty, taboos, fads, peer pressure, education, hygiene and sanitation practices, infections, availability of health services, level of immunization services, political will, corporate interests, national commitment, international influences like trade laws and treaties, export-import dynamics and compulsions, inter country relations, the state of global warming - each one of these have a bearing on the nutritional status of a society. When the etiology is so diverse, the prevention too has to be so much broad based and multifaceted. The issue can be tackled at the levels of the individual, family, community and governments.

Individual level : Health begins with the individual. The individual has to take care of himself. Selecting the correct kind of food is vital, based on his age, physiological state, taste and tradition. Besides good diet, physical activity, adequate sleep, mental peace and appropriate meditative or religious activities go a long way in keeping an individual healthy. Knowing the nearest health centre, services available there and warning signs of common illnesses is also important.

Family level : Most of the foods are ‘handed over’ to us through traditions, and it is not easy to break out of those. Within that framework, it might be decided by the head of the family as to what food stuff is to be brought, cooked or eaten. The family needs to be aware and educated on the issues of nutrition to select the correct foods in different situations of infancy, childhood, pregnancy or lactation. This can happen only when they have risen above the myths, taboos, fads and misconceptions encompassing foods. Misleading advertisements must be put in the right perspective. Children must be explained the hazards of junk food and food additives. Traditional values with respect to food must be highlighted. The family foods used during pregnancy, lactation and weaning must be acknowledged. Locally available foods that are easily available, cheap, fresh and suitable to a particular season are ideal and must be consumed in preference to ‘imported’ foods. A small kitchen garden will go a long way not only in appreciating good and wholesome food but also in fulfilling the nutritional needs of the family in the most inexpensive and enjoyable manner. The most crucial nutritional decisions are taken at the family level, so the family must be empowered through correct knowledge.

Community level : There might be a number of bottlenecks that exist at a local level which prevent the national programmes reach the grassroot. It is up to the community to meet this challenge of making these programmes actually beneficial to the people. For example the Gram Sabha, the local ICDS unit (Anganwadi) etc. must be aware of their rights and duties, and whom to approach in case of neglect. The community must be organized and ‘live’ up to these needs, otherwise they will have to be satisfied with whatever is ‘served’ to them!

Government level : The responsibility of maintaining the health of individuals lies with the state. The government endeavors to provide all the health services possible. Various nutritional programmes are being implemented as direct intervention to improve the nutritional status of the community. Noteworthy of these are the ICDS Programme, Balwadi nutrition programme and the Special Nutrition programme under the Ministry of Social welfare. Ministry of Health and Family Welfare runs the Nutritional anaemia prophylaxis programme, Iodine deficiency disorders control programme and the Vitamin A prophylaxis programme. The Mid Day Meal programme (for primary children) is being run by the Ministry of Education.

Besides these various indirect measures are being taken by the government for rural development, increasing agricultural production, population stabilization and improving the public distribution system. Research in the field of nutrition is being carried out at premier institutions like the National Institute of Nutrition at Hyderabad that has contributed to offering solutions to nutritional problems.

SummaryThe science of foods and nutrients and their action, interaction and balance in relationship to health and disease; the processes by which the organism ingests, digests, absorbs, transports and utilizes nutrients and disposes off their end products is termed as nutrition. Good nutrition is a fundamental requirement for positive health, functional efficiency and productivity. There has been a close association between malnutrition and infections. It is a vicious cycle that perpetuates in the setting of poverty, ignorance and lack of health services.

The variation in the daily requirements of nutrients depends on the genetic differences, age, environment and life style choices. Factors as diverse as pregnancy, lactation, sports training, smoking and pollutants can also cause nutritional needs to vary. However a set of universally acceptable standard nutrient allowances have been devised that are useful to plan the rations and food supplies for diverse groups. The RDA of a nutrient is the amount (of that nutrient) sufficient for the maintenance of health in nearly all people. The RDA is based on the concept of Reference Indian man and woman.

Study ExercisesLong Question : Discuss the role of individual, family, community and government in the prevention of nutrition related diseases.

Short Notes : (1) Indian reference man (2) Nutritional requirement of sedentary man (3) Malnutrition-infection cycle

MCQs1. Who coined the term ‘vitamin’ : (a) McCollum (b) Funk

(c) Hopkins (d) James Lind2. A teacher will be classified as a (a) Sedentary worker

(b) Moderate worker (c) Heavy worker (d) Average worker3. A ‘safety margin’ of + 2 SD is not incorporated for the

RDA of (a) Energy (b) Fats (c) Water soluble vitamins (d) Fat soluble vitamins

4. Which of the following diseases is most notorious to prove fatal in combination with malnutrition : (a) Tetanus (b) Anaemia (c) Measles (d) Diarrhoea

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5. Choosing what type of food to eat in a household is the function of the (a) Family (b) Government (c) Community (d) Any of the above

Answers : (1) b ; (2) a ; (3) a ; (4) c ; (5) a.

ReferencesNix Staci. Williams Basic Nutrition and Diet Therapy. 12th edition. Mosby, 1. Elsevier. Missouri, USA. 2005Bamji MS, Rao NP, Reddy V. Textbook of Human Nutrition. 2nd ed. Oxford & 2. IBH Publishing Co Pvt Ltd, New Delhi.2003.Report of the Working Group on Integrating Nutrition with Health for the 3. XI Five Year Plan (2007-2012 Government Of India Ministry Of Women And Child Development November 2006.Hippocrates, the authentic writings of; Translated by Adams F. Wm Wood 4. and Company., New York, 1929; Vol 1, 272-277 and Vol 2 42, 193-98.

Mc Collum EV. A history of Nutrition, Boston, Houghton Miffin Company, 5. 1957.Todhunter EN. Chronology of some events in the development and application 6. of the science of Nutrition. Nutrition Reviews, 1976, 34 : 354- 375.Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and 7. Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.Mahan LK, Stump SL. Krause’s Food, Nutrition & diet therapy.11th edition 8. Saunder’s Philadelphia, USA. 2000Gabr M. IUNS in the 21st century on the shoulders of 20th century giants of 9. nutrition. In : Modern Aspects of Nutrition, Present knowledge and Future Perspectives. Eds Elmadfa I, Anklam E, Konig JS. 2003. 56 : 13-18Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and 10. Dietetics. Churchill Livingstone, ELBS London. 1986.World Health Organization. Technical Report Series no. 477; 1971.11. National Institute of Nutrition, Nutritional requirements and recommended 12. dietary allowances for Indians; A report of the ICMR, 2004.

128 The Proximate Principles and Energy

Rajul K Gupta

The human body requires various nutrients for survival, maintenance of health and to prevent disease. Proteins, fats, carbohydrates, vitamins, minerals and antioxidants are the most important of these. Proteins, fats and carbohydrates are the ones which form the backbone of the nutrients in terms of quantity and these are termed as the proximate principles of food. In order to appreciate the influence of food on health and the factors which affect food requirements, it is necessary to know the chemical composition of food and its metabolism in man. The most primary function of food is to be broken down in the body to generate energy, which is vital for the very survival of the body.

Energy for basal functions, work metabolism and heat for maintenance of body temperature is produced by the oxidation of carbohydrates, fats and proteins. The intake of food is normally balanced by hunger which thus, indirectly balances energy expenditure. Hunger may, however, not indicate this in various pathological states, notably in certain forms of malnutrition. Moreover, hunger can be modified not only by enough intake of food but also by doing less muscular work. Absence of hunger is not, therefore, necessarily an index of an adequate food intake. Before going into the biochemical and physiological qualities of food let us dwell on the basics of energy.

EnergyEnergy is required for maintaining the body temperature and vital activity of organs, for mechanical work and for growth. Even when an individual is at complete rest and no physical work is being carried out, energy is required for the activity

of internal organs and to maintain the body temperature. This energy is required for maintaining the basal or resting metabolism. Age, sex, height, weight and state of nutrition of the individual are some of the factors that influence it. The Basal Metabolic Rate (BMR) is determined experimentally when the subject is lying down at complete physical and mental rest, wearing light clothing in a thermo-neutral environment and in the post absorptive state (at least 12 hours after the last meal). The BMR is related more closely to lean body mass (fat free body) rather than to the surface area. The reported value of BMR for Indians is 1 Kcal / Kg/ hr.

Units of EnergyCalorie is the basic unit of energy. Kilo calorie is defined as the heat required to raise the temperature of 1 Kg of water by 1°C from 14.5°C to 15.5°C. The Joule (J) is the SI unit of energy. It is defined as the energy expended when a mass of one kilogram is moved one meter by a force of one Newton (N). Since Joule is too small a unit to describe the energy value of diet, kilo Joule (KJ) and mega Joule (MJ) are of more practical use. One KJ is equal to 1000 J and one MJ is equal to 1000 KJ. However, the old unit of energy, namely, kilocalorie (Kcal) has been in use in nutrition for a long time and is still being used (1, 2). For conversion, 1 Kcal = 4.184 KJ and 1 KJ = 0.239 Kcal. Energy contents of common food items are shown in Table -1 & 2 :

ProteinsProteins are large molecules made up of nitrogen containing amino acids that are united together by peptide linkages. In adults approximately 16% of body weight is attributable to proteins. Next to water, protein is the major component of body tissues. Proteins are indispensable constituents of living protoplasm as they participate in all vital processes. Proteins are macromolecules consisting of amino acid chains. The human body has a limited capacity of converting one aminoacid into another (1, 4). A total of 22 aminoacids are now known to be physiologically important for the human body. Under proper conditions, the body is capable of synthesizing some of

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these amino acids, provided the supply of nitrogen is adequate. These amino acids are known as nonessential amino acids. Others cannot be synthesized by the body and must therefore be supplied in diet. These are the eight essential amino acids viz. leucine, isoleucine, lysine, valine, methionine, threonine, tryptophan and phenylalanine. To these may be added histidine which appears to be essential for the growth of infants (5, 6).

Sources of proteins : There are two main dietary sources of proteins :

(a) Animal Sources : These include eggs, milk, meat and fish

(b) Vegetable Sources : Pulses, nuts, cereals, beans and

oilseed cakes

The major sources of proteins are depicted in Table - 3.

Role in health and disease : The important functions of proteins are summarized in the Box- 1.

Quality of ProteinsThe nutritive value of a protein depends upon its amino acid composition. A biologically complete protein is one which contains all the essential amino acids in adequate amounts to meet human requirements. Proteins from foodstuffs of animal origin, such as milk, meat and eggs are biologically superior to proteins of vegetable origin as animal proteins have all the

Table 1 : Major contributors of energy to our diet - (Some raw foods and their energy content per 100g) (1)

Food stuffEnergy (Kcal)

Food stuffEnergy (Kcal)

Cereals & Millets Non vegetarian foods

Wheat flour 341 Egg (hen) 173

Rice polished 345 Fish (Hilsa) 273

Bajra 361 Chicken 109

Maize dry 342 Mutton (lean) 118

Ragi 328 Pork (muscle) 114

Pulses & Legumes Milk & milk products

Bengal gram 360 Milk, cow 67

Soya bean 432 Milk, buffalo 117

Rajmah 346 Milk, human 65

Redgram (Arhar) 335 Butter 729

Greengram (Moong)

334Ghee

900

Lentil (Masoor) 343 Cheese 348

Pea dry 315 Curd 60

Fruits & Vegetables Nuts

Banana 116 Groundnut 567

Apple 59 Cashew nut 596

Grapes, pale green 71 Coconut, fresh 444

Custard apple 104 Miscellaneous

Jack fruit 88 Jaggery 383

Raisins 308 Sugar 398

Potato 97 Veg oils 900

Table 2 : Energy content of selected Indian food items (per serving) (3)

Food item Kcal Food item Kcal

Samosa (1 no.) 256 Dalia (1 plate) 80

Masala dosa (1 no.) 360 Khichri (1 plate) 160

Kachori (2 nos.) 500 Biscuits (4 nos.) 150

Omlette (1 egg) 236 Poha (1 plate) 120

Puri (4 nos. x 25 g each)

320 Bread (2 slices) 125

Chapati with ghee (4 nos.)

360 Chapati ( 2 nos. x 35 g each)

160

Cake (1 small piece) 250 Kheer (1 katori) 120

Butter chicken (1 katori)

400 Cornflakes (1 bowl) 190

Chiken biryani (200 g)

400 Veg salad 50

Malai paneer (1 katori)

270 Butter milk (1 glass) 90

Paratha (2 nos. x 50 g each)

360 Jam (1table spoon) 40

Ice cream (100 ml) 250 Dhokla (2 pcs) 100

Pastry (1 no.) 290 Green leafy veg (1 katori)

130

Milk cake (1 piece) 300 Idli (2 nos. x 55 g each)

155

Butter (2 table spoon) 180 Dosa (2 nos. x 45 g each)

250

Fried Cashew (50 g) 375 Tinned cheese (2 tbsp)

105

Box - 1: Functions of Proteins

(a) Proteins are important for body building, growth, repair and maintenance of body tissues

(b) Proteins are required for the synthesis of plasma proteins, haemoglobin, enzymes and hormones

(c) Proteins like collagen, actin and myosin form the structural tissues - skin and muscles

(d) Proteins act as transport carriers for many molecules like iron, haemoglobin, lipids etc.

(e) Antibodies are also proteins. Proteins are involved in the acute phase of inflammation as well

(f) Albumin, a protein, acts as a buffer in the maintenance of blood pH (7)

• 719 •

essential amino acids present in them. Most of the vegetable proteins lack one or more amino acid and are thus classified as biologically incomplete proteins.

The essential amino acid that is in shortest supply in a given food item is known as the limiting amino acid, for example the limiting amino acid in wheat is lysine and in pulses it is methionine. The quality of vegetable proteins in a vegetarian diet can be improved by providing a suitable combination of vegetable proteins. A relative lack of a particular amino acid in one protein can be compensated by simultaneous consumption of another protein, which contains that limiting amino acid. This is known as supplementary action. Thus a diet combining wheat products such as bread (chapati) with pulses (dal) will compensate for these deficiencies (of lysine and methionine) and provide all the essential amino acids. Other similar examples from Indian diet are Idli-Sambhar, Wada-Pav, Rice-Dal, Khichri etc.

Quantitatively the quality of a protein is worked out in terms of biological value, digestibility co-efficient, net protein utilization and protein efficiency ratio. The working formulae for each of these parameters are shown in the Box- 2. The net protein utilization (NPU) is the most commonly used parameter. A protein with an NPU of more than 65 is considered as of optimum quality. Egg protein is considered to have an NPU of 100 and is considered as ideal or reference protein against which other proteins are compared with.

Box- 2 : Quality of Proteins

The quality of a protein depends upon its amino acid composition. A protein containing all amino acids is considered as ‘ideal’. Egg protein is taken as the reference protein.

Biological value (BV) =Nitrogen retained x 100

Nitrogen absorbed

Digestibility co-efficient =Nitrogen absorbed x 100

Nitrogen intake

Net Protein Utilization (NPU) =Retained Nitrogen x 100

Intake of Nitrogen

Protein Efficiency Ratio (PER) = Weight gain in g

Protein intake in g

Recommended Dietary Allowance (RDA) for Proteins : The requirement of proteins is generally accepted to be 1g/Kg/day for adults. So the recommended dietary allowance for a reference adult male works out to 60g/day and for a reference adult female it is 50g/day. An additional allowance of 15g/day is recommended for pregnancy. During lactation an extra allowance of 25g in the first 6 months and 18g in the subsequent 6 months is recommended. Children have a higher protein requirement as elaborated in Table - 4 (1). A detailed account of the requirements of proteins for pregnant and lactating women, infants and children is discussed in the chapter on “Physiological requirements of nutrients”. An attempt is also made to elaborate as to how this requirement could be met in the typical Indian conditions. Some tips on improving the consumption of proteins is given in the Box- 3.

Deficiency can occur when the diet does not provide enough protein in relation to the requirement which may be high as in the case of young growing children. Secondly, if energy intake is insufficient proteins will be diverted to produce energy and thus causing a deficiency of proteins. Childhood infections (esp. measles) also play an important role in triggering and sustaining a long term protein deficiency. Protein Energy Malnutrition (PEM) is a major cause of concern for children in our country. PEM is discussed in greater details in Chapter on ‘Nutritional Deficiency Diseases’.

Table - 4 : Recommended Dietary Allowance (RDA) for Proteins

Group Activity Body weight

Requirement g/day

Man

Sedentary work

Moderate work 60 60

Heavy work

Woman

Sedentary work

Moderate work 50 50

Heavy work

Pregnant woman 50 +15

Lactation

0-6 months 50 +25

6-12 months +18

Infants0-6 months 5.4 2.05/ Kg

6-12 months 8.6 1.65/ Kg

Children

1-3 years 12.2 22

4-6 years 19.0 30

7-9 years 26.9 41

Boys 10-12 years 35.4 54

Girls 10-12 years 31.5 57

Boys 13·15 years 47.8 70

Girls 13·15 years 46.7 65

Boys 16-18 years 57.1 78

Girls 16-18 years 49.9 63

Table 3 : Major sources including their protein content (g per 100g)

Food Item (Source)

Protein content (g)

Food Item (Source)

Protein content

(g)

Eggs 13.3 Milk (Cow) 3.2

Meat (goat, lean) 21.4 Fish (Hilsa) 21.8

Pulses (red gram) 22.3 Soya bean 43.2

Groundnuts 25.3 Wheat flour 12.1

Rice (raw, milled) 6.8 French Beans 1.7

• 720 •

Box - 3 : Recommendations on Diet for Proteins

Eat nutritionally balanced diet to get adequate protein

Meat and fish are good sources

Vegetarians must eat proper combination of plant proteins from both cereal and pulses groups

Include Soyabean in your diet

Two to three servings of protein-rich food must be ensured every day

One serving may be equivalent to :

- One to two cups of cooked meat, poultry, fish

- Half cup of cooked dry beans/ lentils/ legumes

- One egg

- Handful of fried/roasted- salted groundnuts

- Handful of roasted Bengal grams

FatsFats are organic compounds, which are insoluble in polar solvents (water) but soluble in organic solvents such as ether, chloroform and benzene. These are actual or potential esters of fatty acids. Fats are only distinguished from oils by their different melting points; fats are solid and oils liquid at room temperature. ‘Fats’ and ‘oils’ are the ones which the housewife buys and ‘lipid’ (Greek, lipos meaning fat) is the term used by biochemists. However, the general term fat is commonly used to refer to the whole group and is used interchangeably with lipids.

Sources of fats : Dietary fats are derived from two main sources:

(a) Animal Sources : They are milk and milk products (ghee, butter), lard, egg and fish oils. Animal fats in general are poor sources of essential fatty acids with the exception of certain marine fish oils such as cod liver oil and sardine oil, but they are good sources of retinol and cholecalciferol.

(b) Vegetable Sources : They include various edible oils such as groundnut, gingely, mustard, cottonseed, safflower, rapeseed, palm and coconut oil. Vegetable oils with the exception of coconut oil are all rich sources of essential fatty acids, but they lack retinol and cholecalciferol except red palm oil which is rich in carotenoids. Major sources including their fat content are given in Table - 5.

Visible and invisible fats : The visible fats are generally derived from animal fats e.g. butter or ghee or from plant (vegetable) oils like groundnut, mustard, coconut, sunflower or safflower seeds. Hydrogenated oils and margarine would also be classified as visible oils. The visible fat is added to food for cooking, flavouring or shortening. These are the major sources of fats in our diet. Chemically they are triglycerides of fatty acids and could be saturated or unsaturated. It is now believed that the bare minimal requirement of visible fats to meet the essential fatty acid requirements is 15 to 25 g per day. The upper limit is fixed at 30% of the total energy intake or less

than 80 g / day.

Some amount of fat is present in all food stuffs. From the nutritional standpoint, important of them are cereals, pulses, oilseeds, nuts, milk, eggs and meat. Contrary to general awareness, this invisible fat contributes substantially to the total fat consumption and essential fatty acid intake of our diet. Cereals and pulses which are otherwise perceived to be poor in fats contribute significantly towards fat intake of a Indian diet. This is because most Indians depend on the ‘staple’ of cereals, consumed in a large quantity. The invisible fats may account for 20 to 50% of all fats consumed, depending on the type of diet. It should however contribute to not less than 6% of total energy or about 15g of invisible fats per day.

Types of Fatty AcidsFatty acids are composed of a straight hydrocarbon chain with one methyl group (—CH3) and terminating with a carboxylic acid group (—COOH). Hydrogen atoms are attached to the carbon chain; the number of hydrogen atoms determines the degree of saturation (with hydrogen atoms) of the fatty acid. A fatty acid with hydrogen atoms on every arm is said to be ‘saturated’. Unsaturated fatty acids contain double carbon bonds where there is no hydrogen. If there is only one double bond, the fatty acid is termed as monounsaturated and when more than one double bond is present, the fatty acid will be polyunsaturated.

Saturated Fatty Acids (SFA) : Saturate (Latin, to fill, in this case with hydrogen). Saturated Fatty acids have a relatively high melting point and tend to be solid at room temperature. These are obtained from animal storage fats and their products e.g. meat fat, lard, milk, butter, cheese and cream. Fats from plant origin tend to be unsaturated with the exception of coconut oil and palm oil. A high intake of SFA is associated with an increase in LDL and total cholesterol and thus increases the risk of atherogenesis and cardiovascular disease. Some examples of SFAs are Myristic acid, Palmitic acid and Stearic acid.

Monounsaturated Fatty Acids (MUFA) : MUFA contain only one double bond and are usually liquid (oil) at room temperature. Olive oil and rapeseed oil are good dietary sources

Table-5 : Major sources including their fat content (g/100g)

Food Item (source) Fat content (g/100g)

Eggs (hen) 13.3

Milk, cow 4.1

Meat (Goat lean) 3.6

Fish (Hilsa) 19.4

Ghee 100

Butter 81.0

Groundnut 40.1

Mustard seeds 39.7

Coconut, fresh 41.6

Sunflower seeds 52.1

• 721 •

of MUFA. MUFA are also present in meat fat and lard. Dietary MUFA does not raise plasma cholesterol. They lower LDL cholesterol without affecting the HDL. Oleic acid is an example of MUFA.

Polyunsaturated Fatty Acids (PUFA) : PUFA contain two or more double bonds and they too are liquid at room temperature. They are easily oxidized in food and in the body. PUFA have a vital role in immune response, blood clotting and inflammation. PUFA are divided into omega-3 (ω3) or omega 6 (ω6) groups of PUFA. Omega-3 (ω) polyunsaturated fatty acids PUFA are found in fish and fish oils. The health benefits of these include reducing the cardiovascular risk factors (see Box - 4). Research also indicates their beneficial role in cognitive function of brain. Some common omega-3 fatty acids are α-linolenic acid (linseed, soyabean, rapeseed, leafy vegetables), eicosepentaenoic acid (marine algae, fish oils) and docosahexenoic acid (fish oils).

Box-4 : Omega-3 (ω3) Fatty Acids in Prevention and Therapy

Coronary artery Disease (CAD) : Omega-3 (ω3) Fatty Acids reduce the tendency of platelet aggregation, blot clot formation and thus atherosclerosis. Chances of cardiac arrhythmias also go down, thus benefiting in CAD.

Hypertension : They lower the high blood pressure in hypertensives.

Hyperlipidaemia : They lower the high blood lipids (triglycerides and total cholesterol), while increasing HDL-c.

Bronchial asthma : ω3 Fatty Acids reduce inflammation, frequency and severity of asthma.

Diabetes : They lower the high blood triglycerides blood pressure and reduce leakage of proteins from small vessels, thus improving the overall metabolism and the diabetic state.

Autoimmune disorders : Omega 3-Fatty Acids are known to reduce pain, inflammation and joint stiffness in rheumatoid arthritis. Other autoimmune disorders also improve with their supplementation.

Miscellaneous : They are found to be useful in conditions like migraine, inflammatory skin disorders and osteoarthritis.

Trans Fatty Acids (t-FA)Trans fatty acids rarely occur in nature. These are produced during the partial hydrogenation of PUFA. In Indian homes this process takes place commonly when oil is heated over and over again as it happens during the process of frying puri, pakori or samosa, esp. when the same oil is boiled repeatedly. Trans fatty acids have been associated with adverse effects on lipoprotein status by elevating LDL and depressing HDL.

Essential Fatty Acids (EFA)If fats are entirely excluded from the diet, retarded growth, dermatitis, kidney lesions and an early death might result. Studies have shown that feeding of certain unsaturated fatty acids e.g. linoleic and linolenic acid is effective in curing the condition. It is therefore evident that certain unsaturated fatty acids cannot be synthesized in the body and must be acquired from diet. These are essential fatty acids. EFA are commonly found in plant and fish oils (8). The EFA requirement is 3-6% of the total energy intake depending on the age and physiological status of the individual. Fatty acid content of different fats is given in Table - 6.

Why fats in diet? : If the contemporary literature is to be believed, one tends to agree that fats are well known for their role in causation of many chronic diseases rather than any worthwhile virtue! Then why should fat be consumed at all and how much? The main functions of fat are elaborated in the Box - 5.

Unlike proteins where the precise intake, assimilation, excretion and thus requirement can be worked out, the quantity of fats that should be included in a well balanced diet is a matter of conjecture. The following aspects however are important in considering the recommendation for fat intake : a) The quantity of fat intake should be good enough so that

requirement of essential fatty acids (which are a component of fats) is met.

b) Absorption of fat soluble vitamins should not be compromised.

c) Fat intake should be sufficient enough to make diet palatable.

d) Some stores must be maintained in the body to tide over a lean period.

e) It should not be so much in quantity that it causes undesirable effects on health.

Cholesterol

Cholesterol is always talked as if it is the hazardous abnormal fat. It is considered by many as a type of a saturated fat. In fact it is only a fat related compound. Chemically it falls under the group of sterols. It is named after the body material where it was first identified, the gallstones (Greek, chole, bile; steros, solid)

Synthesis : It is synthesized only in the animal body. All plant products are free of cholesterol. The human body synthesizes indigenous cholesterol primarily in liver (but also in adrenal cortex, skin, intestines, testis and ovaries), for sustaining life. It is a normal constituent of bile and a principal part of the gall stones

Sources : The important dietary sources are egg yolk, meat (liver and kidney). There are no plant sources of cholesterol

RDA : Since it is synthesized indigenously in the body, there is no dietary requirement of cholesterol. However, the upper limit of cholesterol consumption has been put at 300mg per day

Functions : It is vital as a precursor to various steroid hormones e.g. sex hormones and adrenal corticoid hormones.

Hazards : In dysfunctional lipid metabolism, it is considered the major factor for atherosclerosis. Epidemiological studies have linked high cholesterol intake to the increased risk of coronary heart disease

• 722 •

Based on these aspects, the ICMR has recommended levels of fat intake for Indians (RDA) that are summarised in Table - 7.

Recommended Dietary Allowance : The RDA for adults is 20g of visible fat per day. For pregnant and lactating women it is 30 and 45 g respectively. The RDAs for various groups are given in Table - 7 (1). Fat content of diet should not exceed 20 to 30% of the total calories consumed. The dietary cholesterol should be limited to 300 mg/day.

Hazards of Excess Fat in Diet : Excess fat is dangerous on two accounts. First, in case it is consumed in a higher quantity and secondly if the wrong quality of fat is consumed.

Quantity of Fat : With an improving economy and a richer lifestyle we tend to consume a higher calories especially from the fat source. Higher calories lead to obesity and many other lifestyle diseases. A high level of fat in diet is notorious in the causation of atherosclerosis and so is a major risk factor for Cardiovascular Diseases (CVD) including coronary artery disease and strokes. Any amount that contributes to more than 30% of total calorie intake is considered as high. Low physical activity and sedentary lifestyle further augment the risk.

Quality of Fat : High levels of saturated fatty acids are more dangerous. A proportionately higher content of polyunsaturated

Box - 5 : Functions of Fats

They are concentrated sources of energy providing about 37.7 KJ/g or 9 Kcal /g.

Fats serve as vehicle for fat soluble vitamins (A.D, E and K).

Fats are structural components of cell and cell membrane.

They are the sources of essential fatty acids. Linoleic acid and arachidonic acid are precursors of prostaglandins which are required for a wide variety of metabolic functions.

Apart from their nutritional significance, fats improve the palatability of diet, delay gastric emptying & raise the caloric density.

Some fats can be converted to biologically active compounds such as steroid hormones, interleukins, thromboxanes and prostaglandins and bile acids (from cholesterol).

Table - 6 : Approximate fatty acid composition of common fats and oils (g/100g) (8)

Oil/Fat Satu-rated

MUFA Lino-leic acid

α-lino-lenic acid

Predomi-nant FA

Coconut 90 7 2 <0.5 SFA

Palm kernel 82 15 2 <0.5 SFA

Ghee 65 32 2 < 1.0 SFA

Vanaspati 24 19 3 <0.5 SFA (t-FA)

Red palm oil 50 40 9 <0.5

SFA + MUFA

Palm oil 45 44 10 <0.5

SFA + MUFA

Olive 13 76 10 <0.5 MUFA

Groundnut 24 50 25 <0.5 MUFA

Rape/Mustard

8 70 12 10MUFA

Sesame 15 42 42 1.0

MUFA + PUFA

Rice bran 22 41 35 1.5

MUFA + PUFA

Cotton seed 22 25 52 1.0 PUFA

Corn 12 32 55 1.0 PUFA

Sunflower 13 27 60 <0.5 PUFA

Safflower 13 17 70 <0.5 PUFA

Soyabean 15 27 53 5.0 PUFA

Table - 7 : RDA of Fats for Indians

Group Particulars Body wt (Kg) RDA Fat (g/d)

Man

Sedentary work

60 20 Moderate work

Heavy work

Woman

Sedentary work

50 20 Moderate work

Heavy work

Pregnant woman 50 30

Lactation

0-6 months 50 45

6-12 months

Infants 0-6 months 5.4

6-12 months 8.6

Children

1-3 years 12.2

25 4-6 years 19.0

7-9 years 26.9

Boys 10-12 years 35.422

Girls 10-12 years 31.5

Boys 13·15 years 47.822

Girls 13·15 years 46.7

Boys 16-18 years 57.1 22

Girls 16-18 years 49.9

• 723 •

fatty acids is found to be protective for CVD. Unfavourable levels of certain lipoproteins have adverse effects on health. High levels of LDL are associated with higher atherosclerotic risk so LDL is colloquially known as ‘bad cholesterol’. A high level of HDL has favourable effect on the cardiovascular system and is termed as ‘good cholesterol’.

Tips on fat intake

Food preparationUse minimal oil for preparationRotate the types of oil usedUse only lean cuts of meat

Meat Prefer fish to poultryPrefer poultry to mutton/beef/porkLimit added oils in meat preparations

EggsAvoid more than one egg a dayAvoid adding oil to egg preparationsUse egg whites freely

Milk Prefer low fat milk

CarbohydratesCarbohydrates are the basic source of fuel to run life on earth. It is these carbohydrates into which the energy from sun is converted through the process of photosynthesis by plants. In fact this is the energy that is used by all living organisms. Thus carbohydrates can be considered as the very ‘basis’ of life. Chemically carbohydrates are polyhydroxy aldehydes or ketones, or substances that produce such compounds when hydrolyzed. They contain carbon, oxygen and hydrogen in proportion approximating that of a ‘hydrate of carbon’ (CH2O), hence the term carbohydrate.

Classification : From the nutritional or functional point of view, carbohydrates can be divided into two categories.

(a) Available carbohydrates : These are the carbohydrates which can be digested in the upper gastrointestinal tract, absorbed and utilized. These are further sub-classified as polysaccharides, disaccharides, monosaccharides.(i) Polysaccharides such as starch, dextrin and glycogen(ii) Disaccharides such as lactose, sucrose and maltose(iii) Monosaccharides such as glucose, fructose and galactose.(b) Dietary Fibre : The second category comprises of unavailable carbohydrates or dietary fibre, which are difficult to digest. These are cellulose, hemicellulose, gums, pectins etc. A detailed account of these is given later in this chapter.

Sources of Carbohydrates : The major source of dietary carbohydrates in an Indian set up is starch from cereal grains, millets, legumes, roots and tubers (Table - 8).

With increasing prosperity as in industrial societies, sugar has replaced complex carbohydrates as the main source. The presence of monosaccharides (free glucose or fructose) is limited to fruits and vegetables, otherwise they are not abundant in natural foods. Fructose is found in honey, fruits and vegetables. Sucrose and Lactose are the commonest disaccharides. Sucrose is extracted from sugar cane. Table sugar is 99% sucrose. Sucrose gets hydrolysed into glucose and

fructose. Lactose is found in milk. It is hydrolysed to glucose and galactose. Maltose is present in malted wheat and barley. Other sources are nuts and seeds.

Functions of Carbohydrates : Carbohydrates are the most significant and cheapest source of energy in the diet. One gram of carbohydrates provides 4 Kcal energy. Carbohydrates provide 60 to 85% of energy in our Indian diet. Various kinds of sugars (glucose, fructose, sucrose etc.), most literally, impart the sweet taste to life! Carbohydrates play an important role wherein glycogen resources in the muscles and liver are in a state of dynamic exchange with the energy balance (of intake and expenditure) through the liver. A constant supply of carbohydrates has a protein sparing action and proteins are not required to be broken down for energy. Similarly fats are also spared to be used up if enough carbohydrate supply is maintained. The brain exclusively uses glucose and is dependent on its constant supply for its functioning.

Fibre, which is a type of carbohydrate, has the important function of increasing faecal bulk, stimulating peristalsis and blocking cholesterol synthesis in the liver.

Requirement of Carbohydrates : In a prudent diet carbohydrates should contribute to 60 to 70% of total energy (1). This translates to about 360 to 400g carbohydrates for a 2400 Kcal diet. Details about role and requirements of dietary fibre are discussed in forthcoming paragraphs.

Problems Due to Deficiency and Excess : Whenever there is a deficiency of carbohydrates in diet not compensated by other nutrients, a situation of energy deficiency sets in. This is typically seen in infants and children wherein protein calorie malnutrition is not uncommon. A similar situation of energy deficiency may result in food deprived people in cases of starvation as encountered in famines and droughts. Anorexia nervosa is a condition with a major psychological component,

Table - 8 : Major sources of carbohydrates (per 100 g) (1)

Food stuffCarbo-

hydrates (g)

Food stuffCarbo-

hydrates (g)

Cereals & Millets Pulses & Legumes

Wheat flour 69.4 Bengal gram 60.9

Rice polished 78.2 Soya bean 20.9

Bajra 67.5 Rajmah 60.6

Maize dry 66.2 Redgram (Arhar) 57.6

Ragi 72.0 Pea dry 56.5

Fruits & Vegetables Miscellaneous

Banana 27.2 Milk, cow 4.4

Apple 13.4 Groundnut 26.1

Mango 16.9 Cashew nut 22.3

Raisins 74.6 Coconut, fresh 13

Tapioca 38.1 Jaggery 95

Sweet potato 28.2 Sugar 99.4

Potato 22.6 Honey 79.5

• 724 •

wherein the patient doesn’t eat food and ends up being cachexic. A very low carbohydrate diet results in utilization of other macronutrients (lipids and proteins) for energy and result in production of ketone bodies (ketosis). Eventually bone mineral loss, hypercholesterolaemia and increased risk of urolithiasis may result.

Consumption of an excess of carbohydrates seems to be a bigger problem in the present day scenario of progressive economies. If the intake is large enough to provide excessive calories such an individual ends up being obese and might fall prey to a host of lifestyle diseases (discussed in another chapter). It is interesting to note that excess of even few calories per day (100-200 Kcal) over a couple of months accumulates enough calories to cause obesity.

Dietary FibreDenis Burkitt (a surgeon) and Hugh Trowell (a physician), served for 30 years, after the World War II, in Makareree University, Kampala, Uganda, before returning to Britain. They were struck by the great difference in the pattern and nature of disease affecting the affluent West as opposed to more primitive communities. They concluded that the large amount of dietary fibre was not only responsible for the faecal bulk but was also directly or indirectly related to the difference in the pattern of disease. A ‘fibre hypothesis’ was thus formulated which suggested that unrefined complex carbohydrates protected against the ‘western ailments’ : colonic cancer, diverticular disease, appendicitis, constipation, hemorrhoids, hiatus hernia, varicose veins, diabetes, heart disease, gall stones, obesity etc.

Dietary fibres are the remnants of the plant cell resistant to hydrolysis by alimentary enzymes and do not provide significant nourishment. They remain in the ileum but are partially hydrolyzed by the colonic bacteria. The term ‘dietary fibre’ is a broad term which includes Non Starch Polysaccharide (NSP) and related material such as resistant starch, resistant oligosaccharides, lignin and complex assemblies of plant tissue where polysaccharides occur in close association with other molecules (9).

Classification : Fibres can be Carbohydrate fibres and non-carbohydrate fibres. The carbohydrate fibres include Non Starch Polysaccharides (NSP) which are normally present in cell wall, cement, plant gums, mucilages and algal polysaccharides; and the Resistant Oligosaccharides (ROS) which are found in leguminous seeds e.g. Rajma, soy beans and gram (10). The Non Carbohydrate fibres include Lignin which is a large compound forming the woody part of some plants. It strengthens the plant cell walls.

Fibre can also be classified according to solubility in water, as soluble or insoluble. Insoluble fibre consists mainly of cellulose, hemicellulose and lignin. Since they remain undigested in the gut they form bulk and help in movement of the food and peristalsis. Thus they help in elimination of waste products as well. After absorption of water the fibre swells up and facilitates the gut movement further.

On the other hand the natural gel forming fibres like pectins, gums and mucilages are soluble.

Sources and Losses : Cereals, fruits and vegetables are the chief sources of fibres. The important sources of soluble and insoluble fibre are summarised in Table - 9.

Table - 9 : Major food sources of fibre

Insoluble fibres

Vegetables : Peas, beans, amaranth leaves

Cereals : Rye, bran flakes, brown rice, Corn, whole wheat

Whole meal cereals : Dalia, whole meal flour, Ragi porridge

Breads : Granary bread, brown bread

Legumes : Bengal gram (whole), Lentils pulses and dals

Sprouts : Sprouted grains, legumes

Fruits : Fruits with edible seeds

Soluble fibre

Citrus fruits : Orange, lime

Berries : Straw berry, rasp berry

Other Fruits : Pomegranate, Figs, grapes, guava, Sapota, Custard apple

Functions : Dietary fibre stimulates chewing, improves flow of gastric juice and provides a sense of satiety. Insoluble fibre binds to water in the colon and swells. Hence, it forms substrate for colonic bacterial fermentation. This stimulates peristalsis which increases transit time in the colon thereby reducing the risk of constipation and possibly that of colon cancer. Some fibres like lignin helps in prevention of absorption of bile acids by binding to them. On the other hand soluble fibres prevent the micelle formation by binding with bile acids &and other lipids (11).

Recommended Dietary Allowance : The diet should contain 35-40 grams of dietary fibre per day (15g per 100Kcal) (1). Fibre content of selected food stuffs are given in Table - 10.

Table - 10 : Dietary fibre content of common foods (g/100g)

Foodstuff Fibre content (g per 100g) Foodstuff Fibre content

(g per 100g)

Cereals & Legumes Fruits

Rice, raw, milled 0.2 Guava 5.2

Wheat flour, whole 1.9 Mango, papaya 0.7

Bengal gram, whole 3.9 Pomegranate 5.1

Red gram (Dal arhar) 1.5 Peach, pears, apple 1.0-1.2

Peas dry, Rajmah 4.5 Figs, Sapota 2.2-2.6

Green vegetables Nuts

Cabbage, cauliflower, Fenugreek (maithi)

1.0 -1.2Areca nut

11.2

Amaranth 1 to 6.1 Coconut fresh 3.6

Spinach, radish leaves 0.6 Groundnut 3.1

• 725 •

Dietary Fibre in Health and Disease : Fibre helps in achieving prevention of cardiovascular disease through various mechanisms(a) Soluble fibre binds with bile acids and alters the quantity

of cholesterol or fatty acids absorbed.(b) The re-absorption of bile acids is slowed by soluble fibre to

increase cholesterol losses in faeces.(c) Intestinal bacteria reduce soluble fibre to short chain fatty

acids which block cholesterol synthesis in the liver.Fibres also help in the maintenance of weight and prevention of obesity. Soluble fibre blunts the response of blood glucose through prevention of direct glucose absorption in the gut. This helps in the control of hyperglycaemia. Soluble and viscous fibres (pectin and gums) have the greatest hypoglycemic effect (12).

Fibre is also considered to be an important contributory factor to the prevention of colonic cancer (13).

In addition, fibre increases faecal bulk and relieves constipation. This reduces the incidence of colonic cancers, diverticulitis and appendicitis. The alteration in cholesterol production and further metabolism reduces the formation of gallstones as most of them are of cholesterol origin.

Study ExercisesShort Notes : (1) Dietary fibre in prevention of lifestyle diseases (2) Hazards of excess fats in diet (3) Invisible fats (4) Dietary importance of egg (5) Supplementary action of proteins

MCQs1. Which is true for cholesterol (a) It is a type of saturated

fatty acid (b) It is present in egg yolk, ghee and coconut oil (c) The dietary requirement of cholesterol is zero (d) Everyone with high cholesterol gets IHD

2. Which of the following is not a source of dietary fibres (a) Vegetable fibres (b) Muscle fibres (c) Bran (d) Fruits

3. The limiting amino acid in wheat is____ and in pulses it is_____ (a) Lysine, methionine (b) Methionine, lysine (c) Cysteine, lysine (d) Lysine, cysteine

4. Which lipoprotein is termed as ‘good’ cholesterol : (a) LDL (b) HDL (c) VLDL (d) Chilomicrons

5. Which of these will provide energy the quickest : (a) Milk (b) Chapati (c) Butter chicken (d) Fruit juice

Answers : (1) b; (2) b; (3) a; (4) b; (5) d.

ReferencesGopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian 1. foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.World Health Organization. Energy and protein requirements. Technical 2. Report Series No. 724. Geneva, 1985.Pasricha S, Count what you eat. National Institute of Nutrition (ICMR), 3. Hyderabad. 1989.Kleiner SM. Nutrition Guidelines for diet and health, In : Matzen RN and 4. Lang RS (Eds) : Clinical Preventive Medicine. Mosby Publishers USA. 1st Ed 1993 : 385 - 410.Garrow JS, James WPT, Ralph A, Human Nutrition and Dietetics. Churchill 5. Livingstone, UK. 10th Ed 2000.Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed. 6. Wadsworth Thomson Learning, California. 2000.Chaney MS, Ross ML. Nutrition. Houghton Mifflin Company, USA. 1996.7. Ghafoorunissa, Krishnaswamy K. Diet and Heart Disease. 2000 National 8. Institute of Nutrition, Hyderabad - 500007.Gandy JW, Madden A, Holdsworth M. Oxford handbook of Nutrition and 9. Dietetics. Oxford University Press, New Delhi. 2007.Geissler C, Powers H. Human Nutrition.11th ed. Elsevier Churchill Livingstone 10. London. 2005.Antia FP, Abraham P. Clinical Dietetics and Nutrition. 4th ed Oxford University 11. Press, New Delhi 1998.Steyn NP, Mann J,Bennett PH, et al. Diet, nutrition and the prevention of type 12. 2 diabetes. Public health nutrition. 2004 Feb, 7 (1A). 147-165.Key TJ, Schatzkin A, Willett WC, Allen NE, Spencer EA, Travis RC. Diet, 13. nutrition and the prevention of cancer. Public health nutrition. 2004 Feb, 7 (1A). 187-200.Key TJ, Schatzkin A, Willett WC, Allen NE, Spencer EA, Travis RC. Diet, 14. nutrition and the prevention of cancer. Public health nutrition. 2004 Feb, 7 (1A). 187-200.

129 Micronutrients : The Vitamins

Rajul K Gupta

“Milk and leaves occupy a unique position, as they correct the defects of cereals, tuber, roots and meats. Thus…they be distinguished by the term ‘Protective foods’.”

~ EV McCollum (1)

By and large vitamins were discovered during the search for cures of classic deficiency diseases. In 1753 when James Lind, a British naval surgeon, observed that fresh lemons, limes and oranges, prevented/cured scurvy, the British sailors always carried lemons with them on long voyages and were nicknamed

as ‘limeys’.

Many subsequent observations and experiments in 1896 by C Eijkman on rice polishings and beriberi, Frederich Hopkins of Cambridge University on milk in 1906, Verner McCollum (USA) on the fat soluble factor (Vitamin A) in 1916 just to name a few, established them to be vital for life that paved the way for the vitamins to be named so (from the words vital amine) by Casimer Funk, a Polish scientist in 1912.

Definition : Vitamins are organic compounds required in very small but definite quantities for normal growth and maintenance of a healthy life. They are not synthesised in the body and have to be supplied in the diet. They do not furnish energy and play no part in the constitution of the structure of tissues, but are essential for the transformation of energy

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and regulation of tissue metabolism. They are necessary for the efficient functioning of the organism as a whole, each in a specific manner. Deficiency of vitamins causes profound changes in structural and functional wellbeing, the picture of each deficiency being specific.

Dietary sources : Vitamins are widely distributed in diet. Fresh milk, meat, eggs, fresh vegetables and fruits are rich sources. Cereals (esp. whole unrefined cereals) which form the bulk of our diet are also important sources. Storage, processing and cooking of food may cause considerable vitamin loss, so that the maintenance of an adequate intake is more difficult when fresh food is scarce. The pharmaceutical use of vitamins should be restricted to rectify or supplement the envisaged or existing deficiency in the diet or to meet the increased physiological demands (e.g. in pregnancy). No physiological benefit, however, can be expected from a large dose of vitamins under normal circumstances.

Classes of vitamins : Vitamins have long been classified into two groups; water soluble and fat soluble. The water soluble group comprises of vitamins B and C; the fat soluble vitamins are A, D, E and K. This division is still useful, since it helps to understand the distribution of vitamins in foods and their absorption and metabolism in the body.

Storage and excretion : There is an important distinction in the handling of the two classes of vitamins by the body. An excess intake of water soluble vitamins is excreted in the urine. Thus, there is virtually no danger in giving an excess of these vitamins. On the other hand, the fat soluble vitamins cannot be excreted in this way. Any excess of these vitamins, beyond the immediate requirement is stored in the liver. The storage capacity of the human liver is large and it normally holds a reserve of vitamins sufficient for many months; this is a useful provision for times when the dietary supply may temporarily be cut off. However the amount that can be stored is not unlimited (2).

Functions : As mentioned earlier they do not furnish energy and play no part in the constitution of the structure of tissues directly, but are essential for control of cell metabolism, transformation of energy, and prevention of specific nutritional deficiencies.

Many vitamins are now known to have antioxidant properties. This has rejuvenated the interest of scientist in exploring further the hidden potential of these vitamins in maintaining health and also curing disease. The scope of vitamins has now widened from their earlier role of curing specific deficiencies to preventing cancers and even aging! A summary of the traditional functions of major vitamins are given in tables at the end of this chapter.

Water Soluble VitaminsThiamine (Vitamin B1)Thiamine hydrochloride is a crystalline substance which is readily soluble in water. It is rapidly destroyed by heat in neutral or alkaline solutions. In acid solutions however, it is resistant to heat up to 120°C. It is mainly excreted in urine. Thiamine is present in the body mostly as thiamine pyrophosphate (TPP) but about 10 percent as thiamine triphosphate. TPP is the

active form of thiamine in the body.

Sources : The important stores are seeds of plants. The germ of cereals, nuts, pea, beans and other pulses and in addition yeast is a rich source. In cereal grains, thiamine is found in highest concentration in the germ or embryo, less in bran and least in endosperm. All green vegetables, roots, fruits, nuts, flesh foods and dairy produce contain significant amounts of the vitamin. Pork has a higher content of thiamine than beef or mutton. Highly processed foodstuffs like white bread, polished rice and refined sugar are deficient in thiamine (See Table-1).

Table 1: Thiamine content of selected food items (per 100g) (4)

Food stuffThiamine

(mg)Food stuff

Thiamine (mg)

Cereals Vegetables

Wheat flour 0.49 Beans 0.10

Rice polished 0.06 Spinach 0.03

Bajra 0.33 Carrot 0.04

Maize dry/Ragi

0.42Capsicum

0.55

Pulses & Legumes Fruits

Bengal gram 0.30 Pineapple 0.2

Soya bean 0.73 Guava 0.03

Green gram 0.47 Amla 0.03

Red Gram 0.45 Tomato 0.12

Peas dry 0.47 Mango 0.08

Non vegetarian foods Nuts

Egg 0.10 Groundnut 0.90

Liver sheep 0.36 Cashew nuts 0.63

Milk cow 0.05 Almond 0.24

Fish, Rohu 0.05 Coconut, fresh 0.05

Mutton 0.18 Coconut, dry 0.08

Losses : Milling of cereals below an extraction rate of 75 percent reduces the content of thiamine to a great extent. As thiamine is readily soluble in water, considerable amounts may be lost when foodstuffs are cooked in an excess of water which is afterwards discarded. It is relatively stable to heat up to boiling point, provided that medium is slightly acidic, as in baking with yeast. But if baking powder is used, or if soda is added in the cooking of foodstuffs, almost all the vitamin may be destroyed.

Functions : Thiamine is one of the most important water soluble vitamins and acts as a coenzyme in many metabolic reactions. The important ones being the oxidative decarboxylation of pyruvic acid and transketolase reaction in HMP shunt. The vitamin is essential for the health of the nerve tissue and for normal cardiac and gastro-intestinal functions (5,6).

Requirements : Since thiamine plays an important role in carbohydrate metabolism, its dietary allowance is related to energy intake. It is 0.5mg per 1000 Kcal (4).

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Deficiency : Thiamine deficiency causes beriberi and Wernicke- Korsakoff psychosis. Three forms of Beriberi are known: Wet Beriberi (cardiac), Dry Beriberi (neurological) and Infantile Beriberi. The early symptoms and signs are common in both dry and wet Beriberi. The onset is usually insidious, though sometimes precipitated by unwanted exertion or a minor febrile illness (5).

Beriberi

(Singhalese, meaning “I can’t, I can’t”). The disease caused by the deficiency of thiamine, characterized by oedema resulting from cardiac failure (Wet beriberi) or peripheral neuritis, pain in limbs and paralysis (Dry beriberi).

(a) Wet beriberi is the acute form. It is characterized by high output cardiac failure, bounding pulse, warm extremities, peripheral oedema and cardiac dilatation.

(b) Dry beriberi is the chronic form of disease and is characterized by progressive peripheral neuropathy. The tendon jerks are sluggish and anaesthesia of the skin (especially over tibia) is common. The muscles become progressively wasted and weak and walking becomes increasingly difficult. The thin, even emaciated individual needs at first one stick, then two and may finally become bedridden.

(c) Infantile beriberi occurs in the first few months of life (of an infant), if the diet of mother is deficient in thiamine. The infant remains constipated and appears plump due to water retention. The heart is enlarged and the heart sounds are muffled. The infant may die of a heart failure if untreated (7)

(d) Wernicke-Korsakoff psychosis is seen in chronic alcoholics with poor diet. It is characterised by confusion, low levels of consciousness and poor coordination (encephalopathy). Memory loss often follows the encephalopathy.

RiboflavinRiboflavin, the word comes from a Latin word flavous, yellow, containing a sugar named ribose). As is clear from the name it is a yellow green fluorescent compound, soluble in water but not in fats. Though stable in acid solution, in alkaline solution it is readily destroyed by heat. It is also destroyed by short visible and ultraviolet rays.

Sources & Losses : The best sources of riboflavin are liver, milk, eggs and green vegetables (See Table-2). Cereals and yeast extracts also contain the vitamin. Cooking does not destroy the vitamin apart from losses that occur when the water in which green vegetables have been boiled is discarded. If food, especially milk, is left exposed to sunshine, large losses may occur.

Functions : Riboflavin is involved in oxidation-reduction reactions within the cells in many metabolic pathways. The important functions of riboflavin include:(a) Promotion of normal growth(b) Assisting synthesis of steroids, RBC and glycogen(c) Maintenance of mucous membranes, eyes and the nervous

system(d) Aiding iron absorption (5)

Table 2 : Riboflavin content of selected food items (per 100g) (4)

Food stuffRiboflavin

(mg)Food stuff

Riboflavin (mg)

Cereals Vegetables

Wheat flour 0.17 Beans 0.06

Rice polished 0.06 Spinach 0.26

Bajra 0.25 Carrot 0.02

Maize dry 0.1 Amaranth 0.30

Pulses & Legumes Fruits

Bengal gram 0.15 Pineapple 0.12

Soya bean 0.39 Guava 0.03

Green gram 0.47 Raisins 0.19

Red Gram 0.45 Tomato 0.06

Peas dry 0.47 Mango 0.09

Non vegetarian foods Nuts

Egg 0.40 Groundnut 0.13

Liver sheep 1.7 Cashew nuts 0.19

Milk cow 0.19 Almond 0.57

Fish, Rohu 0.07 Coconut, fresh 0.10

Mutton 0.14 Coconut, dry 0.01

Requirements : The requirement of this vitamin is also related to energy intake. It is about 0.6 mg per 1000 Kcal. The daily safe requirement ranges from 0.7 to 2.2 mg/day (4).Deficiency

Certain conditions are known to be at high risk of Riboflavin deficiency (Box - 1).

Box - 1 : Increased Risk of Riboflavin Deficiency

Growth : childhood, adolescents

Pregnancy, lactation

Malabsorbtion : Tropical sprue; Celiac disease; Chronic diarrhoea; Irritable bowel syndrome

Drugs impairing absorbtion : Thyroid hormones; Oral contraceptives; Phenothiazines; Barbiturates

Alcoholism

(1) The clinical signs suggestive of riboflavin deficiency are cheilosis, angular stomatitis, glossitis, magenta tongue, nasolabial seborrhoea and genital (scrotal or vulval) dermatosis. Corneal vascularisation is also seen but is not a specific sign of riboflavin deficiency.

(2) Severe deficiency is rarely seen, however the elderly, people suffering from anorexia nervosa and chronic dieters are at a higher risk.

(3) Secondary nutrient deficiencies may be seen in riboflavin deficient people like: Hypochromic anaemia, Vitamin B6 deficiency and Pellagra (6).

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Niacin (Nicotinic Acid & Nicotinamide)Niacin is the generic term for a group of compounds that prevent pellagra. It is a white crystalline substance readily soluble in water and is resistant to heat, in solution or in a dry state. Although related chemically to nicotine it possesses very different physiological properties. It occurs naturally in the body in the form of an amide - nicotinamide.

Sources : Nicotinic acid is widely distributed in plant and animal foods. Meat (especially the organs), fish, chicken, eggs, milk, whole meal cereals, groundnuts and pulses are good sources (See Table-3). In some cereals, especially maize, the greater part of the vitamin may be in a bound unabsorbable form. The human body is not entirely dependent on dietary sources of nicotinic acid as it may also be synthesized from tryptophan. On an average about 60 mg of tryptophan is needed to form 1mg niacin (4).

Table - 3 : Niacin content of selected food items (per 100g) (4)

Food stuff Niacin (mg) Food stuff Niacin (mg)

Cereals Vegetables

Wheat flour 4.3 Cauliflower 1.0

Rice polished 1.9 Spinach 0.5

Bajra 2.3 Carrot 0.6

Maize dry 1.8 Amaranth 1.2

Jowar 3.1 Potato 1.2

Barley 5.4 Radish 1.4

Pulses & Legumes Fruits

Bengal gram 2.9 Raspberry 0.8

Soya bean 3.2 Guava 0.4

Green gram 2.4 Raisins 0.7

Red Gram 2.9 Tomato 0.4

Peas dry 3.4 Mango 0.9

Lentil 2.6 Custard apple 1.3

Non vegetarian foods Nuts

Egg 0.1 Groundnut 19.9

Liver sheep 17.6 Cashew nuts 1.2

Milk cow 0.1 Almond 4.4

Fish, Rohu 2.8 Coconut, fresh 0.8

Mutton Coconut, dry 3.0

Functions : Nicotinamide is incorporated into the pyridine nucleotide coenzyme, and various other coenzymes, which are involved in numerous oxidoreductase reactions including glycolysis, fatty acid metabolism, tissue respiration and detoxification.

Requirement and Intake : Since this vitamin takes part in many reactions of energy metabolism, its requirement is also related to energy requirement. Its safe level is estimated to be 6.6mg niacin equivalents per 1000 Kcal. The daily requirement varies from 8 to 26 mg (4).

Deficiency : Pellagra (Latin pelle, skin; Greek agra, seizure) results from the deficiency of niacin. This is characterized by the three ‘D’s (5).

(a) Dermatitis: (Pellagrous dermatosis) Skin exposed to sunlight gets inflamed, that progresses to pigmentation, cracking and peeling. The neck is frequently involved and the distinctive distribution of skin lesions is known as Casal’s Collar.

(b) Diarrhoea: This is often accompanied by inflamed scarlet tongue.

(c) Dementia : It may present as mild confusion and disorientation to mania and psychosis.

Folic Acid (Folate or Pteroyl Glutamic Acid)It is a yellow crystalline substance, sparingly soluble in water and a stable molecule. When heated in neutral or alkaline media it undergoes rapid destruction. Free folate is actively absorbed from the upper small intestine. It is stored mainly in the liver. Small amount is excreted in urine and faeces. Free folic acid is converted in the liver into tetrahydrofolic acid (folinic acid) which is the functionally active form in the body.

Sources and Losses : It occurs in green leaves, pulse, cereals, liver, kidney, mushroom and yeast. Canning, prolonged heating, reheating and discarding ‘cooking’ water causes serious losses of folic acid. Reducing agents in food tend to protect folic acid. Folic Acid content of selected food items is depicted in Table-4.

Table - 4 : Folic Acid content of selected food items (per 100g) (4)

Food stuff Folic Acid (µg) Food stuff Folic

Acid (µg)

Cereals Vegetables

Wheat flour 35.8 Cabbage 23

Rice raw, milled 8.0 Spinach 45.5

Bajra 45.5 Carrot 123

Maize dry 20.0 Amaranth 149

Jowar 20.0 Ladies finger 105

Ragi 18.3 Spinach 123

Fruits & Nuts Pulses & Legumes

Tomato 30 Bengal gram 186

Guava 20 Soya bean 100

Groundnut 20 Green gram 140

Coconut, fresh 12.5 Red Gram 103

Coconut, dry 16.5 Peas dry 7.5

Lentil 36

Non vegetarian foods

Egg 78.3 Milk cow 8.5

Liver sheep 188 Mutton 5.8

Functions

(a) Folinic acid plays important role in the synthesis of purines, pyramidines, glycine and methionine. It is essential for the synthesis of DNA.

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(b) It is a potent anti anaemia factor in the treatment of megaloblastic anaemia of malnutrition, pregnancy and malabsorption. It is also effective in treatment of pernicious anaemia.

Folic Acid and Plasma Homocysteine

A high plasma homocysteine level is a risk factor for heart disease and stroke. A strong inverse correlation between folate intake and plasma homocysteine has been found. A significant dose response relationship has also been established. Folate supplementation is known to proportionately reduce the plasma homocysteine levels and thus the risk of heart disease.

Requirement and Intake: The requirement of folic acid ranges from 50 μg to 100 μg. In pregnancy it increases to 150-300 μg (4).

Measurement : Recent intake can be assessed by serum folate. Cellular status is assessed by red cell folate levels.

Uses of Folates in Prevention and Therapy

Birth Defects: Use of supplementary folates (400μg/day) during the early weeks of conception & pregnancy can reduce birth defects like neural tube defects, cleft lip and palate.

Atherosclerosis : Folates are known to reduce high homocysteine levels and thus help prevent atherosclerosis.

Nervous Disorders : Folate supplementation is beneficial in depression, irritability and impaired concentration. It is also useful as an adjunct therapy in MDP and senile dementia.

Infections : Folates augment the immune function of the body, thereby reducing infections.

Cancers : Folate also reduces the chances of cervical, colonic and lung dysplasia.

Deficiency : Dietary folate deficiency is not uncommon. Deficiency results in megaloblastic anaemia. Deficiency may be accompanied by depression, insomnia, forgetfulness, irritability and dementia. Low folate levels are also associated with neural tube defects. Lack of folic acid is known to cause accumulation of homocysteine (hyperhomocysteinaemia), which is a potential risk factor for coronary artery disease. High folate levels overcome the hyper-homocysteinaemia. Low folate levels can also cause an altered methylation of DNA, increasing the risk of cancer (5, 6).

Vitamin B12 (Cyanocobalamin)Cobalamin is a complex molecule containing 4-percent cobalt, besides phosphorous and nitrogen. Cyanocobalamin is the commercially available form. Vitamin B12 is the ‘extrinsic factor’ originally postulated by Castle. It requires the ‘intrinsic factor’, secreted by the parietal cells of the stomach, to be absorbed. It is freely soluble in water and resistant to boiling in neutral solution though unstable in the presence of alkalis.

Sources : It is unique among vitamins in that it is not present in any vegetable foods. It is present in animal products - milk, milk products, meat and fish. It is also synthesized by the micro organisms in the gut and assimilated in the food chain.

Functions(a) It recycles the folate coenzyme.(b) Vitamin B12 plays important role in the synthesis of DNA.(c) It helps in maintenance of myelin in the nervous system.(d) It has an important role in the treatment of pernicious

anaemia.(e) It also helps in conversion of homocysteine to

methionine.Measurement : Serum B12 is assessed by radioligand binding or microbiological assay. Absorption is assessed by Schilling test (5).

Requirement and intake : The daily losses of this vitamin range from 0.25 μg to nearly 1 μg. An intake of 2 μg per day has been recommended by FAO/WHO. The ICMR has, however, suggested a daily intake of 1 μg of the vitamin for Indian adults (4).

Deficiency : Since the vitamin doesn’t occur in vegetable foods, vegans and strict vegetarians are at a high risk of its deficiency. Malabsorption, gastric atrophy, and reduced production of ‘intrinsic factor’ are some other causes of deficiency. Pernicious anaemia, which is a megaloblastic anaemia, results due to deficiency of this vitamin. Neurological symptoms characterized by loss of sensation and motor power in the lower limbs (due to degeneration of myelin) may also be seen. Since it is also synthesized in the gut, many cases of vitamin B12 deficiency are not seen very frequently.

Vitamin C (Ascorbic Acid)It is a water soluble, crystalline, white substance. Ascorbic acid is very sensitive to oxidation, which is accelerated by heat, alkaline solutions, light and traces of metals, especially copper. It is present in all body tissues but is found in a high concentration in the adrenal glands, pituitary gland, and intestinal wall.

Sources and Losses : Its rich sources are citrus fruits (oranges, lemons), guavas, papayas, pineapple, mangoes, gooseberry (amla), kiwi fruit and green leafy vegetables. Root vegetables also contain vitamin C, esp. sweet potato. It is also synthesized in germinating seeds, pulses and grains (See Table-5).

Table - 5 : Vitamin C content of selected food items (per 100g) (4)

Food stuff Vitamin C (mg) Food stuff Vitamin

C (mg)

Fruits Vegetables

Tomato 31 Cabbage 124

Guava 212 Spinach 28

Straw berry 52 Drum stick 120

Amla 600 Amaranth 179

Lime 63 Chillies, green 111

Mousambi 50 Potato 17

Orange 30 Bitter gourd 96

Papaya 57 Capsicum 137

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The vitamin C content of fruits and vegetables is reduced by storage and damage to plant cells by rough handling, bruising or cutting, which results in release of enzyme ascorbic acid oxidase which oxidizes ascorbic acid. Also cooking of vegetables destroys vitamin C through the enzyme action and heat and by its extraction into cooking water. High pressure steaming as well as rapid frying of green vegetables destroys the oxidase enzyme thereby causing a greater retention of vitamin C than boiling.

Functions : Ascorbic acid is a powerful reducing agent (antioxidant) and is essential for many oxidation-reduction reactions.(a) It is required for the formation of collagen and is therefore

necessary for the formation and maintenance of the normal structure of the intercellular ground substance (connective tissue), bone, tendons, skin, teeth and capillaries.

(b) It is important for hydroxylation of dopamine to nor-adrenaline.

(c) It enhances the absorption of iron, through the conversion of ferric (Fe3+) to ferrous ions (Fe2+).

(d) It has anti-oxidant property like vitamins A and E, which has an important role in free radical scavenging, as an anti-aging and anti-cancer factor.

(e) It influences the maturation of the red blood cells, synthesis of bile and metabolism of drugs and carcinogens by the liver (5)

Requirement : The requirement of vitamin C is 40 mg/day for adults. For lactating women 80 mg/day is recommended (4)

Deficiency : Vitamin C deficiency is not common now. It causes defective formation of intercellular ground substance whose characteristic gross lesions occur in gums, bones and capillaries. Reparative process especially involving connective tissues, as in wound healing, are interfered in vitamin C deficiency due to the lack of the formation of collagen. Deficiency leads to a condition called as scurvy. The signs and symptoms include spongy and bleeding gums, perifollicular haemorrhages in the skin, sub periosteal haematomas and poor wound healing. Fatigue and muscle weakness is also reported.

Fat Soluble VitaminsVitamin A (Retinol)Hopkins conducted an experiment in young rats (1906-1912). These were fed on casien, starch, sugar, lard and inorganic salts. These rats failed to grow and died. An addition of only 3 ml milk enabled them to thrive! An ‘Accessory food factor’ was thus demonstrated. Mc Callum isolated it in 1913 and was named as Vitamin A. Wald was awarded Nobel Prize for description of ‘dark vision’ and its association with Vitamin A (2,8)

Vitamin A is a term for the biologically active compound retinol and its provitamin (precursor) carotenoids. Retinol is a fat soluble pale yellow compound. It is stable to heat at ordinary cooking temperatures but liable to oxidation and destruction on rancidity of fat. However, carotenoids cannot wholly be converted into retinol in the body and man absorbs and utilizes these pigments less efficiently. 6 microgram of β-carotene has the biological activity of 1microgram retinol (RE). Other Carotenoids have even lesser vitamin A activity (4)

Sources and losses : Retinol is found in foods of animal origin. The important sources of Retinol are meat, liver, kidney, milk, fish and eggs (See Table- 6). Retinol can also be formed in the intestinal mucosa from the pigments known as carotenoids which are widely distributed in plants. Carotenoids are found in coloured fruits and vegetables. The green outer leaves of vegetables (e.g. cabbage) are good sources of carotene. One of these, β-carotene is by far the most important source of retinol (provitamin A) and is found in abundance in yellow-orange vegetables and fruits (e.g. pumpkin, papaya, mango, apricots, yellow peaches and green leafy vegetables). β-Carotene, another carotenoid, is found in carrots, lutein in dark green leafy vegetables and β-Cryptoxanthin in citrus fruits. The pigments with no vitamin A activity include lycopene in tomatoes and zeaxanthin in sweet corn (4)

Vitamin E protects it from oxidation. It is destroyed by exposure to sunlight. Foods which are heated for long period of time lose an appreciable amount of vitamin A. Boiling, canning or freezing of foods does not cause loss but drying and dehydration causes considerable loss.

Table - 6 : β-Carotene content of selected food items ((µg) per 100g) (4)

Food stuff β-Carotene (µg) Food stuff β-Carotene

(µg)

Cereals Vegetables

Wheat flour 25 Pumpkin 1160

Rice raw, hand pound

2 Fenugreek leaves

9100

Bajra 132 Carrot 6460

Maize dry 90 Amaranth 8340

Spinach 9440

Pulses & Legumes Fruits

Bengal gram 189 Apricot 2160

Soya bean 426 Raspberry 1248

Green gram 94 Papaya 880

Red Gram 132 Tomato 590

Peas dry 39 Mango 1990

Non veg foods Nuts

Egg 420 Groundnut 37

Liver sheep 6690 Cashew nuts 60

Milk cow 53 Almond 0

Mutton 9 Coconut, fresh 0

Retinol Equivalents : Vitamin A activity of a diet is usually expressed in Retinol Equivalents. As mentioned, the term vitamin A is applied to both retinol (preformed vitamin A) and pro-vitamin A (beta-carotene). One microgram retinol is considered as 1 Retinol Equivalent (1RE). It is also known that the biological activity of 6 μg beta carotene has an activity of 1 μg retinol. International Unit or IU is an old unit and is sometimes used.1 IU is equal to 0.3 μg of Retinol (Box - 2).

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Box - 2 : Vitamin A Activity

1 Retinol Equivalent (RE) equals1μg of retinol ●1 μg retinol activity ●6 μg ● β-carotene3.33 IU (International Units) ●

OR1 μg ● β-carotene = 0.167 μg retinol1 IU Vitamin A = 0.3 μg of Retinol ●

Functions(a) It is vital for the formation of retinal pigment rhodopsin in

rods of the retina. Exposure to light results in a series of changes in its configuration, which leads to the adaptation of vision in dark. Retinol deficiency leads to impairment of dark adaptation or night blindness.

(b) Retinol is essential for integrity of cellular structure esp. epithelial tissue - respiratory, gastrointestinal, genitourinary and skin.

(c) It has a role in the immune defence mechanism of the body.

(d) Vitamin A has an antioxidant property of free radical scavenging (For details refer to chapter on antioxidants).

Requirements & Recommended Dietary Allowance : The recommended intake is 600 mg of retinol equivalent per day for adults (including children above 6 years and pregnant women). Lactating mothers require 950 mg. In converting the carotene figures to retinol, a conversion factor of 0.25 has been suggested by ICMR (6). For vitamin A the RDA is given in terms of retinol (vitamin A alcohol). If the diet contains vitamin A and carotene, its content can be expressed as retinol using the following formula:

Retinol content = μg retinol + μg of β-carotene X 0.25

Deficiency : Deficiency of Vitamin A leads to ocular and extra ocular manifestations. The ocular manifestations are more common. The ocular manifestations resulting from vitamin A deficiency are termed as Xerophthalmia. Deficiency is often seen to be associated with weaning, protein energy malnutrition and a diet poor in vegetables, fruits, milk and butter. The deficiency signs / symptoms are given in the Box - 3.

Box - 3 : Signs and symptoms of Vitamin A Deficiency

Dryness, itching, redness of conjunctiva

Night blindness (inability to see in dim light)

Other signs of xerophthalmia : Bitot spots; Corneal xerosis; Keratomalacia

Dry, rough, itchy skin; rash

Dry, brittle hair and nails

Loss of acuity of senses: smell and taste

Loss of appetite

Anaemia, fatigue

Poor growth

Low immunity: Increased vulnerability to infections

Increased risk of certain cancers

Toxicity - Hypervitaminosis A :There are exotic stories of arctic explorers and fishermen who reported reddening and exfoliation of skin after feasting on polar bear liver or halibut liver. Hypervitaminosis A can be induced by a single dose of retinol greater than 200mg (200,000 RE). Chronic hypervitaminosis may result from chronic misuse of supplements which is, greater than 4000 RE (infants) to 7000 RE (adults) consumed daily. Persistent large doses of vitamin A (more than 100 times the required amount), overwhelm the liver storage capacity and produce intoxication and liver disease.

Hypervitaminosis A is characterized by skin/mucous membrane changes. Dry lips (cheilitis), dryness of nasal mucosa and eyes, erythema, scaling, peeling of skin, hair loss and nail fragility are other signs. Headache, nausea and vomiting follow. Bone abnormalities in the form of hip fractures are also reported. Retinoids can be toxic to the fetus, causing craniofacial, CNS, cardiovascular and thymic malformations. Pregnant women are therefore advised against exceeding daily intakes of 3000 RE of vitamin A.

Vitamin D (Calciferols)The term Vitamin D refers to two molecules - ergocalciferol (Vitamin D2) and cholecalciferol (Vitamin D3). Cholecalciferol is the natural form of vitamin and is produced by the ultraviolet irradiation (through sunshine) of 7-dehydrocholesterol widely distributed in animal fats such as the oily secretions in mammalian skin. Dietary ergocalciferol and cholecalciferol are biologically inactive and are activated to 25-hydroxy-cholecalciferol in liver. Further conversion in the kidney results in the production of the more active form 1,25-dihydroxy cholecalciferol (Calcitrol) (8).

How much sunshine is good enough?

Even a brief and casual sunlight exposure of the exposed parts of body (face and arms) is good enough to provide about 5 μg equivalent of vitamin D. The ultraviolet penetration depends on melanin content of the skin and is higher in light skinned people. Window panes and use of sunglasses and sun screen creams block ultraviolet penetration, thus limiting the vitamin D intake. Dark clothing, face masks and burqa will also block UV rays and Vitamin D availability. Therefore a person getting even a casual exposure to sun gets enough Vitamin D through the skin conversion. Conversely, those permanently indoors (as in cold countries) or keeping themselves covered from head to toe (practice of compulsory burqa cover) are those who might be at a risk of vitamin D deficiency.

Food sources : Cod liver oil, other oily fish, milk, margarine, eggs, liver.

Functions : Vitamin D regulates the absorption and excretion of calcium from the small intestine and also plays an essential part in the mechanism for mineralizing bone. It is considered as a hormone rather than a vitamin.Measurement : Vitamin D status can be assessed by the measurement of plasma 25-hydroxy- cholecalciferol. In severe deficiency plasma calcium and phosphate fall and alkaline phosphatase is elevated.

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Requirement and Intake : The vitamin D requirement for a child is placed at 100 to 400 IU/day (2.5-10 μg). This requirement can be obtained from exposure of the body to sunlight. ICMR expert group therefore has not recommended any dietary intake. Whenever this requirement is not met, a therapeutic supplementation may be needed (4). The food and nutrition board, USA recommends a daily dietary intake of 5 μg for adult males, females, pregnant and lactating women.

Deficiency : People who stay indoors and are fully covered (purdah system amongst women in some religious/ethnic groups) are at a higher risk of deficiency due to lack of exposure to UV radiation due to sunlight. Malabsorption also increases the risk of deficiency. Severe deficiency results in rickets in children, characterized by reduced calcification of bone epiphysis. It leads to skeletal deformities, bone pain and muscle weakness. In adults deficiency results in osteomalacia.

Vitamin E (Tocopherol)Eight naturally occurring forms of vitamin E are synthesized in plants; four tocopherols (α,β, γ and δ tocopherols) and four tocotrienols (α,β, γ and δ tocotrienols). Alpha tocopherol which is synthesized commercially has the highest biological activity, and is used as the standard against which activity of other forms is measured. Being fat soluble, vitamin E is found in all cell membranes (5).

Sources : Vitamin E is widely distributed in foods and the richest sources are vegetable oils like groundnut, sunflower, safflower, cotton seed, corn, wheat germ, rape seed, palm and other oils. Nuts (like almonds and peanuts) are also good sources. Eggs, butter, whole meal cereals are moderately good sources. Meat, fruits, vegetables contain small amounts. Foods rich in PUFA are also rich in Vitamin E.

Tocopherol

(Greek, tokos, childbirth; pherin, to carry)

This vitamin was so named in Greek, as the work of early investigators indicated a strong relationship to reproductive function in rats, which was not found to be true in humans.

Functions(a) Like vitamin A and C, it has a strong antioxidant property

and protects cell membranes and lipoproteins against damage from free radicals. It also prevents the non-enzymatic destruction of polyunsaturated fatty acids by molecular oxygen.

(b) It maintains the cell membrane integrity.(c) It has a role in the DNA and prostaglandin synthesis.Requirement & Intake : The human requirement of vitamin E is not known with certainty (4). The US authorities have recommended a daily intake of 12mg/day.

Deficiency : Deficiency of vitamin E in animals interferes with normal reproduction and causes a form of muscular dystrophy, but the effects if any, on human beings are being studied. However, a genetically inherited disease Familial Isolated Vitamin E (FIVE) deficiency is known. Patients develop reduced tendon reflexes by age 3-4, loss of touch and pain sensation, unsteady gait, loss of coordination and impaired eye movement in adolescence. Deficiencies have also been seen in people with

severe fat malabsorption (5).

Vitamin KIt exists in nature in two forms. Vitamin K1 (phylloquinone), originally isolated from lucerine, is the only form that occurs in plants. It is a yellow oil, soluble in fat solvents, but only slightly soluble in water. Vitamin K2 (menaquinone) is produced by bacteria in the lumen of large intestine.

Food sources : Green leafy vegetables, vegetable oils esp. soya bean oil, eggs, meat and dairy products are good food sources of vitamin K.Functions(a) Vitamin K promotes the synthesis of γ-carboxy glutamic

acid (Gla) in the liver which is essential for formation of prothrombin (or factor II) and also factors VII, IX and X. It is well known that these factors participate, in the coagulation of blood.

(b) Some other proteins also contain Gla and require vitamin K for their synthesis e.g. osteocalcin, a bone protein made by osteoblasts (5).

Requirement & Intake : No recommendations are given by the ICMR. The US authorities recommend an intake of 120μg for males and 90μg for females.

Deficiency : This is characterized by poor blood clotting and results in low prothrombin activity. Neonates are born with very low stores of vitamin K due to sterility of intestines (and absence of bacteria producing vitamin K). So neonates are given an injection of this vitamin at birth. Adults rarely manifest the deficiency, but can be seen in cases of obstructive jaundice as lack of bile leads to poor absorption of vitamin K. The anticoagulants Warfarin and Dicoumarol can cause a deficiency.

SummaryVitamins which were historically considered as the vital amines have not lost their vitality, and are as important today as they were at the time of their discovery. They help in many metabolic reactions and are essential for control of cell metabolism, transformation of energy, and prevention of specific nutritional deficiencies. Their role as antioxidant agents has enabled scientists to refocus their attention on vitamins. A summary of the most important vitamins is tabulated at the end of chapter.

Study ExercisesLong Questions : (1) Enumerate the water soluble vitamins. What is the role of vitamin C in the human body? (2) Name the fat soluble vitamins. Discuss the dietary sources, functions and deficiency symptoms of Vitamin A.

Short Notes : (1) Hypervitaminosis A (2) Beriberi (3) Vitamins as antioxidants

MCQs1. Which of the following will help you increase the iron

absorption from diet : (a) Nicotinic acid (b) Ascorbic acid (c) Pantothenic acid (d) Folic acid

2. Which of the following is not a source of beta carotene (a) Green vegetable (b) Potatoe (c) Liver (d) Papaya

3. Which of the following is not known to have an

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antioxidant effect (a) Vitamin A (b) L-Ascorbic acid (c) Alpha-Tocopherol (d) Phylloquinone

4. Which of the following does not fall under ‘xerophthalmia’ (a) Conjunctival xerosis (b) Corneal xerosis (c) Retinal xerosis (d) Lachrymal xerosis

5. Which of these is available only from animal sources (a) Vitamin B12 (b) Vitamin B1 (c) Vitamin B6 (d) Vitamin B2

Answers : (1) b; (2) c; (3) d; (4) d; (5) a.

ReferencesMc Collum EV. A history of Nutrition, Boston, Houghton Miffin Company, 1. 1957.

Garrow JS, James WPT, Ralph A, Human Nutrition and Dietetics. Churchill 2. Livingstone, UK. 10th Ed 2000.Mahan LK, Stump SL. Krause’s Food, Nutrition & diet therapy.11th edition 3. Saunder’s Philadelphia, USA. 2000.Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian 4. foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.Gandy JW, Madden A, Holdsworth M. Oxford handbook of Nutrition and 5. Dietetics. Oxford University Press, New Delhi. 2007.Geissler C, Powers H. Human Nutrition.11th ed. Elsevier Churchill Livingstone 6. London. 2005.Antia FP, Abraham P. Clinical Dietetics and Nutrition. 4th ed Oxford University 7. Press, New Delhi 1998.Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and 8. Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.Zimmermann M. Burgerstein’s Handbook of Nutrition: Micronutrients in the 9. Prevention and Therapy of Disease. 9th Ed. Heidelberg, Germany. 2007

Fat Soluble Vitamins

Vitamin Function RDA Deficiency Sources

Vitamin A (Retinol, Retinal, Carotenes, Cryptoxanthines)

Vision, Integrity of epithelium, Gene regulation, Antioxidant

600 μg/ day Xerophthalmia, Dry skin, impaired immunity, growth and reproduction

Retinol (animal foods): liver, egg, meat, milk Provitamin A (plant foods) yellow, green vegetables

Vitamin D (Cholecalciferol, D3 ; Ergocalciferol, D2)

Calcium homeostasis, Bone metabolism

100 - 400 IU /day - (Child)

Rickets in children Osteomalacia in adults

Synthesised in skin with exposure to sunlight; Fish oils, milk

Vitamin E (Tocopherols) Cellular membrane antioxidant

12mg / day RBC breakdown, anaemia, nerve damage, retinopathy

Vegetable oils, green vegetables, cereal germ, nuts, seeds

Vitamin K (Phylloquinones, Menaquinones, Menadione)

Clotting of blood, Calcium metabolism

120 μg / day (Males)90 μg / day (Females)

Bleeding tendencies Synthesis by intestinal bacteria, green vegetables soya oil, liver, milk

Water Soluble Vitamins

Vitamin Function RDA Deficiency Sources

Vitamin C (Ascorbic acid)

Reductant in hydroxylations in collagen and carnitine synthesis Metabolism of drugs

40mg /day

Scurvy: Spongy, bleeding gums, fatigue, haemearthrosis

Citrus fruits, guava, amla, green vegetables , tomatoes, strawberries

Vitamin B1 (Thiamine)

Normal growth Coenzyme for decarboxylation of 2-keto acids and transketolation reactions

0.5mg / 1000KcalBeriberi - Cardiac (wet), Neuritic (dry) and Infantile

Meat, liver, legumes, wheat germ

Vitamin B2 (Riboflavin)

Normal growth Coenzyme in redox reactions of fatty acids and TCA cycle

0.6mg / 1000Kcal

Ariboflavinosis: Magenta tongue, Cheilosis, angular stomatitis, corneal ulcer

Milk, meat, green vegetables

Niacin (Nicotinic acid, Nicotinamide)

Coenzyme for dehydrogenases 6.6mg / 1000Kcal Pellagra, characterized br 3 Ds- dermatitis, diarrhea, dementia

Meat, groundnus, legumes, grains

Vitamin B6 (Pyridoxamine)

Coenzymes in amino acid metabolism

2mg / day Anaemia, neuritis, convulsions

Grains, seeds, poultry, meat

Folic Acid Coenzymes in single carbon metabolism

100μg / day Megaloblastic anaemia Liver, green vegetables yeast, fruits

Vitamin B12 (Cobalamin)

Coenzymes in amino acid, propionate and single carbon fragment metabolism

1μg / day Pernicious anaemia Liver, lean meat fish, seafood, milk

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130 The Micronutrients : Minerals

Rajul K Gupta

Minerals are required in small quantities and constitute only a small portion of the body weight but enter into the metabolism to a much greater degree than their mere weight indicates. A large portion of the ash of the body is composed of calcium, magnesium, sodium, potassium, phosphorous, sulphur and chlorine. The main functions of the minerals include: providing rigidity and relative permanence to the bones and teeth; providing essential elements for the formation and activities of the muscular, glandular; neural, and epithelial tissues; forming components of enzyme systems; and providing dynamic characteristics to the intra and extra cellular fluids for regulation of pH, osmotic pressure and electro-neutrality and those of secretion and excretions (1).

Minerals like zinc, molybdenum, copper, manganese and magnesium are either structural parts or functionally activate many enzyme systems. Iodine is a part of hormone, thyroxine. Sodium and potassium are important in fluid dynamics and energy transfer. They along with chloride, carbonates and bicarbonates maintain the acid base balance. Some amount of minerals is excreted daily through urine, sweat, skin and intestinal exfoliations and thus has to be replaced. Growing infants, children, pregnant and lactating women require a higher quantity of some of these minerals to meet the physiological needs. Deficiency, leads to a deranged function of systems and various pathological states in extreme conditions.

ClassificationMinerals can be classified into macrominerals and microminerals (See Box- 1). Macrominerals also referred to as major minerals are distinguished from the microminerals by their occurrence in the body. Taking this as criterion, various definitions of macrominerals have evolved, such as “those which constitute at least 0.01% of body weight (5g in a 60 Kg man)” ; or a more quantifiable and unambiguous definition like “mineral whose requirement is more than 100mg per day”. Calcium, phosphorous, magnesium, sodium, potassium, chloride and sulphur are the macrominerals (2).

Box - 1 : Classification of Minerals

The Macrominerals

Calcium, phosphorous, magnesium, sodium, potassium, chloride, sulphur

The Microminerals

Iron, zinc, iodine, Copper, manganese, molybdenum, selenium, chromium and fluorine, cobalt, nickel, tin, silicon, vanadium, arsenic, cadmium, boron, aluminium

As a corollary microminerals or trace elements can be defined as those comprising less than 0.01% of total body weight or more appropriately those which are needed in a concentration of less than 1ppm (3). These were initially known as trace because their concentration in tissues could not be easily

ascertained by early analytic methods (4). Classically, iron appears to be the mineral that divides the macrominerals from microminerals. Thus a trace element (or micromineral) can be defined as one that is required by the body in the concentration equal to or less than that of iron (5). Microminerals include iron, zinc, iodine, copper, manganese, molybdenum, selenium chromium and flourine. Cobalt, nickel, tin, silicon, vanadium, arsenic and boron can be classified as ultra-trace elements (2). An element is termed ‘essential’ if a dietary deficiency of that element consistently results in a suboptimal biological function that is preventable or reversible by physiological amounts of the element (6).

Calcium (Ca)Calcium is essential for the building of bones and teeth. It is the most abundant mineral in the human body. Most is deposited as hydroxyapatite, in bones and teeth. Constant levels of calcium in the body/plasma is maintained under the influence of parathyroid hormone and calcitonin. Factors promoting absorption of calcium are vitamin D, proteins and lactose.

Sources, Absorption and Losses : Rich sources of calcium are milk and milk products, ragi, fish (if eaten whole), dried fruits such as raisins, apricots and dates, and betel leaves with lime, pulses and tofu (See Table- 1).

Table 1: Calcium content of common foods (mg/100g)

FoodstuffCalcium (mg per 100g)

FoodstuffCalcium (mg per 100g)

Cereals & Legumes Fruits

Rice, raw 10 Figs 187

Wheat flour, whole

48 Raisins 87

Ragi 344 Dates, dried 120

Red gram (Dal arhar)

73 Lemon 70

Bengal gram, whole

202 Apricots, dry 110

Vegetables Miscellaneous

Turnip greens 710 Fish, Rohu 650

Amaranth species 200-800 Coconut dry 400

Cauliflower greens

626 Gingelly seeds 1450

Onion 46.9 Almond 230

Spinach 73 Milk, cow 120

Cluster beans 130 Mutton 150

Calcium in food is not uniformly available to the body e.g. calcium in vegetables and fruits is poorly absorbed due to the presence of oxalic acid in these foods which forms insoluble calcium oxalate. Spinach is one of the foods which is very rich in oxalic acid. Phytic acid in the pericarp of cereal grains unites with calcium to form phytin, which is not absorbed. However, many cereals such as rye and wheat contain an enzyme

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phytase, which splits phytic acid so that it can no longer bind with calcium and thus makes calcium available for absorption. Excess of fatty acids, particularly saturated fatty acids in the small intestine may form insoluble soaps with calcium and may carry significant amount of calcium into faeces. Calcium in milk and dairy foods is more readily absorbed (7, 8).

Foods interfering with absorption of Calcium

Protein intake >20% of calories

Phosphorus (milk, meat, colas)

Oxalates (Spinach, tomato)

Sodium (salt)

Tannins (black coffee, tea)

Alcohol

Functions

Bone formation : More than 99% of body calcium is found in the bones. Calcium is essential for providing the structural rigidity to bones and teeth.

Nerve conduction: Calcium is responsible for the maintenance of optimum excitability of the nervous and muscular tissues.

Blood Coagulation: Calcium has an important role in the coagulation of blood as factor IV.

As a cofactor : Calcium acts as a co-factor for a number of enzymes e.g. lipase (9).

Requirement and Intake : The suggested levels for calcium intake for adult men and growing children are 400 to 600mg/day. In case of pregnant and lactating women it is 1000mg/day (10).

Deficiency : Plasma calcium levels are tightly controlled and are not usually affected by dietary insufficiency in healthy adults. Reduction in the level of circulating ionised calcium produces a clinical condition known as tetany. This is characterized by twitching of muscles of face, hand and feet. Cardiac arrhythmias may also result. A long term calcium deficiency during the bone formative age can cause stunted skeletal growth and a low bone density. Vitamin D deficiency leads to rickets in children due to poor calcium absorption (9).

Osteoporosis is an abnormal thinning of bones. It is not due to a primary calcium deficiency but results from conditions leading to chronic calcium deficiency. These factors are inadequate calcium intake, poor absorption, abnormal hormone levels, upsetting the calcium homeostasis and subnormal physical activity. Osteoporotic bones are more likely to get fractured with trivial injuries (falls), as commonly seen in post-menopausal women and the elderly.

PhosphorusThe role of phosphorus in bone formation is almost as important as calcium and so it is a macromineral of extreme value. It gets deposited in bones and teeth as calcium phosphate. An adult human body contains about 400-700 g of phosphorus as phosphate mostly in bones and teeth (10).

Sources : Phosphorus is widely distributed in food stuffs and therefore, its deficiency rarely occurs. Milk, milk products,

cereals, meat, fish, nuts, fruits and vegetables are good sources. A large part of phosphorus present in vegetable foods occurs in combination with phytin (fibre) and is available to the body only to the extent of 40-60 percent.Functions

Bone formation : It is essential for the formation of bones and teeth along with calcium as hydroxyapatite.

Energy metabolism: It also plays an important role in all metabolism for derivation of energy from the phosphate bonds in adenosine triphosphate (ATP).

Acid base balance: Phosphorus acts as an important buffer that prevents changes in the pH of body fluids.

Miscellaneous: It is an important constituent of nucleic acids, phospholipids and membranes (11).

Requirements : It is suggested that phosphorus intake should be about 1 g per day that is about twice as large as that of calcium (10).

Deficiency : Phosphorus deficiency is unlikely to occur as it is widely available in foodstuff. However hypophosphataemia may occur in pathological conditions (sepsis, liver disease, alcoholism, diabetic ketoacidosis) patients on prolonged parenteral nutrition, hypophosphataemic rickets and excessive use of aluminium-containing antacids (9).

SodiumSodium is one of the most abundant minerals present in the human body. An adult male has total body sodium of about 92-110 g, almost equally divided into the Extracellular Fluid (ECF) and bone. In the blood and interstitial fluid it is found to be largely combined with chloride and bicarbonate. Intracellular fluid contains about a third of the sodium content of the extracellular fluid (9).

Sources : Common salt (sodium chloride) is the cheapest, best and most widely available source of sodium; 3 g salt is roughly equivalent to 1.2 g of sodium. Indian diet is particularly rich in sodium (pickles, chutneys, etc.). It is also present in food additives like monosodium glutamate, mainly used in Chinese cuisine. Natural foods like meat, milk, eggs, vegetables and fruits all contain sodium. Salt is added to almost all processed foods, thereby increasing their sodium content.

Functions : Sodium is the main cation in the ECF of human body. It takes an important part in osmotic processes. It is important in the blood pressure regulation along with potassium. Acid-base regulation is a function of sodium. It also maintains the osmotic pressure. Sodium is also a vital component of the electrophysiological control of muscles and nerves.

Requirement : The daily intake varies from 2 to 20 gm/day. The recommended daily intake of sodium chloride is about 5 g (10).

Deficiency : Excessive sweating as in hot and humid climates and extreme exertion, diarrhoea and dehydration can lead to sodium deficiency. This may be manifested as muscle cramps and severe dehydration and hypovolemia.

PotassiumThe adult human body contains about 250 g of potassium

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which is twice the amount of sodium. Potassium occurs widely in foodstuffs, so there is little likelihood of its deficiency. It is the principal intracellular cation.

Sources : Most foods contain useful amounts of potassium, particularly those of vegetable origin. Fruits like melons, apricots, fruit juices, vegetables including potatoes, pulses, meat and whole grain cereals are good sources (See Table- 2).

Table - 2: Potassium content of common foods (mg/100g)

FoodstuffPotassium

(mg per 100g)

FoodstuffPotassium

(mg per 100g)

Cereals & Legumes Fruits

Rice, flakes 154 Apricots 430

Wheat flour, whole

315 Peaches 453

Ragi 408 Musk melon 341

Red gram (Dal arhar)

1104 Mosambi 490

Bengal gram, whole

808 Cherries 320

Vegetables Miscellaneous

Spinach 206 Rohu 288

Amaranth 341 Coconut meal, deoiled

2003

Brussels sprouts

477 Mutton 270

Sweet potato 393 Milk cow 140

Brinjal 200 Drumstick 259

Functions : Potassium is the principal ion in the intracellular compartment, thus plays an important role in the water balance of the body with sodium being in the extracellular compartment. Along with sodium, potassium too is involved in acid-base regulation. Potassium along with sodium is essential for the cellular uptake of molecules through the sodium-potassium pump. Potassium is necessary for the release of insulin from the pancreatic cells in response to high blood glucose. There is an important role of the sodium to potassium ratio in the regulation of blood pressure, rather than sodium alone. This ratio should ideally be 1:1 to have a healthy blood pressure.

Requirements : The daily requirement of potassium has not been determined accurately (10). The acceptable intake appears to be about 4.7 g per day, almost the same as of sodium.

Deficiency : Dietary deficiency is not common. However deficiency could be caused by diarrhoea, vomiting, dehydration, purgatives, chronic acidosis or alkalosis, diuretics, etc. Potassium deficiency affects the electrophysiology of cell. It may cause cardiac arrhyth mias and muscle weakness (9).

MagnesiumMagnesium has wide ranging body functions. All human tissues contain small amounts of magnesium. The adult

body contains about 25 g of the metal and greater part of this amount is present in bones in combination with phosphate and bicarbonate. About one fifth of the total magnesium in the body is present in the soft tissues, where it is mainly bound to protein. Inside the cells, the metal is concentrated within the mitochondria.

Sources : Most foods contain useful amounts of magnesium, particularly those of vegetable origin. Green vegetables, pulses, meat, nuts and whole grain cereals are good sources. Hard drinking water may make a significant contribution to magnesium intake.

Functions : Magnesium is an integral part of bones and teeth. Within the mitochondria it is a co-factor for co-carboxylase and co-enzyme A and is concerned with intracellular energy metabolism. It is important in the replication of DNA, synthesis of proteins and RNA. It is essential for muscle and nerve cell function.

Requirements : Estimated to be about 350 mg/day for adults (10).

Deficiency : It is unlikely that magnesium deficiency would arise in man from simple lack of food. Vitamin D appears to increase magnesium absorption from the intestine. Excessive losses of magnesium in the faeces or urine occur in many diseases e.g. renal or adrenal disease, malabsorption, use of some drugs (e.g. diuretics) and in re-feeding syndrome. Magnesium deficiency leads to apathy and muscular weakness and sometimes to tetany, convulsions, cardiac arrhythmias and cardiac arrest (9).

IronIron is probably one of the most studied minerals in context of human health. It is one of the most important micronutrients and is of fundamental importance to life. The body of an adult human contains iron equal in weight to a large ‘nail’ (about 4 g), of which more than two thirds (about 2.4g) is present in haemoglobin. The rest of the iron in the body is present as a reserve store in liver and to a lesser extent in other organs.

Sources : The sources of iron can be divided into two main groups:

(a) Haem Iron Sources: These are essentially the non-vegetarian sources of iron e.g. meat, fish and eggs. Milk is considered a poor source of iron but breast milk is an efficient source for the infant.

(b) Non-haem Iron Sources : These are the vegetarian sources, namely cereals, dark green leafy vegetables, pulses, nuts and dry fruits. Absorption of iron from these foods is only 1 to 20 percent (See Table- 3).

Non-haem iron is poorly absorbed (1-20%) and is influenced by dietary constituents. Certain compounds like Phytic acid (in cereals, fibre), polyphenols (in plants), tannins (in tea), phosphates (in milk and eggs) present in foods of vegetable origin inhibit the absorption of iron. There are also factors in the diet that increase non-haem iron absorption, such as red meat, fish, chicken and liver. Ascorbic acid and low pH also enhance the absorption of non-haem iron. Haem-iron is absorbed directly into the mucosal cells where iron is released by haem oxidase and then bound to transferrin.

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Table - 3: Iron content of common foods (mg/100g)

FoodstuffIron

(mg per 100g)

FoodstuffIron

(mg per 100g)

Cereals & Legumes Fruits

Rice, raw milled 0.7 Apricots 2.2

Wheat flour, whole

4.9 Pineapple 2.42

Jowar 4.1 Water melon 7.9

Lentil 7.6 Custard apple 4.31

Bengal gram, whole

5.3 Mango 1.3

Soyabean 10.4 Pomegranate 1.79

Vegetables Miscellaneous

Spinach 1.14 Fish, Hilsa 2.1

Amaranth 1.8-38.5 Milk cow 0.2

Cauliflower greens 40 Mutton, muscle 2.5

Radish leaves 18.0 Jaggery 2.64

Maximum absorption of iron takes place in duodenum and upper part of small intestine. The amount of iron absorbed from a given meal depends to a large extent on the iron status of the individual. Iron absorption increases during growth and pregnancy.

When the body needs iron it passes directly through the mucosal cells and is transported by transferrin to the bone marrow. If iron is not required it is stored in the mucosal cells as transferrin. It will be lost in faeces when the mucosal cells are exfoliated. Excess iron is stored as ferritin or haemosiderin in the liver, spleen, or bone marrow. It can be mobilized from these stores when demand is increased.

It is lost mainly during menstruation and from the gastrointestinal tract. Physiological losses from all other routes (exfoliation from alimentary, urinary and respiratory tract and by dermal and hair losses and losses in the sweat) also occur. Excretion of iron is very low (about 1mg/day in men).

Functions : Iron is a component of haemoglobin and myoglobin. Iron is an essential component of heme. It is also a constituent of important enzymes like cytochromes, catalase, peroxidase, etc. As a part of these haemocomplexes and metallo-enzymes, it serves important functions in oxygen transport and cellular respiration. It is also involved in cellular immune response for appropriate functioning of phagocytic cells (9, 11).

Requirements : The requirement of iron is quite small, in the vicinity of 1 to 3 mg/day. It changes constantly depending on the age, sex and the physiological status of the individual like pregnancy, lactation and growth. But since the absorption of iron is rather poor, the dietary intake of iron should be 10 to 25 times the requirement. Hence the RDA of iron is about 28 mg for males and 30 mg for females (38mg for pregnant females) (10).

Group Requirement RDA

Male 0.9 mg 28 mg

Female 2.8 mg 30 mg

Pregnancy 3.5 mg 38 mg

Lactation 2.4 mg 30 mg

Deficiency : Iron deficiency anaemia is the most common nutritional deficiency in the world. It is estimated that up to half of all women and two-thirds of all pregnant women have anaemia esp. in developing countries (9). Contrary to common belief, the prevalence of anaemia in males is also of a very high magnitude of about 40%.

Increased risk of Iron Deficiency

Women

Growing children and adolescents

Pregnancy

Heavy menstruation

Chronic bleedsHaemorrhoids ●Peptic ulcers ●Irritation from drugs/alcohol ●Acute gastritis ●

Iron poor diets

Strict vegetarians

Heavy tea/coffee drinkers

Reduced gastric acid secretion

Atrophic gastritis

Stomach surgery

Chronic antacid use

Reduced transport due to deficiency ofVitamin A ●Vitamin B ● 6

Copper ●

The details of the condition are extensively elaborated in a separate chapter on nutritional deficiencies.

Toxicity : The major cause of iron overload is hereditary haemochromatosis, another cause could be transfusion overload. The latter may be seen in cases receiving frequent transfusions as in Sickle cell anaemia and Thalassemia. Haemosiderosis is a condition seen in individuals consuming an abnormally large amount of iron.

Recent studies suggest that iron plays an active role as a pro-oxidant (opposite to the ‘favourable’ antioxidant activity of certain vitamins and minerals) (See Box- 2).

IodineIodine has also been studied for a very long time. As early as 2800 BC Shan Nuang in China suggested sea weeds as a remedy for goiter. It was discovered as an element in 1811 by Courtois (France). It is an essential trace element because it is

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an integral component of the thyroid hormones: thyroxine and triiodothyroxine, both of which have important metabolic roles. Iodine deficiency is endemic in the mountainous areas with poor soil content such as the sub-Himalayan regions. This is due to iodine being washed from the soil. Its deficiency causes the widely prevalent preventable iodine deficiency disorders that affect all ages: abortions, still births, cretinism, mental retardation, deaf-mutism, dwarfism and goiter.

Sources and losses : The presence of iodine in the food is a function of the iodine content of local soil. Wherever the soil contains adequate amount of iodine, all crops growing there are rich in iodine. Among the natural foods the best sources of iodine are seafoods and vegetables grown on iodine-rich soils. Dairy products, eggs, cereal grains, legumes and green leaves (spinach) are also reasonable sources of iodine. Water contains traces of iodine which contributes to as much as 10% of our total iodine intake.

Goitrogens : Certain vegetables of Brassica group such as cabbage, cauliflower and radish contain goitrogens such as thiocyanates and cynoglycosides. Consumption of large quantities of these foods may lead to the development of goiter by making the iodine present in food unavailable to the body. Goitrogens are inactivated by heating.

Absorption : Dietary iodine absorbed from the small intestine follows two main pathways within the body. Approximately 30 percent is used up by the thyroid gland for the synthesis of thyroxine hormone; the remainder is excreted in the urine (9).

Functions : Iodine is an integral component of the thyroid hormones thyroxine (T4) and tri-iodothyronine (T3). In addition, the fetus and neonate normal protein metabolism in the brain and CNS requires iodine.

Requirement : The daily requirement of iodine is 150μg for an adult (10). However the requirements differ with age and physiological states. See box-3.

Box - 3 : RDA of Iodine

Infants 50 μg

Children 100 μg

Adults 150 μg

Pregnancy 200 μg

Deficiency : Endemic goiter of varying degrees is found in a large proportion of the population in India, where the soil and thus food materials are deficient in iodine. This is particularly true for the sub-Himalayan regions of India. By virtue of the slopes, iodine from the top soil constantly gets washed off by rains. Other regions located close to the hills e.g. Western and Eastern Ghats, Jharkhand, Chhatisgarh etc also face this problem. Hence, iodine deficiency of varying degree is

encountered in many districts in India. The deficiency of iodine leads to various deficiency disorders, commonly termed as Iodine Deficiency Disorders (IDD) that shows a wide spectrum of picture ranging from still births to goiters in adults (See Box - 4). Fortification of salt with iodine is carried out to reduce IDD. The PFA act has specified an iodine concentration of 30 and 15 ppm in salt at source and consumer ends respectively thereby providing 150 mg of iodine in 10 gm of salt.

Box - 4 : Iodine Deficiency Disorders

Adults : Iodine deficiency disorder (IDD) in adults results in hypothyroidism and raised levels of TSH, which cause hyperplasia of thyroid tissues resulting in goitre. Hypothyroidism is characterized by lethargy, poor cold tolerance, bradycardia, and myxoedema. Infertility is known to occur in IDD.

Fetus & infants: In the fetus, IDD results in cretinism. The same is manifested as mental retardation, hearing, speech defects, squint, disorders of gait, and growth retardation in infant life.

At birth : IDD is also linked to an increase in the rates of still birth, miscarriage. Neonatal hypothyroidism is a sensitive indicator of the incidence of IDD in a community.

Recent Advances : Detection of iodine in salt

It must be appreciated that mere iodination of salt does not ensure availability of iodine to the consumer. Iodine has a property to ‘sublimate’ and is thus constantly lost from its ‘iodized vehicle (salt)’ on keeping. It is therefore recommended to consume the iodized salt within a period of 6 months of iodization. There is a simple inexpensive rapid test (UNICEF) available to detect the level of iodine in salt. Test kits can be obtained by directing requests to MBI, 85 GN Chetty Road, III Floor, T Nagar, Madras 600 017 (13)

FluorineIt is normally present in the bones and teeth and is essential for the normal mineralisation of bones and formation of dental enamel.

Sources : Fluorine is widely but unevenly distributed in nature. It is found in many foods, but seafoods, cheese and tea are rich sources. However, the main source of fluorine to man is drinking water. The fluoride content of drinking water in India is about 0.5 mg/l but in fluorosis endemic areas, the natural waters have been found to contain as much as 3 to 12 mg of fluoride/l. A concentration of 0.5 to 0.8 mg/l in water is considered a safe limit in India. In temperate climate where the intake of water, is low, the optimum level of fluorine in drinking water is accepted as 1 mg/l (14).

Box - 2 : Pro-oxidant activity of Iron

There is no doubt in the fact that iron is an important mineral involved in various vital metabolic functions. But lately, a pro-oxidant role of iron is being studied. Excess iron promotes lipid peroxidation and tissue damage in vitro. There is a possibility that, via these pro-oxidant effects, disturbances in iron metabolism play a pathogenic role in many diseases. Therefore iron may be potentially harmful in some situations, esp. during preexisting inflammation and disease (12). For more details section on ‘Antioxidants’ can be referred to.

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Deficiency : Deficiency of fluoride in water below 0.5 mg/1 is usually associated with dental caries.

Excess : Ingestion of large amounts of fluorine (>2-3ppm in water) is associated with dental and skeletal fluorosis. Skeletal fluorosis has been reported to be health problem in rural districts of Andhra Pradesh, Haryana, Karnataka, Kerala, Punjab, Rajasthan and Tamil Nadu. Scientists working at the National Institute of Nutrition Hyderabad found new form of fluorosis characterized by genu valgum and osteoporosis of the lower limbs in some districts of Andhra Pradesh and Tamilnadu.

ZincZinc is present in small amounts in all tissues of the body. Total content of the body is over 2.0 g.

Sources : Zinc is widely distributed in food stuffs of both animal and vegetable origin. Good sources of zinc are meat, whole grains and legumes. Its bioavailability in vegetable foods is poor due to presence of phytates which impair its absorption.

Requirement : The daily requirement of zinc is about 15 mg in men and 12 mg in women (15).

Functions : Zinc is part of over 100 enzymes and is thus of importance in protein and carbohydrate metabolism, bone metabolism, and oxygen transport. Zinc is also important in the immune response and gene expression. It is an important structural constituent of leucocytes and has a vital role to play in the synthesis of nucleic acids (9). Lymphoid tissue too contains substantial amounts of zinc. Zinc interacts with insulin in the pancreas and serves in the efficient storage of the hormone. Zinc is a also powerful antioxidant.

Deficiency : A clinical syndrome characterized by small stature, hypogonadism, mild anaemia and low plasma zinc occurs in older children and adolescents in poor peasant communities in Iran and elsewhere in Middle East, where the staple diet is unleavened bread. The zinc intake is low and its absorption is impaired by phytate in the unleavened bread. However, the common deficiency symptoms are:

Severe deficiency results in growth retardation, failure to ●thrive, delayed sexual maturation esp. in children.Deficiency of zinc impairs cellular immune mechanism ●while excess of it may depress neutrophils.Zinc deficiency may present as a tetrad of symptoms ●comprising of neuro-psychiatric changes, dermal lesions, diarrhoea and alopecia (Acro-dermatitis Enteropathica). Zinc supplementation has been found useful in these conditions (9,15).

CopperIt is an essential trace element as it is a component of many metallo-enzyme systems and iron metabolism is closely dependent on it. The amount of copper in the adult body is estimated to be 80 -100mg. Copper is widely distributed in nature and therefore primary copper deficiency in adults has never been reported in adult man. Even poor diets provide enough copper for human needs.

Sources : Meat, nuts, cereals and fruits are good sources.

Functions : Many metalloenzymes contain Copper. These enzymes have various functions which are summarized in the Box- 5 (9).

Box - 5 : Functions of some copper containing metalloenzymes

Enzyme Function

Caeruloplasmin (Ferrioxidase 1)

- Iron oxidation and transport

Superoxide dismutase - Antioxidant

Cytochrome-c oxidase - Electron transport

Dopamine hydroxylase - Hydroxylation of Dopa in brain

Tyrosinase - Formation of melanin

Clotting factors V and VIII - Thrombogenesis

Requirement : Suggested daily intake is 1-2 mg (10).

Deficiency : Copper deficiency is rare. Hypocupraemia occurs in patients with nephrosis, Wilson’s disease and sometimes in protein energy malnutrition. Neutropaenia is the commonest documented abnormality of copper deficiency. Infants, especially those who are premature, may develop copper deficiency which usually presents as chronic diarrhoea. Neutropaenia and later anaemia develop and they do not respond to iron. Menke’s disease, a rare hereditary defect of copper absorption is invariably fatal. Copper deficiency may be a risk factor for coronary heart disease as it has been associated with raised plasma cholesterol levels and heart-related abnormalities.(9)

SeleniumThere is a resurgence of interest in the mineral selenium due to its antioxidant properties. It is an essential component of glutathione peroxidase, an important enzyme. It is present in all body tissues except fat.

Sources : Meat, fish, nuts and eggs are good sources. Lacto-ova vegetarians and vegans may be at risk of deficiency.

Functions : Selenium is an integral part of over 30 selenoproteins; the most important of which are glutathione peroxidases and iodothyronine deiodinases. Glutathione peroxidase has an important role in the detoxification of peroxides and free radicals. Its antioxidant action might be protective against certain cancers especially prostate, lung, colon and non-melanoma skin cancers. It may also be helpful in delaying the aging process. It is also involved in the production of tri-iodothyronine from thyroxine. It also contributes to antibody responses, the production of eicosanoids as well as cytotoxicity of natural killer cells (9).

Requirements : Recommended daily intake is 70 μg (11).

Deficiency : Its deficiency has a wide range of symptoms, not all attributable to glutathione peroxidase. Its deficiency is associated with increased coronary artery disease. Keshan disease (endemic cardiomyopathy) in China and Kashin Beck syndrome, an osteo-arthropathy in children of 05-13 years age is seen in selenium deficient areas (9,10).

• 740 •

SummaryMinerals are single inorganic elements, used by the body to activate, regulate and control metabolic activities, in structural building of cell/tissue and in neural transmission and muscle

Summary Box - 1 : The Macrominerals

Mineral Function RDA Deficiency Sources

Calcium Bone & teeth formation, Blood clotting, Muscle contraction, Nerve transmission

Adults: 400 mg Pregnancy & Lactation 1 g

Tetany, Rickets, Osteoporosis Dairy products, Meat products, Leafy vegetables

Phosphorus Bone & teeth formation, Energy metabolism, Nucleic acid synthesis, Acid base balance

1 g Not seen often Can cause bone loss, anorexia

Dairy products, Meat products, Leafy vegetables

Sodium Extracellular fluid component, Water balance Acid base balance Nerve transmission, Muscle action

5 g Cramps, Acid-base imbalance, Water imbalance

Table salt

Potassium Major Intracellular fluid component, Acid-base balance; Nerve transmission, Muscle action

5 g Muscle weakness, Arrhythmias

Fresh fruits, meats, whole grains, vegetables

Magnesium Coenzyme in metabolic reactions, Nerve conduction

350 mg Tremors, spasm Meat, cheese, eggs, nuts, legumes

Summary Box - 2 : The Microminerals

Mineral Function RDA Deficiency Sources

Iron Haemoglobin & Myoglobin formation, Cellular oxidation reactions, Antibody formation

Male:28mg Female:30mg Pregnancy:38mg Lactation:30mg

Anaemia, fatiguability. Impaired immune function

Meat products, Liver, Green leafy vegetables

Iodine Thyroxine synthesis Adults 150μg Pregnancy 200μg

Goitre, cretinism, hypothyroidism, Infertilty, still births

Iodized salt, Plant products grown in iodine rich soil

Zinc Essential enzyme constituent, Protein metabolism, Immune function, Insulin storage, Sexual maturation

15mg Retarded sexual and physical activity; Impaired wound healing

Dairy products, Meat products, Eggs, whole grains

Selenium Antioxidant function Forms glutathione peroxidase, spares Vitamin E

70 μg Impaired immune function, Keshan disease

Liver, meats, whole grains, sea food

Fluoride Bone and teeth constituent < 1mg Dental caries Flouridated water, toothpaste

Who is likely to get Selenium Deficiency?

Poor Soil Content : Poor soil content of Selenium compromises its dietary availability through poor contents of crops and animals. It is seen in large parts of Scandinavia, China, Central Europe, Africa and New Zealand.

Increased Oxidative Stress : Strenuous exercise, physical activity, smoking, exposure to environmental chemicals, radiation and chronic illness increase oxidative stress. This escalates the turnover of glutathione peroxidase which in turn increases the requirement of Selenium and likelihood of its deficiency.

Malabsorption : As caused in pancreatic disorders, cystic fibrosis, inflammatory bowel disease also put one to the risk of Selenium deficiency.

contraction. They could be macrominerals or microminerals depending on their requirements (more than 100 mg and less than 100 mg/day respectively). Salient features are tabulated in Summary Box 1 and 2.

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Study ExercisesLong Question : Which are the minerals of importance to public health in India? Discuss the sources, requirement and functions of Iodine.

Short Notes : (1) Importance of selenium as an antioxidant (2) Osteoporosis (3) Trace elements.

MCQs1. Which of the following iron sources falls under the category

of non heme iron (a) Jaggery (b) Meat (c) Eggs (d) Milk2. Calcium homeostasis is maintained by (a) T3 and T4

(b) Vitamin D and parathyroid hormone (c) Phosphorus and magnesium (d) Calcitonin and bone matrix

3. Ideal sodium potassium ratio should be (a) Not specified (b) 1:1 (c) 1:2 (d) 2:1

4. Which of the following does not fall under ‘IDD’ : (a) Cretinism (b) Mongolism (c) Deaf-mutism (d) Infertility

5. Which of these is not a constituent of metallo-enzymes (a) Copper (b) Zinc (c) Iron (d) Nickel

Answers : (1) a; (2) b; (3) b; (4) b; (5) d.

ReferencesChaney MS, Ross ML. Nutrition. Houghton Mifflin Company, USA. 1996.1. 2.Groff JL, Gropper SS. Advanced Nutrition and Human Metabolism. 3rd ed. 2. Wadsworth Thomson Learning, California. 2000Taylor A. Detection and monitoring of disorders of essential trace elements. 3. Ann Clin Biochem. 1996;33:486-510Mertz W. The essential trace elements. Science. 1981; 213:1332-8.4. Tracing the facts about trace elements. Tufts University Diet and Nutrition. 5. Letter March 1987; 5:3-6.Nielsen FH. Ultratrace elements in nutrition. Ann Rev Nutr. 1984;4:21-416. Garrow JS, James WPT, Ralph A, Human Nutrition and Dietetics. Churchill 7. Livingstone, UK. 10th Ed 2000.Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and 8. Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.Gandy JW, Madden A, Holdsworth M. Oxford handbook of Nutrition and 9. Dietetics. Oxford University Press, New Delhi. 2007.Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian 10. foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.Geissler C, Powers H. Human Nutrition.11th ed. Elsevier Churchill Livingstone 11. London. 2005.Thurnham JA. Iron as a pro-oxidant. In Wharton BA, Ashwell M (eds). Iron, 12. nutritional and physiological significance. Chapman & Hall, London. 1995.World Health Organization. Assessment of Iodine Deficiency Disorders and 13. Monitoring their Elimination. A guide for programme managers.2nd ed, 2001Ravindranathan I. Essential trace elements in food. Nutrition 2001. 35(3):9-14. 32.Antia FP, Abraham P. Clinical Dietetics and Nutrition. 4th ed Oxford University 15. Press, New Delhi 1998. Rayman MP. The importance of selenium to human health. Lancet. 2000; 16. 356: 233-241.

131 Major Foods and their Nutritive Value

Rajul K Gupta

The Major Food GroupsThere are innumerable food items that constitute human diet. The major foodstuffs can be broadly classified into ten major groups. These are shown in the Box-1.

Foods have different nutritional profiles. Moreover, availability of foods varies at different places and in different seasons. People from diverse cultures, religions and states tend to consume different types of food stuff. But one thing that is common for the good health of all humans is the absolute necessity of a well balanced diet. To formulate a well balanced diet for optimum health, it is extremely important to appreciate the details of these food items and their nutritive value. Therefore these facts are required to be learnt before we could proceed further in unveiling the complex relationship of food,

health, disease and its prevention. This chapter endeavors to elaborate in brief the commonly used food items.

Box - 1 : Ten major food groups

Cereals and millets

Pulses and legumes

Vegetables, roots and tubers

Fruits and nuts

Animal foodsMeat/Poultry ●Milk and milk products ●Eggs ●

Oilseeds

Sugar, jaggery, salt

Non - Alcoholic beverages

Alcoholic beverages

Spices and condiments

• 742 •

Cereals and MilletsCereals and millets form the staple food for human diet as they are cheap and have a high energy value, approximately 350 Kcal/100g. In an agricultural country like ours, rice, maize, wheat and millets (jowar, bajra and ragi) form the bulk of the diet which makes up for as much as three fourth of the total energy requirement of a rural Indian. Thus knowing about the nutritive quality of these staple cereals is of great importance. Cereals and millets provide almost all major nutrients, as elaborated below.

Carbohydrates : Cereals are most important sources of carbohydrates and energy in our diet. They provide 60 to 75 % of the total energy in our diet.

Proteins : Cereals are moderate sources of proteins (about 6 to 12g/100g). Cereal protein is of poor quality as it is deficient in essential amino acids. Wheat proteins are deficient in Lysine and maize in Tryptophan. Pulse proteins on the other hand, are rich in these deficient amino acids (lysine and tryptophan). A predominantly cereal diet should therefore invariably be supplemented with other sources of proteins like the pulses, especially for the vegetarians. This helps to improve the quality of protein in our diet. This is called as the supplementary action of proteins.

Cereal proteins are quantitatively an ample amount of protein in an otherwise protein deficient Indian diet. As much as 50% of the total proteins in Indian diet is contributed to by cereal proteins. Hence cereals constitute a vital source of proteins in our diet.

Micronutrients : Cereals contain minerals like iron and calcium, little carotene but no vitamin C. Ragi is particularly rich in calcium. The millets are also rich in phytates and tannins which interfere with the absorption of minerals. Whole (unrefined) cereals are relatively good sources of the B complex vitamins. Most of the vitamins lie in the outer layers so milling and polishing removes these vitamins to a great extent.

Fibre : The outer layers of cereals and millets contain the all important fibre in plenty (1-8g/100g). The fibre is lost depending on the level and extent of milling.

Milling : Now a days machine milling of cereals has become an integral part of the processing of grains. Milling not only does the basic processing but also makes the grain more shiny, whiter and sparkling (‘refined white flour and polished white rice’). This appeals to the sense of sight and thus improves the palatability. But we have to pay the cost for it in terms of losing its nutritive value. Milling separates germ and outer layers (pericarp and testa) that are discarded as bran. Such highly milled wheat and rice is thus devoid of fibre. Since the vitamins are also concentrated in the outer layer of the whole grains, which are removed by machine milling, these refined cereals lose not only much of their fibre but also the vitamin, mineral and protein content during processing (1).

Machine milling and refining cause considerable deterioration of nutritive value of cereals that eventually affects public health. For example, beriberi is endemic in countries where polished rice is habitually eaten. Even though whole meal flour has marginally lower energy value than white flour, the protein

content of whole meal flour is relatively higher (3). Milling is undoubtedly a necessary evil. Cereals should not be ‘hard’ milled. Highly milled cereals should be avoided. It is advisable to consume whole wheat atta of 85 percent extraction. Not more than 5 percent bran should be permitted to be removed during milling. Parboiling of rice is also an effective solution. Parboiled rice is the only cereal which does not suffer appreciably when machine milled.

Effects of Refining on Nutrient Content of Wheat Flour (per 100 g) (2).

NutrientContent before

refining (per 100 g)Content after

refining (per 100 g)

Thiamin 580 μg 140 μg

Vitamin B6 750 μg 130 μg

Niacin 2520 μg 340 μg

Folate 57 μg 6 μg

Vitamin E 1.4 mg 0.3 mg

Calcium 44 mg 23 mg

Zinc 29 ppm 8 ppm

Copper 4 ppm 1.3 ppm

Iron 35 ppm 10 ppm

RiceRice is staple to more than half of the world population.

Nutritive value : Rice is high in energy (about 350 Kcal/100g). The protein content is moderate, 6-9 g%. It is richer in lysine than other cereals. Rice is also fairly rich in thiamine, riboflavin and niacin. It is a poor source of vitamins A, C and D. It is poor in calcium and iron as well.

Nutritive losses : Milling and polishing cause the greatest nutritional loss. Polishing is a process where milled rice is passed through rubber rollers to make it smooth, shiny and whiter. During processing the B -complex vitamins, fibre and proteins are lost to a great extent, depending on the level of milling and polishing. Rice also loses substantial amount of water soluble vitamins and minerals during washing it in plenty of water and discarding it. Similarly draining the water in which the rice was cooked also causes loss of water soluble nutrients.

Preventing nutritive losses : The nutritive losses because of milling, polishing, other processing and cooking practices can be prevented by taking suitable and timely measures. One such widely used method is parboiling.

Parboiling : It is an old technique practiced in India for a long time at the household level. This involves steaming the rice that renders it partially cooked. The technique is now being used at a commercial level as well. The ‘Hot Soaking Process’ of parboiling has been recommended by the Central Food Technological Research Institute, Mysore.

The process : The paddy is soaked in hot water at 70°C for 3 to 4 hours. With this soaking the outer husk splits and becomes easier to remove. The excess water is drained. This paddy is then steamed for about 10 minutes. The paddy is dried. At a

• 743 •

domestic level it is home pounded and commercially, it is milled for final use. Advantages of parboiling are given in Box - 2.

Box - 2 : Advantages of parboiling

Parboiling causes the B group vitamins in the outer layers (aleurone) to diffuse in to the interior of the grain (endosperm) thus saving them from being lost during milling.

Drying the rice causes the germ to attach firmly to grain, so that the germ is not lost during milling and polishing.

The heat hardens the grain as the starch gets gelatinized. This increases the keeping quality and storage capacity of rice.

The parboiled grain also becomes more resistant to insects.

Disadvantage of parboiling : There are no disadvantages of the parboiled rice except for the fact that it imparts an off flavour to rice. The rice also attains a pale hue. The off flavour is not liked by people who are used to eating the non-parboiled rice.

WheatWheat is the most widely consumed cereal in North India. It is used to make flour (atta for chapattis and puri), maida for bread, dalia and also suji, to make various savouries.

Nutritive value : The calorie content of wheat is almost the same as that of rice ie about 350 Kcal/100g. The protein content is higher than that of rice i.e. 9 to 16g %. The quality of protein is however poor as it is deficient in the essential amino acids lysine and threonine.

Nutritive losses and their prevention : Hard milling, extraction and discarding the bran causes loss of fibre, vitamins and proteins. As discussed earlier it is advisable to consume whole wheat atta and dalia. Products made up of refined flour like white bread, biscuits, cakes, noodles and burgers should be discouraged.

MaizeMaize is the staple diet in many parts of Africa and Central Asia. However, in most parts of India and many other parts of the world it is commonly eaten only as corn. It is also used to make cornflakes. Cornflour is used in confectionery and to

make custards.

Nutritive value : The calorie content of maize is about 342 Kcal/100g. The protein content is higher than that of rice i.e. 9 to 16g %. The quality of protein is poorer as it is deficient in lysine and tryptophan. It also contains excess leucine which interferes with conversion of tryptophan to niacin (60mg of trytophan is required to produce 1mg niacin). Thus maize eaters may face the deficiency of niacin and a higher risk of pellagra. Maize is also rich in carotenoids. Nutritive values of common Cereals and Millets are given in Table - 1.

MilletsMillets are consumed without milling. The commonly used millets are jowar (sorghum), bajra (pearl millet) and ragi. These are traditional foods in many parts of India. Jowar and Bajra are widely used in Maharashtra and Rajasthan respectively.

Nutritive value : The calorie content of millets is about 350 Kcal/100g. The protein content is about 8 to 14g %. They are also rich in minerals. Ragi contains a high amount of calcium - 344 mg / 100 g.

Jowar is important millet in the western and central India (esp. Maharashtra, MP and Andhra Pradesh) and is the staple for many Indians. It is nutritious millet with a high iron content of 4.1 mg/100g. The protein content is in the range of 9 to 14%. Like other millets the protein is limited in the amino acids lysine and threonine. In some species the leucine content might be higher that interferes with the conversion of tryptophan to niacin thus sole consumption of Jowar could be pellagrogenic.

Bajra (Pearl millet) is grown in the arid regions of our country. It is relished in Rajasthan, Gujarat and some parts of Maharashtra as porridge. It is also used to make flour for preparing chapatis. The protein content is in the range of 10 to 14%. The iron content of Bajra is the highest among all cereals and millets at 8mg/100g. It is also relatively rich in calcium, carotene, riboflavin, niacin and folic acid.

Pulses and LegumesPulses and legumes comprise of dried peas, beans, dals and grams and are an integral part of the Indian diet. Commonly used dals are red gram (arhar), green gram (moong), lentil (masoor), bengal gram (channa) etc. They are, therefore a

Table - 1 : Nutritive value of common cereals and millets (per 100g) (1)

Food

stu

ff

Prot

eins

(g)

Fat(

g)

Fibr

e (g

)

Carb

ohyd

rate

s (g

)

Ene

rgy

(Kca

l)

Iron

(m

g)

Caro

tene

(µg

)

Thia

min

e (m

g)

Rib

ofla

vin

(mg)

Nia

cin

(mg)

Foli

c ac

id (

µg)

Vit

amin

C (

mg)

Rice parboiled 6.4 0.4 0.2 79 346 1 9 0.21 0.05 3.8 8.9 0

Rice polished 6.8 0.5 0.2 78.2 345 0.7 0 0.06 0.06 1.9 8 0

Wheat 11.8 1.5 1.2 71.2 346 5.3 64 0.45 0.17 5.5 142 0

Wheat flour 12.1 1.7 1.9 69.4 341 4.9 25 0.49 0.17 4.3 35.8 0

Maize dry 11.1 3.6 2.7 66.2 342 2.3 90 0.42 0.1 1.8 20.0 0

Bajra 11.6 5 1.2 67.5 361 8 132 0.33 0.25 2.3 45.5 0

• 744 •

valuable constituent of the vegetarian diet. Pulses are cheap and easily available.

Nutritive Value : Pulses and legumes are colloquially referred to as the poor man’s meat as they have high protein content of about 20-25g%. Although they are poor in methionine and cysteine and the biological values of their protein is inferior to foods of animal origin (meat, fish eggs and milk), they are a substantial source of proteins for those not consuming meat. Pulse protein is rich in lysine which compensates for the low lysine content of cereal proteins. They are an important source of vitamins and minerals like calcium, iron and vitamin B. Bengal gram (channa dal) and to a lesser extent green gram (moong) contain a small amount of ascorbic acid in the dry state. The energy content is approximately the same as that of cereals i.e. about 350 Kcal/100g (1).

Germination of Pulses : The ascorbic acid content of all unsplit pulses can be increased by germinating or sprouting. Whole unsplit dal or gram is first soaked in water for 12 to 24 hours and then spread on a damp blanket in a thin layer to allow access of air and covered with another blanket kept damp by sprinkling water. In few hours small sprouts appear; when

these are 10 to 20 mm long the process is complete. The vitamin C content is maximal after about 30 hours of germination. Germination causes an increase in vitamin B also (4).

Fermentation too improves the nutritional value of pulses. The vitamin content of B group of vitamins esp. thiamin, riboflavin and niacin goes up. The digestibility of pulses also improves with germination. The nutritive value of common pulses and legumes is summarized in Table - 2.

Animal FoodsMeat and fishMeat is a word commonly used for the flesh of cattle (beef), goat and sheep (mutton), pig (pork) or chicken. It is a good source of high quality protein (15 to 20g per 100g). Moreover this protein is qualitatively as good as that of fish, egg, milk, cheese and other dairy produce, since it contains all essential amino acids. It is also a good source of most B vitamins like nicotinic acid. Meat is rich in phosphorous but poor in calcium. Liver, a component of meat, too has not only high quality proteins but also vitamin A and vitamin B complex. Meat is also rich in minerals especially iron and zinc. The iron content

Soya bean - The ‘Queen’ of pulses and legumes

Soya bean is a pulse which has very high protein (43.2g/100g) and fat content (19.5g/100g). It possesses high contents of iron as well. It is also rich in carotene, niacin and folic acid. The nutritive value of soya bean proteins is equivalent to milk proteins even though the protein quality is inferior. The rather bland taste of unprocessed soya bean can be made up by suitably cooking or processing it. It can be simply cooked as dal or can be prepared with other legumes as mixed dal. Soya bean can be processed into many foods which are enjoyed by the community. It is commonly eaten as nuggets (baris). Its flour can be mixed in wheat flour to make it more nutritious. Soya milk and curd is also popular. It can be processed to fried nuggets (kurkure), which are relished by the children. In the South East Asian countries its preparations like tofu, miso and soya sauce are relished. By virtue of its high fat contents its oil is extracted and used as cooking oil. This oil is one of the very few oils rich in alpha-linolenic acid (>5%) besides its high contents of linoleic acid (53%). Soya bean is truly the ‘Queen’ of pulses and legumes.

Nutritional profile of Soya bean (per 100g)

Nutrient Contents Nutrient Contents

Protein 43.2 g Thiamin 0.73 mg

Fat 19.5 g Riboflavin 0.39 mg

Iron 10.4 mg Niacin 3.2 mg

Carotene 426 μg Folate (total) 100μg

Table - 2 : Nutritive value of common pulses and legumes (per 100g)

Puls

es a

nd

legu

mes

Prot

eins

(g)

Fat

(g)

Fibr

e (g

)

Carb

ohyd

rate

s (g

)

Ene

rgy

(Kca

l)

Iron

(mg)

Caro

tene

(µg

)

Thia

min

e (m

g)

Rib

ofla

vin

(mg)

Nia

cin

(mg)

Foli

c ac

id (

µg)

Vit

amin

C (

mg)

Peas dry 19.7 1.1 4.5 56.5 315 7.05 39 0.47 0.47 3.4 7.5 0

Green gram 24.5 1.2 0.8 59.9 348 3.9 94 0.47 0.47 2.4 140 0

Bengal gram 17.1 3 3.9 60.9 360 4.6 189 0.30 0.15 2.9 186 3

Soya bean 43.2 19.5 3.7 20.9 432 10.4 426 0.73 0.39 3.2 100 -

Rajmah 22.9 1.3 4.8 60.6 346 5.1 - - - - - 0

Redgram 22.3 1.7 1.5 57.6 335 2.7 132 0.45 0.45 2.9 103 0

• 745 •

of meat is of the heme variety which has high bioavailability. Meat has a high content of fat including the saturated fatty acids, which may be a risk for good health.

Fish is generally considered good for health as it is rich in unsaturated fatty acids including the omega 3 fatty acids and vitamins A and D. Fish has high quantity of proteins (15 - 25g/100g), which are of high biological value and are easily digestible. Sea fish is also rich in minerals like Iodine. With the current emphasis on higher intake of polyunsaturated fatty acids, including the omega-3 fatty acids fish is of immense value in diet.

Milk and Milk ProductsMilk is the complete food on which the young one may subsist for up to six months. It is the sole food for all growing young mammals. The human milk might be poorer than cow’s or buffalo’s milk, but is adequate for the infant. Milk is used to prepare curd, yogurt, butter, ghee and buttermilk. These are used extensively for the preparation of many traditional Indian sweets.

Nutritive Value of Milk : All the important nutrients are well represented in milk except for iron and nicotinic acid. Newly drawn milk contains 2 mg of vitamin C per 100 ml but this readily disappears on storage, heating or processing in any other way. On the average, one liter of cow’s and buffalo’s milk contains 32 and 43 g of protein respectively. Human milk contains about 1.1g % proteins. Milk proteins are caseinogen (85%), lactalbumin (12%) and lactglobulin (3%). These proteins are of high biological value and are rich in tryptophan and cystein. Calcium caseinogenate is a complex formed with calcium in milk.

The fat content in milk varies from 3.4 (human) to 6.5 % (buffalo), depending on the source. Milk fat is an emulsion of extremely fine particles of the glycerides of butyric, palmitic and oleic acid rendering it easily digestible and this is especially so in cow’s milk. Milk is also rich in linoleic acid and oleic acid. Milk is a good source of vitamin A and D as well. Milk contains more than 30 types of sugars, Lactose being the most predominant of them. A litre of milk contains as much as 50 g of lactose. Milk is also very rich in calcium (1200 mg per litre

of cow’s milk) and phosphorus. One litre of cow’s milk provides about 670 Kcal (2.8 Mj) of energy (1).

Curd : Curd is traditionally relished in the Indian diet. It is produced by the action of lactobacilli on lactose (in milk), which is broken down to lactic acid. The proteins are coagulated by the acid and curd is formed. Curd and whole butter milk are easily digestible. They have the same nutritive value as that of the original milk from which they were prepared, being very good sources of protein, calcium, vitamin A and riboflavin.

Cream, Butter and Ghee : Cream, butter and ghee are the various types of fats extracted from milk. Cream can be extracted by centrifugation of unboiled milk. Butter is the fat extracted from buttermilk. Ghee is the clear fat extracted after boiling butter. Cream has nutritive value in between whole milk and butter. Good butter should not contain more than 16 percent of water and not less than 80 percent of fat. 100gm butter yields about 729 Kcal (3.05 Mj). On the other hand, ghee is almost 100% fat, 100 g of ghee yielding 900 Kcal (3.76 Mj). Nutritive value of milk and milk products is summarized in Table - 3.

Skimmed and Toned Milk : The milk available in market may be pure milk from cow or buffalo. Sometimes a mixture of buffalo’s and cow’s milk might also be available. Some people prefer low fat or fat free milk. This is the skimmed milk from which fat has been removed. This is useful for those who have been recommended low fat in diet, due to a medical condition. Toned milk can be manufactured by adding 1 part water and 1/8 part skimmed milk to 1 part milk. This blend is then stirred, pasteurized and bottled. It becomes quite similar to cow’s milk.

Tinned Milk : Powdered or tinned milk could be an alternative to whole milk when fresh milk cannot be made available. Condensed, evaporated or homogenized milk can be tinned. It could be sweetened or unsweetened. Condensed milk contains 50 percent cane sugar, which is a good preservative. Dried or powered milk is reconstituted by adding 7 volumes of boiled water just before consumption. Tinned milk should be reconstituted as per instructions.

EggsEggs contain all the nutrients required for the embryo. They

Table - 3 : Nutritive value of milk and milk products (per 100ml) (1)

Food

stu

ff

Prot

eins

(g)

Fat

(g)

Ene

rgy

(Kca

l)

Iron

(m

g)

Caro

tene

(µg

)

Thia

min

e (m

g)

Rib

ofla

vin

(mg)

Nia

cin

(mg)

Foli

c ac

id (

µg)

Vit

amin

C (

mg)

Milk, buffalo 4.3 6.5 117 0.2 48 0.04 0.10 0.1 3.3 1

Milk, cow 3.2 4.1 67 0.2 53 0.05 0.19 0.1 5.6 2

Milk, human 1.1 3.4 65 - 41 0.02 0.02 - 1.3 3

Ghee - 100 900 - 600 - - - - -

Butter - 81 729 - 960 - - - - -

Cheese 24.1 25.1 348 2.1 82 - - - - -

Curd 3.1 4 60 0.2 31 0.05 0.16 0.1 3.3 1

• 746 •

have a high nutritive value. An egg provides about 70 Kcal. An egg contains about 6 g protein. The proteins are of a high biological value. The NPU of egg protein is 100 and is taken as the standard protein, to compare other proteins with. An egg contains about 6 g of fat. It also has a high cholesterol content of 250mg. The fat is present in the yolk. It is finely emulsified and hence easily assimilated. The minerals and vitamins exist in the yolk, which is also a valuable source of calcium, phosphorus, iron and vitamins A and D. The white of the egg is one of the best sources of riboflavin. It is however deficient in Vitamin C. Nutritive value of egg is given in Table - 4.

VegetablesVegetables and fruits add colour and variety to our food. It is the vegetables and fruits that impart a seasonal touch to the diet, as they change with the seasons. We have green leafy vegetables, coloured vegetables, roots and tubers.

Nutritive Value : Vegetables esp. green leafy and coloured vegetables are a store-house of vitamins, minerals, various phytochemicals and antioxidants, hence they along with fruits are termed as the protective foods.

a) Vitamins and Antioxidants : They contain ample amounts of carotene, ascorbic acid, folic acid, calcium, iron and riboflavin. The carotenoids, vitamin C and numerous other phytochemicals possess antioxidant properties (See Box - 1). A yellow vegetable like pumpkin is rich in carotene. However, the carotene of green vegetables like drumstick, cabbage, amaranth and methi is better utilized than of yellow vegetables. Gourds are generally of poor nutritive value; but the bitter gourd is relatively rich in ascorbic acid. The tomato has good ascorbic acid, riboflavin and antioxidant lycopene contents. Onion may not have outstanding nutritive properties, but is virtually irreplaceable because of its value as a flavouring agent and appetizer.

b) Minerals : Vegetables are good source of minerals like calcium, phosphorus, iron, zinc and many trace elements. The absorption and bioavailability of some of the minerals may not be very good due to various reasons. Iron from green leafy vegetables is not very well absorbed as it is present in the ferric state which is not conducive for absorption. In addition calcium, oxalates, phosphates and phytates present alongside (in the vegetables) inhibit the absorption of minerals further.

c) Fibre : Vegetables are rich in fibre, especially the soluble fibre. Fibre is considered extremely important for normal bowel motility, getting rid of toxins from the intestine and guarding it against the rapid absorption of glucose and lipids, thus

preventing hyperglycemia and hyperlipidaemia.

The Rainbow of Phytochemicals

Colour Fruit or vegetable Phytochemicals

Red Tomato Lycopene

Yellow-green Pumpkin, papaya Zeaxanthin

Red-purple Beet root, Anthocyanins

Orange Pumpkin, papaya, mango

Beta carotene

Orange-yellow Apricots, apple, cherry, tomato, orange

Flavonoids

Green Leafy vegetables, cabbage

Glucosinolates

White-green Garlic, onion Allyl sulphides

d) Calories : There are not many foods in our diet that could be claimed to be low in calorie and yet nutritious! Vegetables have this unique distinction. By virtue of their high moisture and fibre content the calorie content of most of the green vegetables is in the range of 20 to 60 Kcal/100g. This is a boon for those who have been advised to restrict calories.

Root and tuber vegetables are of variable nutritive value. The carrot is outstandingly rich in carotene. Most roots and tubers contain starch and moderate amounts of ascorbic acid. Potatoes and sweet potatoes having high carbohydrate content have a good energy value and contain moderate quantities of ascorbic acid. Nutritive values of common vegetables are given in Table - 5.

FruitsFruits hold a special place in the nutrition of man. They can be eaten any time and as much. Everyone loves them. Different fruits are available in different seasons. They are extremely nutritious. Being eaten raw and fresh, the minerals, vitamins and phytochemicals present in them, do not have to suffer the humiliation of ‘mutilation’ through heat and fire. Fruits can be classified into citrus, non-citrus and dry fruits.Nutritive Value

a) Vitamins and Antioxidants : It is known since James Lind that citrus fruits like oranges, lime, lemon, mosambi, malta, etc are rich sources of vitamin C. Guava and amla too are very rich sources of vitamin C. Papaya and mango are rich in carotene and moderately rich in vitamin C. Pineapples, strawberries

Table - 4 : Nutritive value of egg (per 100g*) (1)

Food

stu

ff

Prot

eins

(g)

Fat

(g)

Ene

rgy

(Kca

l)

Iron

(m

g)

Caro

tene

(µg

)

Thia

min

e (m

g)

Rib

ofla

vin

(mg)

Nia

cin

(mg)

Phos

phor

us

(mg)

Calc

ium

(m

g)

Egg, hen 13.3 13.3 173 2.1 420 0.1 0.4 0.1 220 60

Egg, duck 13.5 13.7 181 2.5 405 0.12 0.26 0.2 260 70

* One egg weighs about 60 to 70 g

• 747 •

and papaya are moderately rich sources of vitamin C. Yellow peaches are a good source of carotene. Banana, orange and strawberries are moderate sources of folates. Dried fruits like dry figs provide thiamin, niacin and riboflavin. Dried apricots and prunes are rich in vitamin A (See Table- 6).

b) Minerals : Watermelon is rich in iron. Custard apple is rich in phosphorus and iron. Apricots, lime, guava and figs are rich in calcium. Apricots are rich in zinc too. Banana and apples are moderately rich in potassium. Dried fruits : Raisins, figs, dates and dry apricots are rich in iron. Dried figs are also rich in phosphorus, calcium, potassium and zinc (1).

c) Energy : Banana and plantain have high energy value.

d) Fibre : Fruits are rich in fibres. Their soluble fibre is particularly useful in inhibiting the rapid absorption of glucose and lipids from the intestine. This is helpful in prevention of hyperglycemia and hyperlipidaemias

A daily recommendation of about 400g of fruits and vegetables has been made by the American Dietetic Association. It is wise to consume fresh, seasonal and locally available fruits that are less costly and more affordable than the imported fruits. Nutritive values of common fruits are given in Table - 6.

NutsThe common nuts in use are almond, cashew nut, groundnut, coconut, pistachio, walnut, etc. Nuts are relished by the young and all primarily for their taste. Nuts have a very high nutritive value (See Table - 7).

Nuts have a high fat and protein content and hence a high energy value. They are a good source of fats, vitamins and proteins as well. They contain minerals too in good quantities. Groundnuts are a good source of proteins, fats & vitamin B complex esp. niacin. Even though the proteins are of low biological value, it is a cheap and ample source of proteins (See Box - 3). Pistachio

Table - 5 : Nutritive value of common vegetables (per 100g) (1)Ve

geta

ble

Fibr

e (g

)

Carb

ohyd

rate

s (g

)

Ene

rgy

(Kca

l)

Iron

(m

g)

Caro

tene

(µg

)

Thia

min

e (m

g)

Rib

ofla

vin

(mg)

Nia

cin

(mg)

Foli

c ac

id (

µg)

Vit

amin

C (

mg)

Beans 1.8 4.5 26 0.61 187 0.10 0.06 0.7 45.5 24

Spinach 0.6 2.9 26 1.14 5580 0.03 0.26 0.5 123 28

Tomato 0.8 3.6 20 0.64 351 0.12 0.06 0.4 30 27

Carrot 1.2 10.6 48 1.03 1890 0.04 0.02 0.6 15 3

Onion 0.6 11.1 50 0.6 15 0.08 0.02 0.5 - 2

Potato 0.4 22.6 97 0.48 24 0.1 0.01 1.2 7 17

Cauliflower 1.2 4 30 1.23 30 0.04 0.1 1 - 56

Cabbage 1 4.6 27 0.8 120 0.06 0.09 0.4 23 124

Pumpkin 0.7 5.8 39 - 50 0.06 0.04 0.5 13 2

Table - 6 : Nutritive value of common fruits (per 100g) (1)

Frui

t

Fibr

e (g

)

Carb

ohyd

rate

s (g

)

Ene

rgy

(Kca

l)

Iron

(m

g)

Caro

tene

(µg

)

Thia

min

e (m

g)

Rib

ofla

vin

(mg)

Nia

cin

(mg)

Vit

amin

C (

mg)

Guava 5.2 11.2 51 0.27 0 0.03 0.03 0.4 212

Amla 3.4 13.7 58 1.2 09 0.03 0.01 0.2 600

Mango 0.7 16.9 74 1.3 2743 0.08 0.09 0.9 16

Orange 0.3 10.9 48 0.32 1104 - - - 30

Banana 0.4 27.2 116 0.36 78 0.05 0.08 0.5 7

Lime 1.3 10.9 59 0.3 15 0.02 0.03 0.1 63

Grape blue 2.8 13.1 58 0.5 3 0.04 0.03 0.2 1

Papaya 0.8 7.2 32 0.5 666 0.04 0.25 0.2 57

• 748 •

is rich in iron, containing 7.7 mg/100g. Almond and cashew nuts are also moderate sources of iron and proteins.

Fats and OilsFats and oils hold a vital place in our daily diet. They are an integral part of cooking as they not only impart good taste, but also contribute to the texture, crispness and energy to our food. They also serve as a medium for cooking as their boiling point is very high.

Fats that are liquid at room temperature are termed as oils. Fats and oils could be of either plant or animal origin. Vegetable oils such as mustard, ground nut, gingelly, coconut and safflower oils are widely used for cooking purposes. Vegetable oils (except red palm oil) are free of any vitamin A activity and contain predominantly unsaturated fatty acids. However, coconut and palm oils are the only commonly used plant oils that are rich in saturated fatty acids.

Butter and ghee are fats of animal origin. These are also used as a cooking medium. They are rich in vitamin A and D. All fats and oils provide 9 Kcal per gram. Excess consumption of these is in disrepute as they are considered to be atherogenic. Excess consumption also contributes to dyslipidaemia, a risk factor for cardiovascular diseases.

Sugar and JaggeryIt is pure sucrose & is used for its sweetening effect & energy value. Excessive consumption of such refined sugar that

provides only ‘blank calories’ at the expense of complex carbohydrates lowers the relative vitamin, mineral and protein intake. Jaggery is a sweet food popular in rural India. Besides being tasty, it contains an appreciable amount of carotene & iron.

SaltSalt contains the essential mineral sodium. Even though the daily sodium requirement is very low, the average daily diet contains salt much in excess. The recommended daily salt intake is 5 g. Excess of salt and a skewed sodium potassium ratio (>1) is known to be a causative factor of hypertension. It is the added salt that is harmful to the body rather than the moderate amounts put in food preparations.

Where does ‘High’ Salt Come From ?

High salt Very High Salt Excessively High Salt

Bread Cheese Pickles

Potato chips Processed meat Chutneys

Cornflakes Soups Salted Nuts

Canned vegetables Ketchups Salted fish

Canned fruits Processed butter Chaat

Table - 7 : Nutritive value of common nuts (per 100g) (1)N

uts

Prot

eins

(g)

Fat

(g)

Carb

ohyd

rate

s (g

)

Ene

rgy

(Kca

l)

Iron

(m

g)

Caro

tene

(µg

)

Thia

min

e (m

g)

Rib

ofla

vin

(mg)

Nia

cin

(mg)

Vit

amin

C (

mg)

Almond 20.8 58.9 10.5 655 5.09 0 0.24 0.57 4.4 0

Cashew nut 21.2 46.9 22.3 596 5.81 60 0.63 0.19 1.2 0

Coconut dry 6.8 62.3 18.4 662 7.8 0 0.08 0.01 3 7

Groundnut 25.3 40.1 26.1 567 2.5 37 0.90 0.13 19.9 0

Pistachio 19.8 53.5 16.2 626 7.7 144 0.67 0.28 2.3 -

Walnut 15.6 64.5 11 687 2.64 6 0.45 0.40 1 0

Box - 3 : Groundnuts - The King of Nuts

Groundnuts are the cheapest and arguably the most nutritious of all nuts. It contains almost as much oils and fats as an oilseed does (40%). Its MUFA content is one of the highest amongst all Indian oilseeds, at 50% (exceeded only by mustard and rape seed). Its protein content is very high (25.3%). Its niacin content is unmatched (about 20mg/100g), that is 5 to 20 times higher than other nuts. It is a household item in many Indian states like Maharashtra, Gujarat and Andhra Pradesh. It is relished boiled, roasted, fried or simply salted. It can be made into powder or flour. Groundnut chikki (with jaggery) is not only favourite with children, but is extremely nutritious even for the pregnant and lactating. Powdered or ground groundnuts are also used in vegetable preparations and curries. Owing to its low cost and high nutrition value, it finds favour in various national nutritional programme menus like in ‘multipurpose food and balahar’ as well.

Multipurpose food used in national nutritional programme is made using a mixture of 75 percent groundnut flour (from which fats have been extracted) and 25 percent roasted red gram. It is further fortified with vitamins and minerals. It is a rich source of proteins.

Its low cost, high nutritive value, immense variety of preparations and delicious taste crowns the groundnuts as the ‘King of nuts’.

• 749 •

Spices and CondimentsSpices are used to flavour food and improve its palatability. They stimulate the appetite and thus improve health. They are essential to the Indian culinary art. They are used in very small quantities as flavouring agents and for their carminative properties. Green or dry chillies have a high carotene and vitamin C content. As per the new research turmeric (haldi) has very high antioxidant content and has medicinal value. Tamarind (Imli) is widely used for its preservative effect and high vitamin C content. Cloves, Black pepper, ginger, garlic and red chillies have been shown to have antioxidant properties. Spices and condiments are used to prepare pickles and chutney which are used as appetizers.

Non Alcoholic BeveragesEarlier it was thought that by themselves tea, coffee, cocoa or other non-alcoholic beverages do not provide energy or vitamins except that from the sugar and milk added to them. Tea contains alkaloids like caffeine, theophylline and theobromine which are cortical stimulants and help relieve fatigue. If used in excess they may cause insomnia, tachycardia and gastritis in some individuals. Recent studies show that they contain substantial amounts of antioxidants which have distinct health benefits. Alcoholic beverages have been discussed in another chapter.

SummaryThe ten major food groups are cereals/millets, pulses/legumes, vegetables (including roots and tubers), fruits/nuts, animal foods (meat/poultry, milk and milk products, eggs), oilseeds, sugar, jaggery, salt, beverages and lastly spices/condiments. Each of these has their own vital value in our diet and for good health.

Cereals and millets contribute to up to 75% of total energy intake. They also contain substantial amount of proteins and invisible fats which contribute handsomely to an Indian diet that is otherwise considered to be poor in these nutrients. Excessive milling denudes cereals of their outer cover and with that the major portion of vitamins, minerals and proteins are lost. Coarse ground flour (atta) and parboiled rice help in reducing the nutritive losses due to milling.

Pulses are the major contributors of proteins esp. in a vegetarian diet. Cereal proteins are poor in lysine which are compensated by the pulse proteins that are rich in these amino acids but poor

in methionine. Groundnuts and soya beans are of exceptionally high nutritive quality with high content of proteins, fat and vitamins. Fats are the storehouse of energy, present in animal oils (ghee/butter) or in vegetable oils (mustard, groundnut, etc).

Fruits and vegetables are rich sources of vitamins, minerals and antioxidants. Roots and tubers also contain starch that is high in calories. Milk which is a complete food is essential for infants and children. Egg protein is one of the best quality proteins available to us and its use must be encouraged. Meat contains high quality iron and proteins. But owing to its high saturated fat content, excessive consumption of meat should be guarded against. Spices and condiments not only provide flavour to the diet but also contribute to the antioxidant content of food.

Study ExercisesLong Question : Enumerate major food groups. Describe the importance of legumes in diet.

Short Notes : (1) Importance of fruits in diet (2) Parboiling of rice (3) Nutritional importance of eggs.

MCQs1. The highest content of niacin is present in : (a) Jaggery

(b) Groundnuts (c) Pistachio (d) Milk2. Yellow-orange fruits and vegetables are rich in

(a) Carotenes (b) Vitamin D (c) B Complex vitamins (d) Zinc

3. Food item with highest protein content is (a) Groundnuts (b) Meat (c) Soyabean (d) Fish

4. Egg is a poor source of vitamin (a) A (b) B (c) C (d) D5. Jaggery is a rich source of (a) Carotene and thiamine (b)

Zinc and iron (c) Iron and carotene (d) Sugar and proteinsAnswers : (1) b; (2) a; (3) a; (4) c; (5) c.

ReferencesGopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian 1. foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.Pederson B. World Rev Nutr Diet, 1989;60 : 12. Davidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and 3. Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.Chaney MS, Ross ML. Nutrition. Houghton Mifflin Company, USA. 1996.4.

Sugar substitutes

There are occasions when sugar substitutes have to be used instead of sugar. They are preferred for their very high sweetening power and negligible calorific value. These are commonly used for preparing ice creams, candies, toffees, jellies, sweets, etc. They are also used as sweetening agents in cold drinks, flavoured milk and even in tooth pastes. They are also popular amongst diabetics and people desirous of loosing weight. Sugar substitutes can be classified into two groups :

(a) Nutritive sweeteners : Sugar alcohols (sorbitol, mannitol, xylitol) used as sugar substitutes in candies, chewing gum and beverages. These provide 4 Kcal/gm of energy.

Advantages : These are not absorbed as rapidly as sucrose, so can be used in those who cannot tolerate a high blood sugar level. ●The risk of dental caries is lower, as these alcohols can not be used by oral bacteria. ●

(b) Non-nutritive sweeteners : These do not supply any calories. Common examples are aspartame, sucralose, alitame and saccharin. They are several hundred times sweeter than sugar, so a small quantity is sufficient to sweeten the food.

• 750 •

132Nutritional Requirements of Special Groups : Mothers, Children and the Elderly

Rajul K Gupta

It is amazing as to how the same human body changes and behaves differently in different ‘periods’ of its lifecycle. At different stages of the organism with reference to changing age and continuously changing physiological status, the requirement of nutrients is based on activity, BMR, growth rate, etc. These factors change constantly as the organism grows over a lifetime. With these variations change the nutritional requirements. This chapter discusses the nutritional requirements over a lifecycle and how to meet that changed requirement through a typical Indian diet.

Pregnancy & LactationPhysiological Changes During Pregnancy and LactationImmense physiological changes take place in the human body during pregnancy. The uterus undergoes hypertrophy and hyperplasia, there is an increased vascularity within the uterus (and placenta). The heart rate, stroke volume and cardiac output increase so do the tidal volume and oxygen consumption. The renal plasma flow and GFR also increase. Appetite changes; cravings and aversions set in for certain foods. This is augmented by certain endocrine changes. Changed peristalsis state leads to constipation. Besides these the requirement for energy and various other nutrients go up steeply to cater for the developing fetus (1). The physiological changes continue during lactation. There are hormonal changes followed by physiological changes in the mammary system, involution of uterus continues. Psychological and emotional changes too play a part. The process of lactation requires energy. The additional

energy required is based on the volume of milk secreted, its energy content and the efficiency of conversion of food energy into milk energy. Women secrete up to 850 ml milk per day at 80% efficiency of conversion of food energy into milk energy.

All these changes demand a change in the woman’s lifestyle including her dietary habits, to cope up with the increased requirement of nutrients. The nutrient requirements during pregnancy and lactation are discussed here. A Table summarizing the same is also appended (Table - 1).

Nutrient Requirements During Pregnancy and LactationEnergy requirements : The energy equivalent of the raised resting oxygen consumption is of the order of about 27,000 Kcal, over the entire duration of pregnancy. The diet also has to provide energy for the fat and proteins laid out in the foetus and maternal tissues. The maternal fat deposited is about 4 kg. The total energy cost of pregnancy could be put at about 73,000 Kcal. Most of this extra energy is needed in the latter two trimesters. An additional requirement of 300Kcal per day is to be met, throughout the pregnancy. The additional energy requirement during lactation has been worked out to 550 Kcal in the first 6 months and 400 Kcal thereafter.

Protein requirements : The rapid growth of foetus, development of placenta and other maternal tissues, the expanding fluids (blood volume, amniotic fluid) and other storage reserves demand extra proteins. It has been recommended that an additional 15 g of proteins per day must be catered for during pregnancy. During lactation, extra protein demand is incurred for the production of milk. Therefore an additional intake of 25 g proteins/day in the first six months and 18 g in the next 6 months (6 - 12 months) is recommended.

Fats & Essential Fatty Acids (EFA) : The linoleic acid requirement during pregnancy is put at 4.5% of total energy. This can be met by the normal intake of invisible fats along with an intake of 12.5% of total energy equivalent of visible fats. The EFA requirement goes up further during lactation

Table - 1: Nutrient requirements for a sedentary woman during Pregnancy and Lactation (2,4)

Nutrient RDA (Sedentary woman) Pregnancy Lactation (1st 6 months) Lactation (6-12 months)

Add Total Add Total Add Total

Energy (Kcal) 1875 300 2175 550 2425 400 2275

Proteins (g) 50 15 65 25 75 18 68

Fat (g) 20 10 30 25 45 25 45

Iron (mg) 30 8 38 0 30 0 30

Vitamin A (RE) 600 0 600 350 950 350 950

Thiamin (mg) 0.9 0.2 1.1 0.3 1.2 0.2 1.1

Riboflavin (mg) 1.1 0.2 1.3 0.3 1.4 0.2 1.3

Niacin (mg) 12 2 14 4 16 3 15

Pyridoxine (mg) 2 0.5 2.5 0.5 2.5 0.5 2.5

Folic Acid (μg) 100 300 400 50 150 50 150

Vitamin B12(μg) 1 0 1 0.5 1.5 0.5 1.5

Vitamin C (mg) 40 0 40 40 80 40 80

• 751 •

to 6% of total energy. This can be met by the normal intake of invisible fats along with an intake of 17.5% of total energy equivalent of visible fats. This would correspond to a total of about 45g of visible fats.

Iron : Additional iron is required to meet the augmented demand for foetal growth, expansion of maternal tissue including RBC mass, iron content in placenta and blood loss during parturition. These additional requirements should be added to the basal ones. Owing to these additional needs the iron requirements go up in the second and third trimester to 3.3 mg and 5 mg respectively (taken as RDA of 38mg during pregnancy). However due to amenorrhoea during pregnancy, the menstrual loss of iron is prevented saving some iron loss. Breast milk contains iron, so this iron need is to be catered for during lactation. But since there is lactational amenorrhea, there is no menstrual loss and the total daily iron requirement remains the same as that of a normal woman i.e. 1mg/day (or the RDA of 30mg).

Taking the poor absorption of iron (only 3 - 5%) from habitual Indian diets into consideration, the RDA of iron for pregnant women has been slated at 37.5mg, rounded off to 38mg per day and for lactating women at 30mg per day.Vitamins

Vitamin A : The vitamin A requirements during pregnancy were calculated on the basis of vitamin A content of livers of the newborn. The additional intake required for this purpose is about 25 μg/day throughout pregnancy. Since this constitutes a very small fraction of the RDA no additional dietary allowance was recommended for pregnancy. On the other hand, a substantial amount of vitamin A is secreted in human milk, hence an additional intake of 350 μg/day is recommended for the lactational period.

Thiamine : The intake of thiamine is based on the energy intake and is normally recommended at 0.5 mg/1000Kcal. The calorie intake does go up during pregnancy and markedly so during lactation so would the thiamine intake. Hence when computed on the basis of energy allowance, it works out to an additional 0.2 mg for pregnancy and 0.3 mg and 0.2 mg for the first six months and latter six months of lactation respectively.

Riboflavin : The RDA of riboflavin is based on the total calorie requirement and is taken as 0.6 mg/1000 Kcal. The higher energy intake during pregnancy and lactation calls for this additional demand which corresponds to an additional 0.2 mg for pregnancy and 0.3 mg and 0.2 mg in the first six months and latter six months of lactation respectively. This increment is the same as that for thiamine.

Niacin : The niacin RDA is fixed at 6.6 mg per 1000 Kcal as is done for adult subjects. This corresponds to an additional 2 mg for pregnancy and 4 mg and 3 mg in the first six months and latter six months of lactation respectively.

Pyridoxine : The Pyridoxine requirement also goes up during pregnancy and lactation. It is recommended that an additional 0.5 mg/day of pyridoxine be catered for pregnancy as well as lactation.

Folic Acid : The additional requirement of folic acid during pregnancy is known to increase by 200 to 400 μg/day. The additional RDA is put at 300 μg/day for the duration of pregnancy. It is however difficult to provide this amount through diet alone, so supplementation through medicinal folates have to be made. An amount of about 25 μg/day is lost through lactation. An additional amount of 50 μg/day is therefore recommended during lactation.

Vitamin B12 : About 0.25 to 0.30 μg of this vitamin is lost per day during lactation. An additional intake of 0.5 μg per day is recommended.

Vitamin C : There is no data to indicate that vitamin C requirement is increased during pregnancy. The foetal requirement is too small to justify any additional requirement. Therefore no additional allowances are considered necessary. The additional requirement during lactation is about 20 mg per day. Taking into consideration the cooking losses of 50%, an additional allowance of 40 mg per day is recommended.

Effect of Micronutrient Deficiency During PregnancyThe micronutrient demands of the rapidly growing fetus are mandatory and inevitable. It is extremely sensitive to the deficiency of micronutrients during the organogenesis and growth. Whenever there is micronutrient deficiency in the mother’s diet, the high demand of the foetus is initially met by the maternal resources. But when these resources are exhausted, the maternal reserves are tapped and besides foetus, the mother’s health is also compromised. The likely adverse effects of micronutrient deficiency on foetus and mother are shown in Box - 1.

Diet During PregnancyVarious studies indicate that diet of pregnant ladies in India are generally deficient, esp. so in the rural areas and in the urban lower class (5). These two groups form a major proportion of our society. The diet is mainly a cereal based diet supplemented with little pulses and vegetables. Many a times only a chilly - salt mixture or onion is eaten with rice or chapati, with no pulses, vegetables, fat or fruits. Milk is used only to prepare tea. Usually only two main meals are taken. The nutrient value of such a diet is grossly limited even for a non pregnant woman.

This inadequate diet is not only limited in calories, but is poor in proteins, fats and micronutrients as well. The pregnant woman becomes malnourished. She is more prone to post-partum haemorrhage and death. This anaemic and malnourished woman delivers a physically and/or mentally retarded neonate. There may be bone deformities, mental deficiencies and due to low immunity and nutritional reserves such a child would be more prone to infections and malnutrition. In case it was a girl child, she grows into a nutritionally deficient teenaged girl and mother. The cycle continues and so perpetuates the malnutrition cycle. It is therefore important to offer and consume a balanced diet. The diet should be so modified that more of the protective foods (vitamins and minerals) and body building foods (proteins) are included rather than only excess of energy. A typical balanced diet (raw) is given in Table - 2. The general advise to be given is laid out in Box - 2.

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The Meals : In the first trimester the woman suffers from gastritis and morning sickness. In the third trimester the abdomen feels too full and she may not be able to eat much food. Therefore it is advisable to eat small quantities of food more frequently, rather than large quantities in, say only two meals. This means that long inter - meal spans must be interrupted with snacks like the mid - morning snacks after breakfast and the evening snacks with tea.

Diet During LactationJust like the diet of a pregnant woman the diet consumed by a lactating woman is also poor in quality and quantity, particularly in the poor rural and urban slum areas, if particular attention is not paid to it. First, the woman might have been undernourished during pregnancy and such a person, when starts breastfeeding her child puts herself to great nutritional strain. Secondly her own demand of nutrients is very high as she has to breastfeed the child. Thirdly, women esp. in the rural, hilly and tribal areas breastfeed the child for a prolonged period. Lactational amenorrhoea serves as a contraceptive incentive for them, and the breast feeding continues till they become pregnant again. This cycle of pregnancy, lactation and repeated pregnancies continue, rendering the mother malnourished. The principles of diet during lactation are basically the same as during pregnancy (please refer

Box - 1 : Adverse effects of micronutrient deficiency on foetus and mother

Nutrient Adverse effect on mother Adverse effect on foetus/infant

Thiamin - Infantile Beriberi

Folic Acid Anaemia Iugr, Neural Tube Defects, Low Birth Weight, Abortion

Vitamin A Anaemia Low Birth Weight, Premature Birth

Vitamin D Increased risk of osteomalacia Impaired Bone Development, Hypocalcemia, Rickets

Vitamin E - Birth Defect, Spontaneous Abortion

CalciumHigher risk of hypertension, eclampsia, osteoporosis

Impaired Bone Development, Hypocalcemia, Rickets

MagnesiumHigher risk of hypertension, eclampsia

Premature Birth

Iron Anaemia Low Birth Weight, Premature Birth, Higher Infant Mortality

Iodine Hypothyroidism Still Birth, Cretinism, Neonatal Hypothyroidism, Deaf Mutism

Zinc - Birth Defect, Premature Birth, Low Birth Weight, Hypogonadism

Table - 2 : Balanced diet for a pregnant woman* (3)

Food Group Food stuff Amount per day

Cereals Rice, wheat, millets 300 g

Fats Oil, ghee, butter 30 g

Sugars Sugar, Jaggery 20 g

Milk Milk, curds, etc 500 ml

Pulses & Nuts Pulses, legumes, dry beans, nuts 60 g

Fruits & vegetables

Fruits 200 g

Vegetable 350 g

Green Leafy Vegetables 150 g

Other vegetables 120 g

Roots and tubers 100 g

*The diet shown in the table is a vegetarian diet for a pregnant sedentary woman, for non vegetarians additional 30 g of flesh foods (meat, fish, chicken) or one egg is suggested in lieu of 30 g pulses..

Box - 2 : Public Health Manager’s Advise to Pregnant ladies

Eat one extra meal a day, to ensure adequacy of all nutrients ●Try and eat with the whole family and not alone ●Prefer high fibre cereals and legumes - include sprouts ●Include ample amounts of vegetables and fruits ●Take meat, milk and eggs regularly ●If vegetarian, insist on at least ½ lit of milk, and extra pulses ●Prefer nutritious foods like groundnuts and soya beans ●No fad diets ●Take iron and folate supplements regularly ●No un-prescribed medicines, alcohol and tobacco ●Attend ANC clinic regularly and follow your doctor’s advise ●

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to the earlier paragraphs for nutritional requirements during lactation). A lactating mother must increase her diet by about 10% than what she was eating during pregnancy. A typical diet is outlined in Table - 3.

Table - 3 : Balanced diet for a lactating woman* (3)

Food Group

Food stuff Amount per day

Cereals Rice, wheat, millets 330 g

Fats Oil, ghee, butter 30 g

Sugars Sugar, jaggery 20 g

Milk Milk, curds, etc 500 ml

Pulses & Nuts

Pulses, legumes, dry beans, nuts

90 g

Fruits and vegetables

Fruits 200 g

Vegetable 350 g

Green Leafy Vegetables 150 g

Other vegetables 130 g

Roots and tubers 120 g*The diet shown in the table is a vegetarian diet for a lactating sedentary woman, for non vegetarians additional 30 g of flesh foods (meat, fish, chicken) or one egg is suggested in lieu of 30 g pulses.

Nutrient Requirements for Infants and ChildrenWeight for weight, the infants and children require more food as compared to adults. This is because the children not only need food for maintaining the BMR, thermogenesis, repairing wear and tear, but also for the important function of continuous growth. Child therefore needs all kinds of extra nutrients, namely, proteins, fats carbohydrates, minerals and vitamins.Energy Requirements of Infants and Children

Infants : The energy requirement for Indian infants are adapted from the FAO/WHO expert group and the same is summarized in the Table - 4.

Table - 4 : Daily Energy Requirements of Infants

Age Kcal/kg Average during 1st year

0 - 3 months 116

103 Kcal/kg3 - 6 months 99

6 - 9 months 95

9 - 12 months 101

Children : Based on the FAO/WHO recommendations the energy requirements are worked out for Indian children. These are given in Table - 5.Protein Requirements

Infants : The protein requirements for infants are derived from the breast milk intake of normally growing infants (FAO/WHO expert consultation group, 1985) and the same is summarized in the Table - 6.

Children : The RDAs are given in Table - 7.

Table - 5 : Daily Energy Requirements for Children

Age (years) Boys (Kcal/kg) Girls (Kcal/kg)

1-3 1287 1193

4-6 1752 1630

7-9 2075 1833

10-12 2194 1965

13 - 15 2447 2056

16 - 18 2642 2064

Table - 6 : Daily Protein* Requirement for Infants

Age (months) Proteins (g/kg body weight)

0 - 3 2.3

3-6 1.85

6-9 1.65

9-12 1.5*In terms of milk proteins

Table - 7 : Daily Protein* Requirements of Children

Age (years) Boys (g/kg body weight)

Girls (g/kg body weight)

1 - 2 1.81 1.81

2 - 3 1.67 1.67

3 - 4 1.61 1.61

4 - 6 1.52 1.52

7 - 9 1.48 1.48

10-12 1.46 1.45

13 - 15 1.4 1.33

16 - 18 1.31 1.21*In terms of proteins present in routine Indian diets (cereals and pulses)

Fat Requirements

Children and Adolescents : The minimum visible fat intake would also be 5% of total energy. For their energy intake of 2400 Kcal, minimum visible fat intake works out to 12 g/day, but the desirable intake levels should be 20 g/day, which helps to reduce the bulk of diet.

Young Children ( 1 to 5 years) : For young children the linoleic acid requirement of 3% of the total energy can be satisfied by the minimum visible fat intake of 10 g/day (which would also be 5% of total energy intake). Hence visible fat intake of up to 25 g/day is desirable.

Infants : Breast milk meets the EFA needs of infants which is about 6% of total energy intake. It provides about 30g fat per day, of which about 10% is linoleic acid and 1% linolenic acid. Infants who are not taking breast milk for some reason should be given enough vegetable oils with high linoleic acid content (e.g. safflower, sunflower, corn, soyabean, cottonseed oils) to provide 6% energy equivalent.

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Minerals Requirements

Calcium, Phosphorus and Magnesium : These minerals are extremely important for the infants and growing children. They help in bone formation, teeth development, neuro - muscular activities, impulse conduction and structural and metabolic integrity of cells. Suggested intakes of calcium and phosphorus are summarized in Table - 8.Iron Requirements

Infancy and childhood : The demand of iron is not great during infancy as the infant is born with storage iron and a high haemoglobin count, which disintegrates to provide iron. Therefore as little as 0.3 mg iron per day is sufficient to meet his excretory losses. The demand of iron picks up in the second year of life when 0.4 mg iron is required every day. From second to the twelfth year in males and 10th in females, the mean increase in body weight is 2.5 - 2.7 kg/year, which corresponds to an iron demand of 0.3 mg/day. The daily requirement is further increased by a rise in the haemoglobin concentration by about 1 g/100ml during this period. The amount of iron required to replace the losses, also increases from 0.2 mg /day in infancy to 0.5 mg/day in the 12th year (a total requirement of 0.5 mg and 0.8 mg respectively).

Adolescence : During adolescence, there is an increase in iron demand owing to increase in body mass, growth, further increase in haemoglobin. The obligatory losses also increase with age. In young girls from 13 years onwards, the menstrual losses also become significant (about 0.45 mg daily).

Considering all these issues the iron requirement for Indians have been worked out which are summarized in Table - 9.Vitamin Requirements

Vitamin A : The RDA of vitamin A for infants are recommended on the basis of its intake through breast milk and extrapolated for children. A summary of the recommendations is given in Table - 10.

Water Soluble Vitamins : The RDA of various B complex vitamins for infants & children are summarized in Table - 11.

Diet for the infants up to 6 months of age : The documented virtue of breast milk goes back to 2000 years to the Charak Samhita. There is no variation in the opinion of the scientists that breast milk is the best for the baby. It contains all the nutrients required by the baby in the correct proportion for at least the first 4 - 6 months. It is well balanced nutritionally and immunologically and is easily digestible.

Composition of Breast Milk : Breast milk is an astonishing emulsion that contains more than 200 known substances, including more than 30 types of sugars, 10 types of fats and many proteins and minerals. Its primary constituents are :

Nutrients : Milk contains almost all known nutrients : fats, proteins, sugars, minerals, vitamins, etc.

Enzymes : These are present to digest and absorb the nutrients.

Immune factors : Many antibodies, lysozymes, etc are present to protect the baby from infections.

Growth factors and hormones : These are present for adequate growth of child.

Breast feeding : The mother must begin breast feeding at the earliest. The milk that is secreted by the woman in the first week after birth is a thick yellowish mixture, called as colostrum. It is highly recommended that the colostrum must be fed to the child as it is not only rich in fats, proteins, minerals and vitamins but also has anti - infective properties (antibodies, immunoglobulins, etc). The carotene content of colostrum is 10 times higher than milk. Vitamin A and E along with other antioxidants play an important role in the growth and immunological defence of the neonate. The practice of pre - lacteal feeding with honey, glucose water or formula feeds must be discouraged. It is advisable to exclusively breast feed the child till about 4 to 6 months. Following this some liquid feeds/supplements may be started (e.g. orange / tomato juice).

Non availability of breast milk : Use of milk other than mother’s must be avoided as far as possible. In case breast milk

Table - 8 : Suggested intakes of Calcium and Phosphorus (mg/day)

Group (years) Calcium (mg) Phosphorus (mg)

Infants 500 750

Children 1 - 9 yrs 400 400

Children 10 - 15yrs 600 600

Children 16 - 18yrs 500 500

Table - 10 : Recommended Daily Intake of Vitamin A for infants and Children

Group Age Retinol (µg)

Infants 0 - 6 months 350

Infants 6 - 12 months 350

Preschool children 1 - 5 years 400

School children 7 - 12 years 600

Adolescents 13 - 18 years 600

Table - 9 : Daily Iron Requirements

Group AgeDaily

requirement (mg)

RDA (mg)

Infants 0 - 6 months 0.32 -

Children

1 - 3 yrs 0.35 11.5

4 - 6 yrs 0.55 18.4

7 - 9 yrs 0.78 26

Adolescents

Boys 10 - 12 yrs 1.03 34.2

Girls 10 - 12 yrs 0.95 18.9

Boys 13 - 15 yrs 1.24 41.4

Girls 13 - 15 yrs 1.4 28

Boys 16 - 18 yrs 1.49 49.5

Girls 16 - 18 yrs 1.5 29.9

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is not available the best alternative is cow’s or buffalo’s milk. Whenever this milk is to be given in the first month one part of boiled clean water must be added to 2 parts of milk. With passing time the proportion of water must be reduced to 1 part water and 3 parts milk. By 8 weeks of age the infant gets whole milk without any dilution. Since this milk is poor in iron, iron supplementation is recommended from 2 to at least 8 months.

Diet for the infants from 6 months to 1 year : Breast milk is good enough to meet the nutritional requirements of infant till about 4 to 6 months of age, thereafter the requirements of the infant goes up and the milk yield also starts declining. As a result it is advisable to supplement feeding at six months of age to maintain good growth rate. Introduction of a dilute and nutritionally inadequate cereal gruel as a supplement to breast feeding is unpardonable. This is the time when the mother might become pregnant again and breast feeding is ceased abruptly. A child in such a situation is quite likely to end up as a malnourished child. The weaning has to be understood and practiced scientifically, if good growth of the child is to be maintained.

Weaning is the introduction of supplementary foods to augment the energy and nutrient intake of the infant. During this phase breast feeding is continued and maintained till about 1 year of age. Supplementary foods are gradually introduced and increased in quantity whilst breast feeding is slowly withdrawn. The process starts with omitting one breast feed and supplementing it with a chosen food in suitable quantity. Gradually the baby is given higher quantities of top - feeds and more frequently. This allows the mother to withdraw and eventually cease breast feeding smoothly. It is ideal to wean the child completely by 18 months of age. Some basic guidelines to weaning an infant through 4 to 12 months are given in

Table - 12.Supplementary Feeding for infants aged 6 months to 1 year : Depending on the age of the baby the supplements could be :

a) Liquid supplements : Breast milk must be continued in this period of the 1st year of life. However supplementation and substitution with certain liquids is recommended. Foods that can be used could be fruit juices like orange, mousambi and grapes. These would cater for mineral and vitamin requirement of the growing infant. Green leafy vegetable soups can be used as alternatives. Cow/buffalo milk is also introduced in a graded manner as described in an earlier paragraph.

b) Mashed solid supplements :

(i) Mashed solids like boiled and mashed potatoes with salt and ghee, cereal gruels like sweet dalia, porridge, etc. must be introduced in the 7th month. These foods contribute to the energy required for the rapidly growing baby. Well boiled and if required mashed dals can also be added. These will add to the variety and protein content of diet.

(ii) Vegetables : Green leafy vegetables can be used as semisolid soups suitably garnished with salt and ghee.

(iii) Other vegetables can also be used. The skin and seeds of these boiled vegetables can be removed and only the pulp used for the baby. The mother should start feeding with small quantity and increase gradually.

(iv) Boiled egg : It is a very useful, nutritious and easy to cook foodstuff. One may start with egg yolk. Egg white can be introduced later. Initially a partially boiled egg can be given later on a boiled or poached egg is fed.

(v) Meat : Well cooked, finely minced or ground meat or mashed fish can also be introduced at this time.

Table - 11: Recommended Daily Intake of B Complex Vitamins for Infants and Children

Group Age Pyridoxine (mg) Folate (µg) Vitamin B12 (µg) Vitamin C (mg)

Infants0-6months 0.3 25 0.2

256-12 months 0.4 25 0.2

Preschool children1-3 years 0.9 40

0.2 to 1.0 40

4-6 years 0.9 50

School children7-9 years 1.6 60

10-12 years 1.6 70

Adolescents13-15years 2 100

16-18 years 2 100

Table - 12: Guidelines to weaning

Age Supplementary foods Frequency

4-6 monthsMashed banana, Wheat flour, porridge, Ground rice and/or ragi mixed with oil or ghee

Start with 1 feed/day. Gradually increase to 3 feeds/day by 6 months of age

6-9 monthsBanana, mango, chickoo, Boiled egg yolk, Khichri, Mashed vegetables, Chapati softened in milk, Green leafy vegetables. Add little ghee/oil to all

4-5 times a day

9-12 monthsFruits, Khichri, Upma, Idli, Chapati, Curd-rice, Vegetables, Egg (boiled/scrambled), Minced meat/fish

4-5 times a day

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(vi) Fruits : Mashed ripe banana, mango, chickoo, apple, etc can be given depending on the availability and taste.

c) Unmashed solid supplements : When the baby starts cutting his teeth it is time to introduce chopped and solid foods. Chopped vegetables and minced meat of a coarser consistency can be used. Bit of potato, well cooked rice or dalia can also be given. A piece of toast, biscuits, banana, carrots can also be given for healthy teeth and gums. Fruit slices should be preferred to fruit juices now.Supplementary Feeds for children aged 1 to 2 years

Cereals : Cereals (wheat or rice) based preparations which the child could easily masticate and digest must be encouraged. Potato, sweet potato, tapioca and other starchy vegetables must be continued. These can be given at least three times a day.

Pulses : A pulse or legume preparation must be given at least once a day, to cater for the protein requirement.

Milk : While the breast milk quantity is being tapered off, the dairy milk must be supplemented, starting from about 200ml to 500 ml a day.

Vegetables and Fruits : Well cooked green leafy vegetables and other vegetables must be given twice a day to the child. Fruits must also be given at least once a day.

Eggs : One egg a day, prepared in any form is advisable to be given. As discussed earlier, it could be half boiled, boiled, poached or in any other acceptable form.

Meat : Meat, fish, chicken and their products can also be given as per dietary practices. Easily digestible forms are preferable. Minced meat, keema, mashed, shredded or meat soups can be used.

Diet for children aged 3 to 5 years : A three year old child might not be eating much more than a two year one, as the rate of growth in this period (2 - 4 years) is not as fast. So the mother need not be unnecessarily alarmed as long as it is following the height weight norms (Table - 13). The principles of diet are the same as those for a 1 to 2 year child. The only difference might be that a 3 to 5 years child is able to eat a variety of foods as he is capable of chewing and he likes to experiment with new foods. Hence the mother may try and feed him everything that is cooked for the family. Thus the child adapts to the adult diet. The frequency of feeding the child is however more as compared to adults. Children routinely need mid - meal snacks, couple of glasses of milk, variety of ‘well presented’ foods and an early dinner.

Table - 13 : Expected Height and weight for age (NCHS Standards)

Age (yrs)

Boys Girls

Height (cm)

Weight (kg)

Height (cm)

Weight (kg)

2 85.6 12.3 84.5 11.8

3 99.1 15.7 93.9 14.1

4 102.9 16.7 101.6 16

5 109.9 18.7 108.4 17.7

The Nutritional Requirements for the ElderlyProvision of good nutrition for the elderly is not as easy as it appears. Many physiological, social, economic, medical and psychological alterations take place in the old age, which directly or indirectly affect the food intake, digestion and nutritional status. The BMR goes down with age and so does the physical activity. These factors dictate the reduction of diet. Just like every other system the efficiency of gastrointestinal system goes down, resulting in a lower appetite. The elderly may be lonely and socially aloof, so the zest to cook and enjoy food is lost, thereby compromising with availability of good food intake. The old man may be affected by many chronic illnesses that restrict his food intake, for example salt has to be restricted in hypertension, sugar in diabetes, fat in CVD and proteins in renal disease. The ‘taste’ of food is thus lost and so is the interest. Certain psycho - social factors like loneliness, lack of family support, feeling of worthlessness, stresses of daily living and possible economic constraints further limit the intake (6).Nutritional Requirements

Energy : There has not been any conclusive word regarding energy requirement and recommendation for the elderly. Results of various studies have at best been highly variable. Therefore the expert groups have not come out with any special requirements for the elderly. But since it is known that BMR and physical activity go down in the elderly the energy requirement might have to be curtailed. Some authorities recommended energy requirement to be reduced by 11% in elderly men and 10% in women, as compared to young adults (7).

Proteins : Lean body mass protein, turnover and protein synthesis fall with age. WHO/FAO/UNU expert group has recommended a safe protein intake of 1 to 1.25g/kg per day.

Fats and Oils : Fats and oils are recommended at the same level as for the young. In case the person suffers from any chronic lifestyle disease e.g. CVD, hypertension, stroke, etc he might be advised to restrict fat.

Vitamins : It is felt that the vitamin requirement goes up in old age. However no special requirement has been slated for them.

Calcium : Calcium along with vitamin D is required for the integrity of bones. A deficiency of calcium may lead to osteoporosis in the elderly. Sufficient amount of calcium must therefore be taken every day. A slightly higher amount of calcium is recommended, about 0.8 - 1g per day.

Iron : The elderly may have lower iron requirements than the young. At the same time there might be a higher prevalence of disorders that might interfere either with iron absorption (atrophic gastritis etc.) or cause blood loss (hiatus hernia, peptic ulcer, haemorrhoids and cancer). Hence their iron requirement cannot be scaled down and it should be the same as for the young.

Diet for the Elderly : Except for a marginal reduction in energy requirement, the need for other nutrients almost remains the same. Besides the diet being nutritionally adequate the food preparations for the elderly should be tasty, soft and easily palatable. These basic principles are summarized in Box - 3

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and some common preparations to be preferred are listed in Box - 4.

Box - 3 : Principles of Diet for the Elderly

Box - 4 : Foods to be preferred

Simple but nutritious food

Include green leafy vegetables

Eat plenty of fruits

Include whole cereals

Insist on frequent, small meals

Drink plenty of fluids

Avoid fasting

Avoid fried foods

Consume low salt and sugar

Food should be easy to cook

Dalia

Khichdi

Upma

Kheer

Pohe

Canned foods

Fruit juices

Vegetable soups

Meat stew

With this background of nutritional requirements in mind, a typical balanced diet, along with the nutrients supplied with it is given in Table - 14.

Table - 14 : Balanced Diet for the Elderly

Foodstuff Quantity (raw in gm)

Males Females

Cereals 350 225

Pulses 50 40

Vegetables 200 150

Green leafy vegetables 50 50

Roots and tubers 100 100

Fruits 200 200

Milk and milk products 300 300

Sugar 20 20

Fats and oil 25 20

Approximate nutrient contents of above food items

Calories 2200 1700

Protein 65 g 50 g

Fat 50 g 40 g

Calcium 1 g 0.9 g

Iron 38 mg 30 mg

Vitamin A (Retinol) 1030 μg 930 μg

Thiamin 1.96 mg 1.45 mg

Riboflavin 1.78 mg 1.51mg

SummaryPregnancy and lactation : Many physiological changes take place during pregnancy and lactation. The nutritional requirement increases substantially during this time. The daily energy requirement increases by 300 Kcal, protein and fat requirement by 15 g and 10 g respectively. The iron requirement

also goes by about 8 mg. The demand during lactation is still higher. The energy requirement goes up by 550 Kcal and protein and fat requirement by 25 g each. Suitable modification in diet should to be made through addition of another meal, mid meal snacks and nutrient dense foods. Protein, iron and vitamin rich foods should be included in diet. It is wise to include fruits, vegetables, whole grains, milk products, meat, egg, legumes, nuts, etc. Also include vitamin C rich foods to improve iron absorption. Minimise coffee/tea during mealtime. It is advisable to take iron - folate supplement. Don’t take any medicines without prescription and abstain from smoking and alcohol.

Infants and children : Weight for weight the infant and children require more food than adults. It is advisable to exclusively breast feed infants till about 6 months. Thereafter they should be gradually weaned through introduction of fruit juice, cow’s milk, semisolid foods, boiled vegetables, potatoes, eggs and fat. As the children grow, so do their nutrient requirements. It is wise to keep an eye on the age - weight chart while the child is growing up.

Elderly : It is a challenge to meet the nutritional requirements of the elderly people for more than one reason. There is not enough research to base our recommendations for various nutrient requirements. Unlike adults where only the physical requirements govern the nutritional demand, in elderly the social, psychological, economic, emotional and physical needs are all important when it comes to eating food. Moreover the biological process of ageing differs in each individual. The challenges increase with increasing longevity. Illness, psychological voids, bereavements all pose varied impact. It is understood that the nutritional requirements for elderly are almost the same as that for adults. The food must be simple, easy to cook and more palatable.

Study QuestionsLong Question : What are the nutritional requirements elderly age? Elaborate a plan to meet these requirements.

Short Notes : (1) Weaning (2) Meeting Iron demand of a pregnant woman (3) Diet during lactation

MCQs1. Which of the following is not true regarding diet for the

elderly : (a) Their poor dentition restricts their food intake (b) The zeal to cook and eat goes down (c) Their food requirement is about half that of a robust young adult (d) There is not enough research to accurately predict RDA for elderly.

2. Which of the following is not true regarding diet during lactation : (a) Energy requirement during lactation is higher than during pregnancy (b) Iron requirement during lactation is higher than during pregnancy (c) Vitamin C requirement during lactation is higher than during pregnancy (d) Vitamin A requirement during lactation is higher than during pregnancy

3. Higher need of vitamin A during pregnancy can be met by all except : (a) Carrots (b) Cod liver oil capsules (c) Extra egg whites (d) Extra milk

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4. Which of the following is true about diet during pregnancy: (a) Salt intake must be minimized to prevent edema (b) Diet before pregnancy has no bearing on health of neonate (c) Strict weight control helps minimize childbirth complications (d) One extra meal per day is recommended during pregnancy

5. Which of these is not true for weaning : (a) Weaning means gradually replacing breast milk with other foods (b) It should be started at 1 year of age (c) One must start weaning with fruit juices and cow’s milk (d) Infant is more vulnerable to infections during this period

Answers : (1) c; (2) b; (3) c; (4) d; (5) b.

ReferencesGeissler C, Powers H. Human Nutrition.11th ed. Elsevier Churchill Livingstone 1. London. 2005.Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian 2. foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.Venkatachalam PS, Rebello LM. Nutrition for Mother and Child. National 3. Institute of Nutrition (ICMR), Hyderabad. 5th edition, 2004.National Institute of Nutrition, Nutritional Requirements and Recommended 4. Dietary Allowances for Indians; A report of the ICMR, 2004.Gupta RK. Towards better nutrition of pregnant women in the developing 5. world. Indian J of PSMPasricha S, Thimmayamma BVS. Dietary Tips for the Elderly. National 6. Institute of Nutrition (ICMR), Hyderabad. 1st edition, 2005.Rankford RT, Morie P, Steward J. Foundation of normal and therapeutic 7. nutrition. Wiley Medical Publication, New York. 1982.

133 Nutritional Deficiency Diseases of Public Health Importance

Rajul K Gupta

A large part of our population particularly the poor suffer from serious deficiencies in their diet. This might be an actual deficiency or one due to lack of knowledge about food and nutrients. As a consequence of this, several nutritional deficiencies with clinical manifestations and disabilities are encountered in our country. Most important of them are Protein Energy Malnutrition (PEM), Anaemia, Vitamin A Deficiency and Iodine Deficiency Disorders (IDD) and have been the concern of health authorities in our country for a very long time. Anaemia is the most prevalent affecting all ages. In India an astounding three fourths of all females and more than half of all males suffer from anaemia. PEM and vitamin A deficiency occur mostly among preschool children. More than 85% of Indian children suffer from some degree of undernutrition (mild, moderate or severe), making it a national priority. Vitamin A deficiency is of grave concern as it causes blindness that is easily preventable. Thyroid insufficiency due to iodine deficiency, which affects all age groups results in many a serious condition including goitre, impaired metabolism, cretinism, mental retardation and deaths (still births).

Protein Energy Malnutrition (PEM)Malnutrition is a range of conditions occurring when intake of one or more nutrients doesn’t meet the requirements. Protein Energy Malnutrition (PEM) is a malnutrition resulting from the deficiency of protein and/or energy in diet. PEM is an important nutritional problem among preschool age children. This leads to various degrees of growth retardation. When growth retardation is severe, functional deficiencies, like resistance to infection and poor intellectual development may result. The main cause of PEM is food inadequacy i.e. the deficiency of

energy or proteins or both. In these cases deficiency in other nutrients like vitamin A, iron, calcium and riboflavin is also seen. It is also known that infections like measles and diarrhoea aggravate PEM. In 1959, Jelliffe introduced the term ‘Protein Calorie Malnutrition’ (PCM) as there was close association between the two poles of the syndrome namely, Kwashiorkor and Marasmus. The term PCM, was later rephrased as Protein Energy Malnutrition (PEM).

Undernutrition includes underweight (being underweight for one’s age), stunted (being too short for one’s age), wasted (being dangerously thin), and micronutrient malnutrition (being deficient in vitamins and minerals).Magnitude of the Problem

World : The magnitude of the problem at a global level can be reckoned from the fact that malnutrition contributes to 60% of the total 10 million deaths of children under five years of age. Its contribution to child deaths is highest during first six months of life (1).

India : As per NFHS-2 (1998-99), 47% of children under three years are underweight, 45.5% stunted and 15.5% wasted. India fares poorly even among the South East Asian countries, occupying the third place from the bottom with only Nepal and Bangladesh faring worse than India. The prevalence of low birth weight continues to be about 30% for last three decades. Low birth weight babies are more likely to die because of neonatal infections and undernutrition (1). Chronic Energy Deficiency in adults is 39% in females and 37% in males (NNMB 2002) (2).

As per the NFHS report of the National Health Profile, 2007, considering various parameters, as many as one fourth to half of all Indian children are undernourished in various age groups (3). Even during the first six months of life, when most babies are breastfed, 20-30 percent of children are undernourished according to each of the three criteria, namely stunting (or too short a height for age), wasting (or too thin for height) and underweight. However, malnutrition peaks during the first two years of life. From 11.9% prevalence among 0-6 month old

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Table - 1 : Classification of PEM (FAO/WHO) (6)

TypePercent of standard

body weightOedema

Deficit in weight for

height

Kwashiorkor 80-60 + +

Marasmic- kwashiorkor

<60 + ++

Marasmus <60 0 ++

Dwarfing <60 0 Minimal

Underweight 80-60 0 +

Marasmus : Conditions conducive to the evolution of marasmus typically exist in the lower socio-economic classes of the urban community. A low birth weight neonate born to an economically and nutritionally deprived working woman in a setting of ignorance and poverty is most vulnerable to marasmus. The weaning is often early and abrupt. The mother stops breast feeding for various reasons. Most often she has to return to work early. She might be suffering from infections like mastitis, etc. which don’t allow breastfeeding to continue. The infant might be having an illness (gastrointestinal or respiratory infections), during which it is not wise to feed the child, in the mother’s opinion. Social influences in the form of peer pressure, advertisements of alternative feeds could also be major reasons for discontinuing breast feeding. Another quick pregnancy could change the priority and infant is neglected. Taboos restricting the use of colostrums and breast milk also limit its full utilization. The sheer inconvenience or non availability of a private place to breast feed the child at the work place could dissuade the mother.

A typical epidemiological case is illustrated as follows : Let us take a pregnant construction labourer in an urban setting as an example. Being economically deprived she is in a poor nutritional state. More often than not, she has rapid succession of pregnancies. She delivers low birth weight babies. She breastfeeds the infant for a short duration since she has to return to work at the earliest. The infant is handed over to the elder sibling. This is invariably followed by dirty and dilute formula for feeding. The infant is inadequately fed because of ignorance and to limit expenditure. The diet is low in both proteins and energy. Moreover poor housing/sanitation, lack of fuel, water and utensils makes it impossible to prepare a clean and healthy weaning food. Repeated infections develop (particularly gastroenteritis), which are treated by starvation for long periods. The child is fed with water, weak tea and rice water. This forced early, abrupt and faulty weaning takes its toll on the nutritional state of the infant. The infant ends up being Marasmic.

Clinical features of Marasmus : Marasmus is most commonly seen in children aged less than 5 years (most cases are less than 1 year of age in the urban areas). There is failure to thrive, irritability or apathy. Many infants are hungry and some anorexic. Diarrhoea and dehydration are frequent. The weight is grossly below standards and the child is ‘skin and bones’ owing to loss of subcutaneous tissue. The common clinical

infants, it reaches to 58.5% in one to two year old children. This steep rise in malnutrition during the first two years is mainly due to poor infant feeding practices (1). Among the children under 3 years of age, 38.4% are stunted, 19.1 are wasted and as many as 45.9% are underweight. The highest number of underweight children (under 3 years) is reported from Madhya Pradesh 60.3%. Other states reporting high percentage of underweight children are Jharkhand (59.2%), Bihar (58.4%) and Chattisgarh (52.1%). Mizoram reports the lowest number of underweight children at 21.6%. Other states reporting low percentage of underweight children are Sikkim (22.6%), Manipur (23.8%), Punjab (27%), Kerala (28.8%) and Goa (29.3%) (3). In the under-fives year age group, almost half of all children are stunted, which indicates that they have been undernourished for some time. Twenty percent are wasted, which may result from inadequate recent food intake or a recent illness. Forty-three percent are underweight, which takes into account both chronic and acute undernutrition.

Adults in India suffer from a dual burden of malnutrition; more than one-third of adults are too thin, and more than 10 percent are overweight or obese. Only 57 percent of men and 52 percent of women are at a healthy weight for their height.

Undernutrition is particularly serious in rural areas. The condition is worst in the lower wealth quintiles, among scheduled tribes and scheduled castes, and among those with no education. More than two out of five women are too thin in Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, and Orissa; similar proportions of men are too thin in Tripura, Madhya Pradesh, and Rajasthan.

Overweight or obesity is most common among adults in Punjab, Kerala, and Delhi. These conditions are most common in older adults, those in urban areas, the well-educated, and those in the highest wealth quintile (3).

Etiology and Epidemiology : PEM characteristically occurs in children less than 5 years of age, whenever the diet is poor in energy and proteins. PEM was earlier attributed to the concept of ‘protein gap’ (deficiency of proteins in diet), which has now given way to the new etiological theory of ‘Food gap’, wherein it is not only the deficiency of proteins but inappropriate food (low in energy density, protein and micronutrients - Vitamin A, Iron, Zinc) which is poor both quantitatively and qualitatively, is the chief cause of PEM (5).

Under-nutrition in fetal life, esp. last trimester, lactation failure, low energy dense weaning foods, incorrectly constituted formula, contaminated water and infections (diarrhoea, measles, acute respiratory infections, intestinal worms etc.) also play important role in the causation of PEM. The other associated social factors are poverty, poor environmental conditions, large families, poor MCH services and poor cooking practices. Ignorance and the inability to provide adequate food also seem to be important contributory factors.

Classification of PEM : Even though Marasmus and Kwashiorkor are the two main and polar forms of PEM, clinically it can be broadly classified into five forms (Table-1). These varied syndromes result from the types, severity and duration of dietary deficiency.

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features of marasmus are enumerated in Box - 1. A standard text on paediatrics could be consulted for more details on the clinical aspects.

Box - 1 : Clinical features of Marasmus

Constant featuresGrowth retardation ●Wasting of muscles and subcutaneous fat ●‘Wisened old man’s look’ ●

Other featuresHair changes like easily pluckable hair ●Infection ●Vitamin deficiency ●No psychomotor changes ●

Kwashiorkor : The term Kwashiorkor was introduced by Cicely Williams into modern medicine. It comes from language of ‘Ga’ tribe of Ghana, meaning “Sickness the older child gets when the next baby is born”.

If the epidemiological events for the causation of PEM had to be greatly simplified, while marasmus is seen in an early and abruptly weaned baby in an urban setting, the other ‘pole’ of PEM, Kwashiorkor is typical in an older child who is breast fed for a rather prolonged period and weaned late in a rural setting. Poverty, insufficient food and land, poor agricultural practices, religious issues and taboos compromise the nutrient intake. Protein sources like milk, eggs and meat are costly so their supply tends to be inadequate. In some areas Kwashiorkor runs an endemic course, when food supply becomes scarce every year before the harvest season.

In such children the protein and energy supplies are almost always at brink. Frank Kwashiorkor may be precipitated by acute febrile infections like ARI, measles, whooping cough or diarrhoea as the nutritional demand shoots up.

Clinical features of Kwashiorkor : Kwashiorkor is most commonly seen in children aged 2 to 5 years of age. Many children of a given locality sharing the same socio-economic milieu may suffer from Kwashiorkor. The child may be brought to the doctor for an underlying infection. Failure of growth may be an early sign. There may be weight loss, anorexia or diarrhoea. Oedema is present, which is more marked on the lower limbs. Quite often it is grossly present all over the body including face. The common clinical features of Kwashiorkor are enumerated in Box - 2.

Prevention of PEM : “Prevention of PEM is the fight against poverty and ignorance” (7). As was discussed earlier it must be appreciated that there is no single shot solution to the treatment or prevention of PEM. It is a complex problem involving each of the social, economic, educational, political, administrative, medical and health dimensions. An integrated effort involving all these and also awareness and a positive attitude towards the condition might help to limit it. The most vital preventive measures that are executable through the classical health and medical infrastructure and classifiable under the traditional heads of the preventive strategy are enumerated here. Details on mitigation of poverty, improving the health infrastructure, provision of health care and hygiene-sanitation facilities, strengthening immunization facilities, making the PDS more efficient or provision of nutritional education though extremely important, are beyond the scope of this book. Hence these issues have not been elaborated.

Health promotion(a) Good ante-natal care(b) Education on food, hygiene and family planning(c) Education on the importance of colostrum, diet during

lactation(d) Various measures under the ICDS initiative, like good

nutrition, immunization, education, hygiene and sanitation etc.

(e) Promotion of breast feeding(f) Good weaning practices, correct time of weaning,

importance of low cost weaning foods(g) Prevention and control of infections during weaning(h) Improve family diet(j) Correct knowledge on balanced diet(k) Utilization of family planning practices(l) Hygiene & sanitationSpecific protection

a) Diet : Protein and energy rich food should be consumed by children. Special attention must be paid to diet during weaning. Adequate quantities of fruits and vegetables must be included in the diet.

b) Immunization : The child must be immunized as per the national schedule.

Early Diagnosis & Treatment

a) Growth monitoring : Vulnerable children must be identified. Children must be monitored through growth charts. Early diagnosis of growth failure must be done and treated as appropriate.

Box - 2 : Clinical features of Kwashiorkor

Constant featuresOedema ●Growth retardation ●Muscular wasting ●Retention of subcutaneous fat ●Psychomotor changes ●

Other featuresHair changes - Flag sign ●Diffuse pigmentation of skin and dermatoses-- Flaky paint dermatosis ●Moon face ●Anaemia ●Hepatomegaly ●Associated vitamin deficiencies (retinol, tocopherols, folate, pyridoxin, Vitamin K) ●Associated mineral deficiencies (iron, potassium, zinc, copper, selenium, magnesium) ●Associated acute infections ●

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b) Early diagnosis and treatment : Early diagnosis and treatment of infections is also vital. To achieve this, health worker must be alert and mothers should be aware of the signs and symptoms of common infections. Preparation and use of ORS should be known to all mothers. The services available through the IMNCI initiative must be fully utilized.

c) Medical advice : In extreme and serious cases early medical advice and treatment facilities must be available. Hospitalization of the case remains the only choice in complicated cases.

Rehabilitation : Even if PEM patients are treated well in a hospital setting, many follow up studies have shown that they tend to die of the same disease and infections for which they were treated earlier. It is because the immediate disease in question was treated but the family and community milieu which was responsible for the problem remains largely unchanged. The poverty, hygiene, sanitation, dietary/ feeding knowledge and practices, taboos, predisposing factors for infection etc remain the same. While it may not be possible for the medical fraternity to improve the socio-economic condition of the family, but substantial changes can be brought to the knowledge, attitude and practice about the disease. After an intensive hospital resuscitation session, knowledge can be imparted to the mothers about the disease. Correct feeding practices and skills can be taught. Myths and taboos can be busted. These principles can be undertaken in three settings :

(a) Residential Units : Mothers are admitted with their sick children. The mother gets hands on experience in the practical learning of preparation and administration of a therapeutic diet for her child with an expert. This demonstration and involvement of the mother in her child’s recovery goes a long way in understanding the problem and mitigating it.

(b) Day Care Centre : The mother attends the day care centre along with the child where cooking and feeding is taught to the mother. While the child attends every day, involvement of the mother is partial.

(c) Domicilliary Rehabilitation : The expert comes home and assesses the situation as a whole. The mother is then rendered suitable advice with regards not only to feeding but also about improving various domestic contributory factors to PEM.

AnaemiaAnaemia is a global menace affecting both developing and developed countries with major consequences for human health as well as social and economic development. It occurs at all stages of the life cycle, but is more prevalent in women esp pregnant women and young children. In 2002, iron deficiency anaemia (IDA) was considered to be among the most important contributing factors to the global burden of disease (8). The numbers are staggering; as many as 2 billion people or over 30% of the world’s population is anaemic. This is frequently exacerbated by infectious diseases like malaria, tuberculosis, HIV/AIDS, hookworm infestation and schistosomiasis in some areas. It is a major public health problem. More subtle in its manifestations than, protein-energy malnutrition, iron deficiency exacts its heaviest overall toll in terms of ill-health, premature death and lost earnings. Iron deficiency and anaemia reduce the work capacity of individuals and populations, bringing serious economic consequences and obstacles to

national development. Overall, it is the most vulnerable, (poorest and the least educated) who are disproportionately affected by iron deficiency, and it is they who stand to gain the most by its reduction. See Box - 3 and 4.

Box - 3 : Facts about Anaemia (9)

In developing countries every second pregnant woman and about 70% of preschool children are estimated to be anaemic.

Anaemia is aggravated by infectious diseases like worm infestations, malaria, HIV and tuberculosis.

The major health consequences include poor pregnancy outcome, impaired physical and cognitive development, increased risk of morbidity in children and reduced work productivity.

Anaemia contributes to 20% of all maternal deaths

Box - 4 : Consequences of Anaemia

General : Weakness, easy fatigability, lethargy, Inhibition of lymphocyte proliferation lowered cell mediated immunity, reduced neutrophil bactericidal activity, vulnerability to infections, diminished physical and earning capacity, reduced work capacity reduced endurance

Pregnant and Lactating Women : Weakness, diminished physical and mental capacity, increased morbidity from infectious diseases, Increased risk of low birth baby, abortion, premature delivery, intra-uterine growth retardation, Congenial fetal malformations, PPH, maternal mortality

Children : Low birth weight, Perinatal mortality, impaired cognitive performance, motor development and scholastic achievement, Psychological and behavioural effects like inattention, fatigue and insecurity

Defining Anaemia : Anaemia is traditionally defined as the reduced oxygen carrying capacity of the blood due to a reduction in its haemoglobin content. The WHO defines anaemia as “a condition in which the haemoglobin content is lower than normal as a result of deficiency of essential nutrients, regardless of the cause of such deficiency”. The WHO has further defined as to when should the haemoglobin content be considered as low. The level of ‘low’ haemoglobin levels vary with sex, age and physiological status. These are summarised in Table - 2 .

Table - 2 : Haemoglobin thresholds used to define Anaemia (10)

Age or gender group Haemoglobin threshold (g/dl)

Children (0.50-4.99 yrs) 11.0

Children (5.00-11.99 yrs) 11.5

Children (12.00-14.99 yrs) 12.0

Non-pregnant women (≥15.00 yrs) 12.0

Pregnant women 11.0

Men (15 yrs and more) 13.0

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Anaemia as a public health problem : Globally, anaemia is considered to be a problem of public health significance when the prevalence exceeds certain levels, as elaborated in Table-3.

World : Anaemia is a huge public health problem globally. As per the WHO (2008) estimates about half (48.8%) of the entire world population suffers from anaemia. More than 3/4th of all preschool children, 1/3rd of all school aged children, 69% of all pregnant women and 73% of the non pregnant women have anaemia. More than 40% men suffer from anaemia (8).

India : Anaemia is a major health problem in India, especially among women and children (See Table- 4). Specific groups are elaborated here. The WHO classifies India to be having a ‘severe’ level of public health problem in the form of anaemia (>40% prevalence in all groups - preschool children, pregnant women, non pregnant women) (8). Among the age group of 6 and 59 months, the great majority i.e. 70 percent of children are anaemic. This includes 26 percent who are mildly anaemic, 40 percent who are moderately anaemic and 3 percent who suffer from severe anaemia. Boys and girls are equally likely to have anaemia. Children of mothers who have anaemia are much more likely to be anaemic. Although anaemia levels do vary, by and large anaemia among children is widespread in every group and every state in India. Even when the mothers were Class XII educated and/or economically well off, the prevalence of anaemia amongst their children too was 50% (3).

More than half of women in India (55%) have anaemia. About 39 % have mild anaemia, 15 % moderate anaemia and 2 percent severe anaemia. Anaemia is particularly high amongst women with no education, women from scheduled tribes, and women in the lowest wealth quintiles. Pregnant and lactating women too have high prevalence of anaemia (3).

Among men, while globally the prevalence of anaemia is about 40%, only one-fourth of the Indian men are anaemic. Men under 20 and over 40 years of age are more likely to suffer from

anaemia. Men at higher risk of anaemia are the widowed men, scheduled-tribe men, and men belonging to the lowest wealth quintile. In these vulnerable groups the prevalence of anaemia goes up to 40% (3).

Etiology : Causation of anaemia is a maze of a multitude of social, cultural, religious, dietary and environmental factors. Poor economic condition, religious practices disallowing certain nutritious foods, dietary practices like vegetarianism limiting food choices, faulty cooking practices discarding nutrients from food, faulty child rearing practices (premature weaning) enabling predisposition of PEM and anaemia, large families limiting food intake and poor environmental sanitation and non availability of sanitary latrines and drinking water, all predispose to anaemia either directly or indirectly.

Anaemia is the result of a wide variety of causes that can be identified, but more often they coexist. Globally, the most significant contributor to the onset of nutritional anaemia is iron deficiency so the terms iron deficiency anaemia and anaemia are often used synonymously, and the prevalence of anaemia has often been used as a proxy for iron deficiency anaemia. It is generally assumed that most of the cases of anaemia are due to iron deficiency. Therefore the causes of iron deficiency are discussed in detail here. These can be enumerated in a simply manner as shown in the Box - 5.

a) Inadequate intake of iron : The sources of iron have been discussed in greater details in the chapter on minerals. Poor diet is an important cause of inadequate intake of iron. While economic constraints make one’s diet poor, it is also the ignorance about the dietary sources of iron which also makes even a well to do man’s diet poor in iron. For example it is generally believed that spinach is a ‘very good’ source of iron. But the fact is that it is a poor source as it contains only 1.1mg iron per 100g. On the other hand almost all other green leafy vegetables like radish leaves (18 mg), rape leaves (12.5mg),

Table - 3 : Classification of anaemia as public health problem (3,8)

Prevalence of anaemia Health significance Examples (Countries) Examples (Indian states)

<4.9%No public health problem

Chile (Non pregnant women), USA (Preschool children)

-

5.0-19.9%Mild public health problem

Australia, Israel, UK, USA and most Western European countries

-

20.0-39.9%Moderate public health problem

Japan, Malaysia, China, Pakistan and most of the middle east countries

Goa, Kerala (pregnant and non pregnant women), Mizoram, Manipur (Non pregnant women), Delhi (pregnant women)

> 40.0%Severe public health problem

India, most of the SE Asian and African countries

All Indian states, except the categories mentioned in the row above

Table - 4 : India - WHO estimates of anaemia prevalence amongst preschool children and women (8)

Age Cut off haemoglobin Prevalence % Estimated Number Level of public

health problem

Preschool children (6m-3yrs) <11g/dl 74.3% 8,90,90000 Severe

Pregnant women (15-49 yrs) <11g/dl 49.7% 1,27,99000 Severe

Non-pregnant women (15-49yrs) <12 g/dl 52.0% 13,44,95000 Severe

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turnip greens (28.4mg), amaranth species (1.8 -38.5mg), methi leaves (1.9 mg) and lettuce (2.4) mg all contain high iron.

Box - 5 : Causes of Anaemia

Inadequate intake of ironPoor diet ●Poverty ●Ignorance ●Inadequate folate/vitamin C intake ●

Poor absorption and bioavailability of ironAbsorption -Only 5% ●Poor absorption-Non haeme iron (Ferric iron) ●Inhibitors: Phosphates, phytates, oxalates, fibre ●Tea (tannin), Eggs (Phosphate), Milk (Calcium) ●

Excessive loss of ironNormal man (1mg/day) ●Menstruation (2mg/day) ●IUDs ●Intestinal worms ●Malaria ●Repeated / frequent pregnancies ●

Increased demand of ironPregnancy ●Growth ●

b) Poor absorption and bioavailability of iron : It must also be appreciated that the non heme iron (as present in green leafy vegetables) is absorbed poorly. Moreover a poor intake of vitamin C also limits the absorption of non heme iron, as ascorbic acid acts as a dietary reducing agent converting the non absorbable Ferric (Fe3+) ions into Ferrous (Fe2+) ions. Similarly concomitant intake of folate also helps in haemopoisis and thus preventing anaemia. There are certain inhibitors of iron absorption which are inherently present in our diet. For example phytates are present in fibres and cereals, phosphates in milk and eggs, oxalates in vegetables, tannins in tea, calcium in milk, etc. All these normal constituents of diet tend to retard the absorption of iron, contributing to anaemia.

c) Excessive loss of iron : The normal physiological loss of iron per day is about 1mg for men and 2mg for women. But there are certain conditions in which this loss becomes excessive and abnormal. Heavy blood loss may be a result of abnormal menstruation (menorrhagia, metrorrhagia), parasite infections such as hookworms, ascaris, and schistosomiasis. Acute and chronic infections, including malaria, tuberculosis, and HIV can also lower blood haemoglobin concentration. Other conditions like haemorrhoids, peptic ulcers and cancer may also result in blood loss causing anaemia. In our context IUD insertions and repeated pregnancies/deliveries are also frequent causes of anaemia.

d) Increased demand of iron and other micronutrients : There are certain periods in the life cycle when iron requirements are especially high. Commonly this happens during growth and pregnancy. This has already been deliberated in the previous chapter.

A neonate is born with sufficient iron resources, therefore the chances that it should get anaemia in the early infanthood (6

months) are remote. Moreover breastfed infants are in a happy iron state as iron from breast milk is very well absorbed. It is the preterm and low birth weight babies that have poor iron stores. The requirement of folates is also high for the preterm babies. Preterm babies are thus more likely to develop anaemia at 2-3 months. Babies that are not allowed colostrum intake and are not breastfed are also likely to develop anaemia as iron from artificial feeds or animal milk is not well absorbed. A condition “Goat Milk Anaemia” is known in babies that are fed goat milk as it is deficient in folate.

Prevention and Control of Anaemia : Given the multifactorial nature of this disease, correcting anaemia often requires an integrated approach. The benefits of preventing and controlling anaemia are substantial. Timely intervention can restore personal health and raise national productivity levels by as much as 20%. In order to effectively combat it the contributing factors must be identified and addressed. Additional iron intake is usually provided through iron supplements to vulnerable groups, in particular pregnant women and young children. Food based approaches to increase iron intake through food fortification and dietary diversification are important sustainable strategies for preventing IDA in the general population.

Strategies should also include addressing other causes of anaemia and should be built into the primary health care system and existing programmes. These strategies should be tailored to local conditions, taking into account the specific etiology and prevalence of anaemia in a given setting and population group. The main strategies for prevention and control of anaemia are as follows :

1. Breastfeeding and appropriate weaning : While it is true that milk is not a very rich source of iron, but the bioavailability of iron from breast milk is exceptionally good. Breast milk thus is a source that in itself is adequate to suffice the iron requirement of the young infant, till about 6 months of age. Breast feeding is therefore the first step to the prevention of anaemia. The iron requirement of a growing infant increases by 1 year. It is important to wean the child with iron rich foods. Food stuffs like meat/chicken soups, vegetable soups, jaggery, etc must be included. Iron supplementation must be considered if necessary. Prevention and control of infections and deworming must also be carried out.

2. Dietary modification : The diet must be assessed and suitable dietary modification must be undertaken with a view to increase iron intake. Nutritious diet which includes rich sources of iron must be consumed. Use of green leafy vegetables, pulses, non vegetarian foods, ragi, jaggery and fruits like custard apple must be promoted. Foods with high contents of vitamin C (lime, lemons, guava, amla, orange, green vegetables, etc.) must be encouraged as vitamin C promotes iron absorption through reduction. Food stuffs that inhibit iron absorption like tea, tamarind and high fibre should be spaced out away from the main (iron containing) meal.

3. Deworming : Deworming as required, must be undertaken for all, esp. infants and children.

4. Control of infection : Prevention and control of infections through good health care, immunization, early diagnosis and treatment, hygiene and sanitation practices and potable

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water provision facilities is an important indirect step towards anaemia control.

5. Supplementation : Iron supplementation is routinely recommended for the pregnant women and children, under the national programme. Details are available on the chapter on National Nutritional Programmes. Therapeutic iron supplementation may also be required in moderate to severe cases of anaemia.

6. Iron Fortification : Trials are already completed at the National Institute of Nutrition for fortification of certain food items with iron. Common salt can be fortified with Ferric-ortho-phosphate or Ferrous sulphate and Sodium bisulplate. Double fortification of salt with iron along with Iodine is also feasible. However these fortified foods are still awaiting induction at a public level.

7. Nutrition education : It can be well appreciated that anaemia is not caused solely due to poverty and lack of resources. Ignorance on various facets of dietary intake, hygiene, sanitation, immunization, dietary interactions is also important and must be dispelled. This could be achieved through health education. The health education can be carried out at all levels including children at schools, for housewives, men and pregnant women. Using the locally available foods that are fresh, nutritious and cheap is also an important part of the nutritional education.

8. Home gardening : Promoting and utilizing a kitchen garden and poultry can go a long way in having good nutrition and preventing anaemia.

9. Care of pregnant and lactating women : Adequate care of the pregnant and lactating women can go a long way in preventing anaemia in them as well as the infant.

Iodine Deficiency Disorders (IDD)Iodine deficiency is a major public health problem throughout the world, particularly for pregnant women and young children. They are a threat to the social and economic development of community. IDD is the cause of cretinism and a substantially increased perinatal mortality. A large proportion of mental retardation in infants and young children is attributable to IDD. In fact, iodine deficiency is the greatest cause of preventable brain damage in childhood. Hence no effort must be spared to implement measures to eliminate it.

Etiology : The content of iodine in water, crops or food materials is a function of the soil content of iodine. Therefore populations living in areas where the soil has low iodine content suffer from iodine deficiency. Heavy rainfall, past glaciation and snow drain of iodine from the top soil layer. Crops grown in this iodine depleted soil are devoid of iodine leading to a low dietary supply of iodine (11). Although goitre is primarily due to iodine deficiency in some areas, certain chemicals, collectively known as goitrogens that are present in some of the habitual foods, may contribute to the precipitation of iodine deficiency when iodine intake is marginal. These are present in vegetables of Brassica family, e.g. mustard, cabbage, etc.Magnitude of the problem

World : It is estimated by the WHO that Iodine nutrition is optimal in 43 countries (including India). Nevertheless, in 54

countries, located in all regions of the world, iodine intake of the population is insufficient and it is a public health problem (11) More than 7% of world population suffers from iodine deficiency. In the developing countries alone, 800 million people are at risk and 200 million suffer from Goitre. As many as 3 million cretins are born. In our neighbourhood other South East Asian countries like Bangladesh, Bhutan, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand are also prone to iodine deficiency.

India : Even though WHO classifies India as a country with ‘optimal iodine nutrition’, about 1/3rd (31.3%) of Indian school age children have a urinary iodine excretion of less than 100μg/l. This indicates ‘insufficient iodine intake’ and ‘mild iodine deficiency’. This might be true for the country as a whole, but the fact remains that the ‘sub-Himalayan goitre belt’ is the world’s most intense Goitre endemic region affecting nearly 120 million people. More than 55 million people suffer from the condition in this region. The total Goitre prevalence amongst school age children in India is 17.9% (11). The prevalence of goitre in an iodine replete population should be 5% or less.

Lately it has been appreciated that it is not only the sub Himalayan regions that are endemic for IDD but some extra Himalayan foci close to low lying hills like Chota Nagpur region of Bihar, hilly regions of Madhya Pradesh and Chattisgarh, Aravali ranges of Rajasthan, Narmada valley in Gujarat, parts of Western Ghats (Maharashtra, Kerala and Karnataka), Eastern Ghats (Andhra Pradesh and Tamilnadu) and Nilgiris are also endemic for IDD.

It is estimated that the total population at risk in India is about 200 million and 70 million are estimated to suffer from IDD.

Clinical Features : IDD may present as a spectrum of disorders and illnesses throughout the life cycle (See Box-6) (12). Though goitre is the most visible manifestation of IDD, the spectrum ranges from abortions, stillbirths and congenital anomalies to frank cretinism and mental/physical underdevelopment. If iodine deficiency occurs during the most critical period of brain development (from the fetal stage up to the third month after birth), the resulting thyroid failure will lead to irreversible alterations in brain function. Iodine deficiency might be responsible for a mean IQ loss of up to 13.5 points in the population (13). Cretinism is the most extreme and well known manifestation of IDD. Numerically however, subtle degrees of mental impairment (leading to poor school performance), reduced intellectual ability and impaired work capacity are of considerably greater significance, in a large number of children (12).

Indicators for Assessment and Monitoring : Urinary Iodine Excretion (UI), Total Goitre Prevalence (TGP), radiology, ultrasonography, TSH, T3 and T4 level estimation are useful to assess and monitor the cases.

Urinary iodine (UI) excretion is a marker of recent dietary intake of iodine (over the past 48 hrs.) & therefore, is the index of choice for evaluating the degree of iodine deficiency & its correction. Iodine concentration in casual urine specimen provides an adequate assessment of the population iodine nutrition. Median urinary iodine is used to classify countries into different grades of public health significance. Median UI of

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<100 μg/l indicates insufficient iodine intake and hence mild to severe iodine deficiency. A very commonly used epidemiological parameter is TGP (Box-7).

Box - 7 : Total Goitre Prevalence (TGP) (12)

The size of thyroid gland changes inversely in response to alterations in iodine intake, with a lag interval that varies from a few months to several years. The prevalence of goitre is an index of the degree of longstanding iodine deficiency and therefore, is less sensitive than urinary iodine in the evaluation of a recent change in the status of iodine nutrition. Thyroid size is traditionally determined by inspection and palpation. However, the evaluation of the prevalence of goitre based on palpation has been questioned because the reproducibility of assessment by palpation is low, especially with the size estimation of smaller glands, particularly in children. But it is still employed as a useful field tool for assessing goitre prevalence. The prevalence of goitre in an iodine replete population is below 5%.

Table - 5 shows the revised and simplified classification of goitre.

Table - 5 : Classification of goitre (14)

Classification Description

Grade 0 Not palpable or visible goitre

Grade 1 A goitre that is palpable but not visible when the neck is in the normal position (i.e. the thyroid is not visibly enlarged). Thyroid nodules in a thyroid which is otherwise not enlarged fall in this category

Grade 2 A swelling in the neck that is visible when the neck is in a normal position and is consistent with an enlarged thyroid when the neck is palpated

Determining presence of iodine in salt : Presence of iodine in salt can be qualitatively determined using rapid test kits (containing starch-based indicator e.g. MBI Kit by UNICEF). One drop of this solution placed on salt containing iodine (potassium iodate) produces a blue/purple color. Coverage of adequately iodised salt is an important indicator used for assessment of iodine status in a population besides urinary iodine excretion

and total goitre prevalence. To meet the WHO criteria for monitoring progress towards sustainable IDD elimination, salt Iodization coverage or proportion of households consuming adequately iodized salt should be more than 90% (See Box-8).

Box - 8 : Present Status of Salt Iodization

Unfortunately the legal policy on mandatory iodization of salt has not been consistent. As a result only about half of all households in India (49% as per NFHS-2 report year 2000 and 51% as per NFHS-3 report) are using sufficiently iodized salt. Use of iodized salt varies greatly by region; it is highest in the northeast region and in some states in the north. However, now a nationwide ban on non-iodized salt is taking effect and the current figures could well be more encouraging.

Prevention and Control : The recommended strategy for IDD control is based on correcting the iodine deficiency by increasing iodine intake through supplementation or food fortification. Under the National IDD Control Programme four main components of the IDD control strategy are : 1. Use of Iodized salt or oil2. Iodine monitoring3. Manpower training4. Mass communicationUsing iodized Salt / Oil : This prevents iodine deficiency. Control and prevention of goitre has been principally based on providing extra iodine to the population through iodised salt distribution or iodised oil injection (in hyper-endemic areas). Commonest prophylactic public health measure against endemic goitre is iodization of salt. Various agents can be used. Potassium iodate is most commonly used. Sodium & Potassium iodide can also be used. Iodization of salt is undertaken in a dose of 30 ppm at source so as to render at least 15 ppm at the consumer end.

Iodized Oil : Injectable and oral iodized oil are available as oral drops (400 mg/ml) and intramuscular (IM) injections (480mg/ml). Single IM injection of iodized oil can protect a woman through pregnancy and one year post partum. Oral supplementation is to be repeated every 6 months to 1 year (See Table - 6). More details are available in standard recommendations (15).

Box - 6 : Clinical Features of IDD through the Life Cycle

Foetus and neonate : Abortions, stillbirths, congenital anomalies, high unexplained perinatal and infant mortality, low birth weight, neonatal goitre, lethargy, poor feeding, prolonged physiological jaundice. Congenital anomalies like umbilical hernia and large anterior fontanella.

Infancy & early childhood : Signs of cretinism that include mental deficiency, squint, short stature, hoarseness of voice, deaf-mutism and motor spasticity characterized by proximal rigidity of both lower and upper extremities and trunk.

Child & adolescent : Poor scholastic performance, retarded mental and physical development. Goitre and/or signs of juvenile hypothyroidism (growth retardation, mental retardation, hoarse voice). In addition there may be features of puffiness, thickened and dry skin, dry and rare hair/eyelashes/eyebrows and much delayed sexual maturation.

Adult : Mental and physical underdevelopment. Patients appear to be slow and rather ‘sleepy’. Impaired mental function and impaired decision making. On examination, an enlarged thyroid may be palpable in normal position of neck (goitre), equal to the size of terminal phalanx of patient’s thumb or visible in addition to being palpable. There may be symptoms of hypothyroidism - intolerance to cold, weight gain, somnolence, hoarseness of voice, menorrhagia and non-pitting oedema.

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With the wide availability of iodized salt, iodized oil is now recommended only for populations living in severely endemic areas where a quick and definite outcome is required within a short period or where there is no access to iodized salt.

Nutritional Education : The importance of iodized salt in prevention of IDD has to be emphasized repeatedly to the community. It must be reiterated that only iodized salt must be consumed by all. It must be consumed within 6 months of iodization, as the concentration of iodine diminishes with time. The community must be made aware of the fact that selling of non-iodized salt may attract legal action. Suitable health education methods must be resorted to, for effective dissemination of this information e.g. through lectures, road shows, audiovisual aids, schools and women groups, etc. The experiences of IDD patients and their parents may help in making the community more aware of this malady.

The other strategies namely iodine monitoring, manpower training and mass communication are discussed in the chapter on national nutritional programmes.

Vitamin A deficiencyVitamin A Deficiency (VAD) is the leading cause of preventable blindness in children. It also increases the risk of disease and death from severe infections. In pregnant women VAD causes night blindness and may increase the risk of maternal mortality.Magnitude of the Problem

World : Vitamin A deficiency is a public health problem in more than half of all countries, especially in Africa and South-East Asia. Young children and the pregnant women bear the major brunt of Vitamin A deficiency in poorer developing countries. Millions of children (esp preschool children) are at risk of xerophthalmia. About 36 countries in South East Asia, Western Pacific and Africa are severely affected. World - over 256 million people suffer from preclinical xerophthalmia and 2.7 million from xerophthalmia. As many as 7,00,000 patients develop corneal lesions and 3,50,000 become blind of xerophthalmia.

India : In India it is commonest amongst preschool children particularly in Andhra Pradesh, Tamilnadu, Karnataka, West Bengal and Bihar. The prevalence of Bitot Spots in the 1 to 5 years age group is about 1 to 5%. Very few studies report corneal lesions in India (0.05-0.1 per 100 preschool children in South India) (17)

Etiological Factors : Vitamin A deficiency is most common in the age group of 1 to 3 years, the preschool children. It results from a very complex web of causation involving ignorance, poverty, infections, lack of food, malnutrition, environmental and social factors. A compromised state of any one of these factors could tip the balance leading to vitamin A deficiency.

Weaning and Infections : It is often seen to be associated with weaning. The mothers may not be conversant with the correct weaning practices. During weaning the child is offered low vitamin A diet in the form of dilute milk, poor starchy food with hardly any fruits, vegetables butter or other animal products. It is primarily because of ignorance and economic reasons. The vitamin A content of this poor diet cannot keep pace with the high demand of the growing child. Repeated infections during this crucial period of weaning, teething and increased exposure to the outside world further puts pressure of extra vitamin A and other micronutrients on the system. Concomitant protein energy malnutrition makes the situation worse making the child immunologically even more vulnerable to infections. Consequently attacks of measles, acute respiratory infections and diarrhoea further compromise the child’s vitamin A status. This prepares a favourable ground for xerophthalmia to flourish.

Other Social Factors : These also play an important role in the causation of xerophthalmia. Cultural beliefs on breast feeding and weaning practices are vital. Discarding colostrums, early or late weaning, restriction of certain food items, excessive dilution of milk, vegetarianism, unscientific management of infections, belief in quacks and unsound indigenous ‘medicine’, all play an important role in the causation of this problem. While poverty and inability to manage nutritious food could be a genuine reason, ignorance about the disease and faulty food practices is also rampant and is largely preventable through nutritional education.

Poor Environment Sanitation Practices : Non availability of sanitary latrines, open air defecation, poor hygienic practices and lack of potable water invite infection and disease, which have a definite role to play in causation of the condition.

Clinical Features : The clinical features of vitamin A deficiency can be divided into two broad groups, namely those concerning the eyes (xerophthalmia) and the extra-ocular features.

Xerophthalmia : Xerophthalmia is the ocular manifestation of vitamin A deficiency in various clinical forms. Xerophthalmia

Table - 6 : Iodized Oil - Recommended Doses and Duration of Action (15)

Age groups

Duration of effect of iodine

Oral iodine (mg) Intramuscular (mg)

3 months 6 months 12 months > 1 year

Women of child bearing age 100-200 200-480 400-960 480

Pregnant women 50-100 100-300 300-480 480

0 - 1 year 20-40 50-100 100-300 240

1 - 5 years 40-100 100-300 300-480 480

6 - 15 years 100-200 200-480 400-960 480

Males 16 - 45 yrs 100-200 200-480 400-960 480

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assumes extreme importance because of its seriousness may lead to blindness and is preventable. Public health problem of xerophthalmia can be ascertained by prevalence of the levels of its various stages amongst preschool children in the community (Table - 7).

Table - 7: Xerophthalmia as a public health problem (18)

WHO

Classi-fication

Clinical condition of xerophthalmia

Prevalence among

preschool children

XN Night blindness >1%

X1A Conjunctival xerosis -

X1B Bitot’s spots >0.5%

X2 Corneal xerosis -

X3A Corneal ulceration/keratomalacia (involving <1/3 of cornea)

>0.01%

X3B Corneal ulceration/keratomalacia (involving >1/3 of cornea)

>0.01%

XS Corneal scar >0.05%

XF Xerophthalmic fundus -

Bio-chemical

Plasma retinol <0.35 μmol/l>5%

Night Blindness : Night blindness is classically associated with vitamin A deficiency. The age group most commonly affected is the pre-school children. Mother of the child typically complains that in the evening child strikes against a stone while playing and falls down frequently. He is unable to see the contents of his food plate and gropes for food. In a dimly lit classroom he can’t see what’s written on the black-board. Night blindness usually responds rapidly to vitamin A tablets/oil or injections.

Conjunctival Xerosis : Conjunctival xerosis is one of the earliest detectable signs of vitamin A deficiency. It manifests as thick, wrinkled (vertically folded) conjunctiva with a tendency to dryness. It is restricted to ‘exposed’ bulbar conjunctiva. The dryness looks like “Waxy Paint” as there is loss of transparency and no shine in the affected conjunctiva. It is un-wettable, classically referred to as a “Receding tide” of the tear drop. The un-wettability is because of the affected epithelium leading to reduced goblet cells/mucin secretion from the lachrymal glands. The ‘break-up time of tears’ is also reduced.

Bitot’s spots : Bitot’s spots are white triangular patches present on the conjunctiva. They resemble flakes of foam or plaster on the surface of the conjunctivae. They are formed due to Vitamin A deficiency leading to hyper-keratinizing metaplasia of the epithelium and accumulation of seborrhoeic excretions.

Corneal xerosis : If the preceding condition (conjunctival xerosis) is not treated early, corneal xerosis results. The cornea becomes pale, lustreless and looses its sheen. This may progress to a state of corneal ulceration and subsequently keratomalacia may ensue. There may be an eventual perforation through which the contents of the eye may extrude out and the patient looses his sight.

Extra - ocular manifestations : Some extra-ocular manifestations of vitamin A deficiency are also known. Follicular hyperkeratosis, growth retardation and anorexia are some of them. They respond to vitamin A supplementation.

Treatment of Xerophthalmia (17) : An established case of xerophthalmia responds well to treatment with vitamin A. The following regime can be followed :

2,00,000 IU (110mg) of Retinol palmitate (oil miscible ●vitamin A) is administered orally for 2 days. In cases of persistent vomiting/diarrhoea, water miscible vitamin A 1,00.000 IU is administered as IM Injection, followed by 2,00,000 IU, 1 to 4 weeks later.For infants less than 1 year old or less than 8 Kg weight, ●half the dose is used.

Prevention

Dietary modifications should be achieved through promotion of growth, production and consumption of vitamin A / beta-carotene rich foods. Rich sources of vitamin A like dark green leafy vegetables, deep yellow/ orange fruits, eggs, milk and meat must be included in diet.

Nutrition education : Educate the community on the importance of vitamin rich diet, its regular intake and the harmful effects of its deficiency. Importance of home gardening, consumption of fresh seasonal fruits and vegetables must be reiterated. Healthy food preservation techniques must also be emphasized. Public meetings, schools and mass media can be used to the fullest to disseminate these messages.

Fortification of ghee, hydrogenated vegetable oil and butter are being done as a government policy to augment the vitamin A status of the community. Technology for the fortification of sugar, mono sodium glutamate, bread and milk also exists.

Periodic massive dosage (17) : Vitamin A administration is now integrated with immunization program. The first dose of 100,000 IU is given at 9 months of age along with measles vaccines. Thereafter, the second and subsequent doses of 200,000 IU are given at 6 monthly intervals till 3 years of age. In all, a total dose of 9,00,000 IU is administered.

Long term action : Constant nutritional education emphasizing good diet (including fruits and vegetables), importance of immunization, environmental sanitation, breast feeding, early treatment of infections and good maternal and child health care would go a long way in the prevention of this condition.

Diseases Due to Excess and Deficiency of FluorineFluorine Excess (Fluorosis) : Ingestion of large amounts of fluorine occurs when the drinking water contains fluorine in excess of 3-5 ppm. Such a situation leads to endemic fluorosis. It is associated with dental and skeletal fluorosis. Fluorosis has been reported to be a health problem in rural districts of Andhra Pradesh (esp. Nellore, Nalgonda and Prakasham districts), Haryana, Karnataka, Kerala, Punjab, Rajasthan and Tamil Nadu.

Clinical Features : Fluorosis presents as dental or skeletal fluorosis, depending on the water content of fluorine, duration and level of exposure.

Dental fluorosis : For a patient to suffer from dental fluorosis, the fluorine intake through water has to be moderately in

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excess (> 1.5 ppm). Moreover, if this exposure takes place during calcification of teeth (first 7 years of life), the teeth are more likely to get affected by fluorosis. The mottling of teeth is common. The enamel loses its lustre and the texture becomes rough. There could be brown bands alternating with white chalky patches. Mottling may progress to small pits. Upper incisors are affected the most, even though all the teeth are vulnerable. Dental fluorosis as such, is not usually associated with skeletal fluorosis or impairment of health.

Skeletal Fluorosis and Fluoride Poisoning : When the concentration of fluorine exceeds 10 ppm, a crippling skeletal fluorosis may ensue. This may occur as a result of high fluoride content of water (endemic) or as a result of an industrial poisoning. As a result there may be heavy deposition of fluorides in the bone (sclerosis). The condition may begin as anorexia. There may be sclerosis of spine, pelvis and limbs. The ligaments of spine may be calcified, producing a ‘poker back’. The tendinous insertion of muscles may be ossified, producing the characteristic ‘rose thorn’ shadow in the X-Ray.

Genu valgum : Scientists working at the National Institute of Nutrition, Hyderabad found new form of fluorosis characterized by genu valgum and osteoporosis of the lower limbs in some districts of Andhra Pradesh and Tamilnadu. This was seen in people subsisting on sorghum (Jowar) as staple. It was concluded that jowar promoted a higher retention ingested fluoride in the body.

Prevention : In the endemic areas, fluoride is present in excess in water and if the community is dependent solely on that water, it is not easy to prevent the condition. It becomes even more difficult because there are no household methods to remove fluoride from water. However the following preventive measures are suggested :

1. Changing water source : Running surface water has lower fluoride content as compared to ground water. The community should shift from ground water (wells) to running water (rivers) if possible. Ideally the water should have a fluoride content of less than 0.5ppm.

2. Defluoridation : There is technology available that can be used to remove fluoride from water. An Indian technology called as the Nalgonda technique is an accepted defluoridation technique. It involves sequentially adding lime and alum to water. It is then followed up with flocculation, sedimentation and filtration of water.

3. Avoiding additional fluoride : Any additional fluoride intake must be avoided in endemic areas, as through fluoride tooth pastes for children up to 7 years of age.Fluorine Deficiency - Dental Caries

Epidemiology : Communities subsisting almost exclusively on meat, like the Eskimos (raw walrus meat and fish), Masai tribes in Kenya (milk, raw blood and milk) have little caries. Caries occurs among people who adopted the British dietary habits throughout the world. Medieval records suggest that dental health was much better then. Altered dietary habits took a severe toll on dental hygiene in the past century or two. The dietary changes thought to be important are : a) Decline in milk consumption.

b) General use of refined sugar that was earlier an aristocratic delicacy.

c) Introduction of roller milled fine flour.Further lifestyle changes like introduction and wide use of sweetened soft drinks, refined wheat flour, excessive use of sugar, sweets and chocolates, sweetened milk and tea, made the teeth more vulnerable to caries.

Host factors : The buffering action of saliva and its ability to reduce acidity helps in preventing caries. Lysozymes present in saliva also help in caries prevention. Decreased saliva secretion due to less chewing, leads to caries.

Agent factors : Streptococcus mutans is notorious to cause caries. It flourishes in the mouth and teeth on sugars and refined carbohydrates.

Time : The frequency of consumption of refined carbohydrates and sugars and the duration for which they stay in the mouth is directly related to the chances of causation of caries.

Substrate and diet : The substrate for the bacteria is defined by the diet one eats. Refined carbohydrates and sugars are fermented by the bacteria and produce caries. Sucrose, fructose, glucose, xylitol and other sweeteners all cause caries. Strongly acidic drinks (sweetened, aerated drinks) consumed frequently can predispose to caries. A sharp increase in caries is seen in the developing countries with the increasing consumption of sugars. Firm fruits like apples have scouring action that reduces the chances of caries. Cheese increases pH and also saliva flow, inhibiting bacteria. Chewing betel increases saliva flow and lime content of pan also increases the pH thus preventing caries.

Fluoride : The water content of fluoride at a rate of 0.5 to 1 ppm prevents caries. In areas where fluoride content of water is low the prevalence of caries is high. Addition of fluoride to water can prevent caries in these situations.

Prevention

Reduction of sugar intake : Since sugar intake has a bearing on dental caries it is advisable to reduce sugar consumption. The following measures could be useful : a) Reduce sugar in diet. Avoid adding sugar to milk, tea

and coffee. No added sugar to be made available. Reduce consumption of sweets, chocolates and cold drinks.

b) No sugar should be added to infant/baby foods/pediatric medicine, fruit juices, vitamin preparations

c) Sugar added to jams, jellies, cold drinks must be reduced to the minimum,

d) Sugar free snacks and drinks must be made availablePromotion of dental hygiene : It is important to appreciate and promote dental hygiene. Regular brushing and dental checkups are important in prevention of dental caries.

Fluoridation of water supplies : In areas where fluoride levels are less than 0.7 ppm, it is advisable to add fluoride to raise its level optimally. This single measure is known to reduce the caries incidence by half.

Professional dental care : Besides regular dental examination, dentists help in prevention and deterioration of caries through filling cavities, cleaning, removing calculus, removing overcrowding of teeth through orthodontic treatment etc.

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Application of topical fluoride solution and sealants is also effective. Good school dental hygiene services are also very useful.

SummaryFour important nutritional deficiency disorders are Protein Energy Malnutrition (PEM), Anaemia, Vitamin A Deficiency and Iodine Deficiency Disorders (IDD). Anaemia affects three fourths of all females and more than half of all males. PEM and vitamin A deficiency occur mostly among preschool children. Vitamin A deficiency is an easily preventable cause of blindness. Thyroid insufficiency due to iodine deficiency, results in many a serious condition including goitre, impaired metabolism, cretinism, mental retardation and deaths (still births).

PEM contributes to 60% of the total 10 million deaths of children under five years of age. The cause is diet poor in energy and proteins latest concept being of ‘Food gap’, wherein it is not only the deficiency of proteins but inappropriate food (low in energy density, protein and micronutrients - Vitamin A, Iron, Zinc) which is poor both quantitatively and qualitatively. PEM is classified into Kwashiorkor, Marasmic- kwashiorkor, Marasmus, Dwarfing and Underweight. Marasmus is characterised by Growth retardation, wasting of muscles and subcutaneous fat. Clinical features of Kwashiorkar include oedema, growth retardation, muscular wasting, retention of subcutaneous fat and psychomotor changes. Prevention of PEM includes Health promotion (Good ante-natal care, education on food, hygiene and family planning, good weaning practices). Specific protection measures are adequate Diet and Immunization. Growth monitoring, early diagnosis and treatment of infections and Hospitalization of the case are measures of Early Diagnosis & Treatment. Rehabilitation of a PEM case requires substantial changes in the knowledge, attitude and practice about the disease.

Anaemia is a global public health menace affecting over 30% of world population. The health implications range from General symptoms like : weakness, easy fatigability, lethargy, reduced work capacity, reduced endurance to pregnant and lactating women suffering increased risk of low birth baby, abortion, premature delivery, intra-uterine growth retardation, and in children suffering from low birth weight, impaired cognitive performance, motor development and scholastic achievement, inattention, fatigue and insecurity. Anaemia threshold is 11.0 for young children and pregnant women, 12.0 in Non pregnant women and 13.0 in men over 15 yrs.

Anaemia can be due to inadequate intake of iron, poor absorption and bioavailability of iron, excessive loss of iron and increased demand of iron. Measures for prevention and control of anaemia are Breastfeeding and appropriate weaning, Dietary modification (Use of green leafy vegetables, pulses, non vegetarian foods, ragi, jaggery and fruits like custard apple to be promoted), deworming & control of infection, iron supplementation, iron fortification and nutrition education.

Iodine deficiency is a major public health problem throughout the world, particularly for pregnant women and young children causing avoidable pregnancy losses and mental retardation/ cretinism. Iodine deficiency in soil is main cause in addition to certain chemicals (goitrogens) that are present in some of

the habitual foods, like vegetables of Brassica family (mustard, cabbage etc.). The ‘sub-Himalayan goitre belt’ is the world’s most intense goitre endemic region affecting nearly 120 million people. The total population at risk in India is about 200 million and 70 million are estimated to suffer from IDD. Clinical Features of IDD through the Life Cycle can be divided into Foetus and neonate (Abortions, stillbirths, congenital anomalies, high unexplained perinatal and infant mortality, low birth weight); Infancy & early childhood (mental deficiency, squint, short stature, hoarseness of voice, deaf-mutism and motor spasticity); Child & adolescent (Poor scholastic performance, retarded mental and physical development, Goitre) and in Adult (mental and physical underdevelopment, goitre, intolerance to cold, weight gain, menorrhagia). Urinary Iodine Excretion (UI), Total Goitre Prevalence (TGP), radiology, ultrasonography, TSH, T3 and T4 level estimation are useful to assess and monitor the cases. National IDD Control Programme has four main components : Use of Iodized salt or oil, Iodine monitoring, Manpower training and Mass communication.

Vitamin A deficiency (VAD) is the leading cause of preventable blindness in children. It also increases the risk of disease and death from severe infections. It is commonest amongst preschool children particularly in Andhra Pradesh, Tamilnadu, Karnataka, West Bengal and Bihar. The causes include weaning infections and poor environmental sanitation. The clinical features of vitamin A deficiency include those concerning the eyes (xerophthalmia, night blindness, conjunctival xerosis, Bitot’s spots, corneal xerosis, corneal ulceration and keratomalacia) and the extra-ocular features. Prevention measures are dietary modifications (dark green leafy vegetables, deep yellow/ orange fruits, eggs, milk and meat), nutrition education of community, fortification (of ghee, hydrogenated vegetable oil and butter) and periodic massive dosage.

Fluorosis is a condition resulting due to Ingestion of large amounts of fluorine when the drinking water contains fluorine in excess of 3-5 ppm. Dental and skeletal fluorosis are two forms known. Preventive measures are changing water source, defluoridation and avoiding additional fluoride for at least next seven years.

Fluoride deficiency leads to dental caries. The water content of fluoride at a rate of 0.5 to 1 ppm prevents caries. Other measures are reduction of sugar intake (reduce sugar in diet, avoid adding sugar to milk, tea and coffee, reduce consumption of sweets, chocolates and cold drinks, no sugar should be added to infant/baby foods/pediatric medicine, lowering sugar added to jams, jellies, cold drinks to the minimum); Promotion of dental hygiene (regular brushing and dental checkups); Fluoridation of water supplies (where fluoride levels are less than 0.7 ppm) and professional dental care.

Study ExercisesLong Questions : (1) Define PEM (Protein Energy Malnutrition). Explain in detail etiology, classification, management and prevention of PEM (2) Describe in detail epidemiology of Anaemia in India. Elaborate on community measures for prevention of Anaemia in Pregnant and lactating women (3) Explain the process of assessing level of Iodine in salt. Describe various control and prevention measures undertaken

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by National Iodine deficiency Disorder Control Programme (4) What are various grades of Xerophthalmia used to assess Vitamin A deficiency? Explain the preventive measures against Vitamin A deficiency in Pre-school children (5) Describe in detail the Epidemiology of Fluorosis.

Short Notes : (1) PEM (2) Kwashiorkar (3) Marasmus (4) Food Gap (5) Prevention of PEM (6) Classification of anaemia as public health problem (7) Prevention & Control of anaemia (8) sub-Himalayan goitre belt (9) Goitrogens (10) Urinary Iodine Excretion (11) Treatment of Xerophthalmia (12) Dental Fluorosis (13) Prevention of Dental Caries

MCQs(1) Jelliffe gave the ___________ term in year 1959 (a) PEM (b)

PCM (c) Food Gap (d) Marasmus.(2) The highest number (60.3%) of underweight children (under

3 years) is reported from (a) Bihar (b) Madhya Pradesh (c) Uttar Pradesh (d) Jharkhand

(3) In _______________ child is ‘skin and bones’ owing to loss of subcutaneous tissue (a) Kwashiorkar (b) Stunting (c) Nephrotic Syndrome (d) Marasmus

(4) Term ‘Kwashiorkor’ was introduced by __________into modern medicine (a) Cicely Williams (b) Jelliffe (c) Ghai (d) Barbar Mc Klintok

(5) Anaemia contributes to ________ % of all maternal deaths (a) 10% (b) 20 % (c) 5% (d) 30%

(6) It is generally believed that spinach is a ‘very good’ source of iron. But the fact is that it is a poor source as it contains only __________ mg iron per 100g (a) 5.5 (b) 6.0 (c) 1.1 (d) 10.0

(7) Apart from India, other South East Asian country/ies prone to iodine deficiency is/are _______________ (a) Myanmar (b) Thailand (c) Sri Lanka (d) All of these.

(8) It is estimated that the total population at risk in India is about ________ million and ________ million are estimated to suffer from IDD (a) 20 & 7 (b) 100 & 35 (c) 40 & 14 (d) 200 & 70.

(9) For infants less than 1year old or less than 8 Kg weight, the dose of Vit A used is _________ (a) 4,00,000 IU (110mg) of Retinol palmitate (oil miscible vitamin A) administered orally for 2 days (b) 2,00,000 IU (110mg) of Retinol palmitate (oil miscible vitamin A) administered orally for 2 days (c) 1,00,000 IU (110mg) of Retinol palmitate (oil miscible vitamin A) administered orally for 2 days (d) 2,00,000 IU (110mg) of Retinol palmitate (oil miscible vitamin A) administered orally for 1 day

(10) Hb Threshold (mg%) to label Anaemia in Non-pregnant women (≥15.00 yrs) is _____________ (a) 13.0 (b) 12.0 (c) 10.5 (d) 11.0

(11) For a patient to suffer from dental fluorosis, the fluorine intake through water has to be at least (a) > 1.5 ppm (b) 1.0 ppm (c) 0.5 ppm (d) 5.0 ppm.

(12) Poker Back, Rose Thorn appearance on Chest X-Ray and Genu Valgum are features of _____________ . (a) Hypervitaminosis D (b) Hypervitaminosis A (c) Skeletal fluorosis (d) Congenital Hypercalcemia.

Answers : (1) b; (2) b; (3) d; (4) a; (5) b; (6) c; (7) d; (8) d; (9) c; (10) b; (11)a; (12) c.

ReferencesReport of the Working Group on Integrating Nutrition with Health for the 1. XI Five Year Plan (2007-2012 Government Of India Ministry Of Women And Child Development November 2006.Diet and Nutritional Status of Rural Population. NNMB Technical Report 2. No.21, National Nutrition Monitoring Bureau National Institute of Nutrition, Indian Council of Medical Research,Hyderabad-500 007National Health Profile 2007; International Institute for Population Sciences 3. (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005-06, India : Key Findings. Mumbai : IIPS.K R G Nair, Malnourishment among Children in India : A Regional Analysis. 4. Economic and Political Weekly. September 15, 2007Gopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian 5. foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.FAO/WHO 1971. Expert Committee on Nutrition, 8th report. WHO Tech 6. Report Series no. 471.Passmore R, Eastwood MA. Human Nutrition and Dietetics. 8th ed. Churchill 7. Livingstone, ELBS London. 1986.Worldwide prevalence of anaemia 1993-2005 : WHO global database on 8. anaemia / Edited by Bruno de Benoist, 2008.WHO, Micronutrient deficiencies Iron deficiency anaemia.http.WHO%209. Book%20Resources/Minerals/anemia%201st.htm. accessed on 11 Aug 2008.Iron deficiency anaemia : assessment, prevention, and control. A guide for 10. programme managers. Geneva, World Health Organization, 2001 (WHO/NHD/01.3).WHO Iodine status worldwide : WHO Global Database on Iodine Deficiency, 11. 2004.Ghai OP, Gupta P, Paul VK. Ghai Essential Paediatrics, 6th ed. CBS Publishers, 12. New Delhi. 2006.Bleichrodt N, Born MP. A meta-analysis of research on iodine and its 13. relationship to cognitive development. In : Stanbury JB, ed. The damaged brain of iodine deficiency. New York, Cognizant Communication, 1994 : 195-200.WHO / UNICEF / ICCIDD. Assessment of iodine deficiency disorders and 14. monitoring their elimination. Geneva, 2001, WHO/NHD/01.1WHO. Standard Treatment Guidelines. WHO and AFMC, Pune. 200815. Micronutrient deficiencies : Vitamin A deficiency; http ; WHO%20Book% 16. 20Resources/Vitamins/vitA%201st.htm; dated 11 Aug 2008Vijayaraghavan K. Vitamin A Deficiency. In. Textbook of Human Nutrition. 17. 2ne edition. Ed. Bamji MS, Rao NP, Reddy V. Oxford & IBH Publishing Co PvtLtd. New Delhi 2003.World Health Organisation. Vitamin A -Technical Report Series No. 672. 18. Geneva, 1982.

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134Public Health Aspects of Food Hygiene & Sanitary Regulation of Eating Establishments

Rajul K Gupta

While food is the most important item to sustain life on this planet, next only to oxygen, it is a potent source of pathogens, toxins and disease. A food borne disease is one where the agent is toxic or infectious, and is transmitted to the body through food. Detailed discussions on the epidemiology and prevention/ control of specific food and water borne diseases have been made in the section on communicable diseases of this book and readers are advised to refer to the same. In this chapter, we would discuss the details of prevention and control of food borne infections.

General PrinciplesProcurement and StorageProcurement : Food should be procured from a reliable supplier. The hygiene standards maintained by the supplier should be noted, such as cold and chilled storage, separation of raw and cooked foods, handling of raw and cooked foods, cleanliness of premises and equipment. No more food should be purchased than the amount which can be stored in the available deep freeze cabinet or refrigerator (4°C).

Non-vegetarian foods : Raw and cooked meat and poultry, milk, cream, and fish should be bought in quantities sufficient for one day only. Meat and fish should not be refrigerated for more than three days.

Dry and canned foods : Dry foods and canned foods should be bought in reasonable quantities. Avoid overstocking; there is danger from vermin and deterioration where storage facilities are poor. These products should be stored in a dry, well ventilated storeroom.

Refrigerate perishable foods : Meat, poultry, dairy products, fish, and cooked rice must be refrigerated. Store raw and cooked meat and poultry separately to prevent cross-contamination. The temperature of the refrigerator should be 1-4°C.

Storing non-perishable food : Non-perishable food must be stored in a storeroom. It should be kept cool, well ventilated, and dry. Adequate precautions must be taken for rodents, flies and cockroaches. Surfaces of shelves, walls and floors should be easy to clean.

Deep freeze unit : For longer storage Deep freezer is used. A temperature of -18°C is desirable.

Vegetables : Vegetables should also be procured on a daily basis. They must be kept in a cool dry storage place away from direct sunlight. Most vegetables can be refrigerated.

Food Handlers’ Hygiene : Cooks should be provided with special clothing consisting of 4 aprons, 4 caps (or pugrees), 4 shirts, 2 shorts, 2 trousers to wear while on duty. A clean set of jharons (mops) should be available to the cooks every morning. Facilities for scrubbing hands with brush and washing with soap and running water should always be available.

Immaculate personal hygiene of the cooks is of prime importance in the prevention of food borne infections. Infective organisms from all sources can be passed to food by hands. All cooks should take a thorough bath before starting daily work, keep their hair and nails clipped short and invariably scrub and wash their hands with brush, soap and water after every visit to the latrine or urinal and before handling food or raw rations. As far as possible, touching food with bare hands must be avoided. There should be access to toilets, hand washing facilities and wash rooms for the kitchen staff. The cooks must be subjected to regular medical examinations for communicable diseases that have a potential to be transmitted through food (e.g. wounds, boils, diarrhoea). Those found positive must be immediately excluded from kitchen duties and treated. Since it is not possible to detect carriers from a medical examination, it is worthwhile doing a stool examination as well. They should also be vaccinated against the enteric group of fevers.

Kitchen hygiene and sanitation : Besides personal hygiene, it is vital to have an immaculate kitchen hygiene as well. The storing, cooking and all working surfaces must be cleaned after each session of cooking. Utensils, equipment and mops, etc should also be in a good shape. More details are discussed in another section of this chapter.

Cooking Practices : The following healthy cooking practices must be adhered to : 1. Food must be ‘fully’ cooked and not merely cooked

partially.2. Food must be cooked rapidly and consumed quickly.

Otherwise refrigerate at the earliest (store cooked food below 4°C).

3. Reheating of food must be avoided. If it is essential to reheat, the food must be heated to beyond 60°C for at least 5 minutes, ensuring that heat penetrates to the core of food. A mere warming of food is not good enough.

4. Insist on consuming fresh and hot food.5. Use of pressure cookers, microwave, frying and grilling are

safer cooking methods as compared to inadequate boiling, roasting or warming.

Serving of food1. Avoid prolonged exposure of susceptible foods to warm

environment. This will encourage rapid bacterial growth and deterioration of food. Keep cold food cold, below 5°C.

2. Avoid warm storage of cooked food. Keep hot food hot, above 63°C or else below 4°C.

3. Do not reheat cold food to store in a warm holding apparatus (hot cupboard, hot case, casserole). Place only hot food in such equipment, that too for a short while before consumption.

4. Minimize handling of cooked foods with bare hands. Use suitable kitchen tools.

5. Use new clean paper/cloth for wrapping and covering food.

6. Keep animals and insects out of the kitchen.

Sanitation of Some Specific FoodsSome foods require special attention. These are mainly the non vegetarian foods and fresh salads.

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Poultry : Poultry may harbour food-poisoning organisms on the skin, offal and inside the carcass. Thus care should be taken where and how birds are dressed. Surfaces and utensils should be well cleaned after use, and hands should be washed well after handling the raw materials. Clothes should not be used to wipe carcasses either inside or outside, or to cover them. Frozen meat and poultry should be thawed properly before cooking

Sausages : Sausages, raw scraps, and minced meat may be contaminated with salmonellae. Great care should be taken when preparing sausages for cooking. If they are pricked the fork should be washed immediately with hot water. Sausages should be well cooked.

Meat : Dishes should be prepared fresh from raw meat. If there is likely to be any delay in using cooked meat, steaming under pressure is the best way to ensure the destruction heat-resistant organisms; it is a safe method of cooking. If left-overs are used after warming, they must be cooked thoroughly to boiling point to destroy contaminants and toxins which may have been formed. Spores on the outer surfaces of meat are more likely to survive if not well cooked. So it must be cooked thoroughly and eaten freshly cooked. It must not be allowed to cool slowly and stored at atmospheric temperature, as that promotes rapid multiplication of bacteria.

Salads and fruits : Salad vegetables including spinach, cabbage and lettuce could have been grown in sewage farming. Salads and cut fruits (which cannot be peeled), should be scrubbed and washed well, preferably with water containing hypochlorite.

Cooked rice : Cooked rice should not be stored without refrigeration.

Milk/eggs : Milk should be consumed after pasteurization or boiling. The most hygienic way to consume eggs is to boil them and eat.

Health education : There should be a continuous endeavor to educate the kitchen staff and public at large regarding food hygiene and its practice.

Milk HygieneThere is a potential of disease causation through milk when it is not handled hygienically and therefore it is important to care for milk hygiene. The milk hygiene begins at its source of production namely the dairy farm. Milk can become a good nidus for many organisms (2). Some common diseases conveyed through milk are summarized in Table - 1.

Sanitation of Dairy Farms : Dairy farms should ensure a pure, wholesome and protected milk supply. A dairy consists of the farm, the milk depot and the pasteurization and bottling/ packing plant, staff changing rooms, and a manure disposal yard. The dairy proper has milk receiving, pooling, cooling and blending room. A pasteurization plant should also be integrated. All these are housed in permanent, solid, fly and dust

proof structures.

To prevent outbreaks of milk borne diseases hygiene of cattle, personnel, equipment, process (of milching and pasteurization), as well as sanitary packing and delivery should be ensured. A periodical medical examination of personnel, inspection of premises and equipments, veterinary inspection of cattle, scrutiny of the process in the dairy, inspection of functional efficiency of the farm, depot and plant, and laboratory tests for purity and quality of pasteurization are required to be carried out. These measures should ensure the following :

Care of Cattle : The quality and the quantity of milk not only depends upon the particular breed but also on the care that is devoted to the cattle. The milk yield also depends on comfort, feeding, watering, and cleanliness; hence a clean, airy, cool and spacious cattle shed is of prime importance. Ample water supply for drinking, to wash the cattle sheds and bathe the cattle should be available. Fodder, cottonseed, oilcake, bran and meal consisting of a coarsely crushed mixture of grains must be given to each animal. Stores should be rat proof. Sick animals must be immediately isolated and contacts segregated. Cattle should be inspected by a veterinary surgeon at least once a month. Preventive inoculation against common diseases must be ensured.

Cow Sheds : The cow shed should be well drained and higher than the surrounding ground. The floor area per cattle head should be minimum 6 m2. The walls should be of reinforced concrete and whitewashed inside. Good cross ventilation is essential. The shed should be well lit. The whole flooring should be of impervious concrete. The sheds should be washed every day and cleaned twice a day. They should be sprayed with insecticide once a week.

Disposal of Cattle Dung and Sullage : All channels carrying sullage and liquid cattle dung should always be made of concrete. Semisolid cattle dung, a potent source of fly breeding, should be removed daily to a cow dung depot made of concrete and situated at least 200 m away from the cattle sheds. Anti-fly measures must be ensured.

Health of Workers : Medical inspection of the employees should be carried out very regularly and frequently, strict attention being paid to personal cleanliness. A regular immunization

Table - 1 : Diseases conveyed through milk

Disease Organism Reservoir/Source

Tuberculosis M tuberculosis (bovine) Cattle

Brucellosis B abortus / melitensis Cattle, Goat

Q Fever Coxiella burnetti Cattle

Septic Sore throat Streptococcus pyogenes Cattle, milk handlers

Food Poisoning Staphylococcus aureus Cattle, milk handlers

Diarrhoea and dysenteries Shigella, E histolytica Milk handlers

Cholera Vibrio cholerae Water, milk

Enteric fever Salmonella species Milk

Viral hepatitis, polio Hepatitis A, Polio viruses Milk

Diphtheria Corynebacterium diphtheriae Milk

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against enteric group of fevers must be ensured. All cases of illnesses, especially diarrhoea, dysentery, enteric fever, infected fingers or boils, running nose or ears, sore throat, or cough must be attended to. Exclusion of carriers of communicable diseases should also be rigidly enforced.

All indoor workers should scrub their hands thoroughly with soap, hot water and a nail brush and change into their working clothes including cotton masks. All workers should have adequate sanitary and bathing facilities. They should wash their hands with soap and water before entering the processing premises or milking.Pasteurization

Boiling kills the microorganisms but is likely to adversely affect the quality, taste and flavour of milk, as milk constituents are heat-labile. Pasteurization involves rapidly heating milk (to less than the boiling point), maintaining it uniformly over a definite period and rapidly cooling it. This destroys most of the pathogenic microorganisms, reduces the total quantity of all the microorganisms without affecting its inherent qualities (taste and flavour). It may not sterilize milk but makes it non-infective, retains its nutritive and aesthetic qualities and improves its keeping quality. The important pathogens that are destroyed by pasteurization of milk are M tuberculosis, B abortus, Streptococci and Staphylococci and the non-lactose fermenting pathogenic organisms of the Salmonella-Shigella group. The subsequent rapid cooling of the heated milk inhibits the multiplication of any viable residual microorganisms or of the ones subsequently gaining access to the liquid. The low temperature must be maintained till the milk is consumed.

The nutritive value of pasteurized milk remains reasonably satisfactory. Its fat, protein, calcium, phosphorus, and vitamins A and D contents are not affected. There is a 10% loss of vitamins B and 20% loss of vitamin C. Pasteurization improves the keeping quality of milk, reduces the number of bacteria, and destroys tuberculosis bacilli and other pathogenic organisms except spores and thermoduric bacteria. However, milk with a high bacterial count in a raw state will not pasteurize so efficiently as clean milk. Pasteurized milk can be preserved for 8 to 12 hours at 18°C.

Methods of Pasteurization : The methods of pasteurizing milk are as follows :

(a) Holder (Vat) method : This method consists of heating the milk to the temperatures between 63ºC and 65.5º C and holding it in large tanks at that temperature for 30 min before cooling it rapidly to 5°C. Milk gets heated efficiently and pathogenic bacteria are killed with certainty. From these holding tanks the milk runs directly to the cooler and then to the packing / bottling machine through a closed system.

(b) Continuous Flow Method : This method is the modification of the Holder method. The milk is first heated to 63ºC or more and then led through a series of heated metal coils so that the milk remains at that temperature in the apparatus for 30 minutes.

(c) High Temperature Short Time (HTST) Method : In this method milk is heated to 72°C for 15 seconds and then rapidly cooled to 4ºC.

(d) Ultra high temperature (UHT) Method : Milk is rapidly heated usually in two stages, the second stage being under pressure, between 125º to 150º C for a few seconds only. It is then rapidly cooled and packed / bottled as quickly as possible.

(e) Pasteurization in Bottles : The filled bottles can also be pasteurized. They are well sealed and heated by a shower of hot water or steam. The simplest method is to place the milk bottles in water-bath brought to 63ºC held there for 30 min and then chilled. The theoretical risk of contamination after pasteurization is entirely eliminated.

Supervision of Pasteurization Process : The pasteurization process needs constant supervision and the following are the most important factors to ensure efficient pasteurization : (a) Raw milk must be clean and free from extraneous matter.(b) A pasteurization chart should show the range of and the

period for which the temperature, as specified for the method, was maintained.

(c) Milk must be protected from contamination during cooling and bottling / packing; unprotected open coolers are undesirable.

(d) Excessive foaming of milk must be avoided as the temperature of the foam is too low to kill pathogens and may even encourage the growth of thermophilic organisms.

(e) The apparatus must be efficiently cleaned and sterilized after each day’s work.

(f) Besides ensuring efficient supervision, the process of pasteurization should be checked from time to time by the colorimetric phosphatase test as described earlier.

(g) If there is any doubt, about the effectiveness of pasteurization, the issue of such milk must be reconsidered. It is much safer for the consumer to assume that the milk he receives is untreated and is therefore boiled rather than to enjoy a false security.

Inspection of Milk : Inspection of milk involves physical and laboratory tests. Objectives of inspecting fresh milk are to detect visible dirt, deterioration, adulteration, nutritive quality, keeping quality, and to ascertain efficiency of pasteurization. The physical tests involve the inspection and taste of milk. The interpretation is given in Table - 2.Laboratory Tests

Specific Gravity : The specific gravity of milk should be 1.029 to 1.033 but milk diluted with water can be readily restored to its normal specific gravity by adding sugar or cornflour.

Chemical Tests : A further chemical analysis is necessary to detect adulteration.

(i) Gerber’s Test : Gerber’s Test is carried out for estimation of fat.

(ii) Total Solids : These are estimated by the evaporation of whole milk in a water bath and then weighing the dried residue Solids Not Fat (SNF) are estimated by deducting the fat value from the total solids.

(iii) Methylene Blue Test : It is carried out for testing the keeping quality and bacterial contamination in the milk. The basis of the test is that the dye is reduced and decolourised

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by the bacterial enzymes. The rate of reduction is an index of the extent of bacterial contamination. One ml of methylene blue solution of 1 : 300,000 strength is added to 10 ml of milk sample in a test tube and then incubated at 37 ºC in a water bath or incubator. The mixture should not decolourise within 5½ hours. If kept at room temperature above 37 ºC it should not decolourise within 4½ hours.

(iv) Phosphatase Test : This test is meant for ascertaining the efficiency of pasteurization and depends on the fact that the enzyme phosphatase is destroyed by the pasteurization temperatures; but not completely destroyed at a lower temperature, or in a shorter period than that required for pasteurization. Milk containing as little as 0.25 percent of raw milk in the properly pasteurized milk still contains detectable quantities of enzyme. The test is performed by addition of disodium phenyl-phosphate to pasteurized milk. The enzyme phosphatase, if present, splits up the phenol by means of a phenol test reagent which gives different shades of blue colour depending upon the amount of phosphatase enzyme present. The colour is matched against the standard colours in a Lovibond colorimeter. Pasteurized milk must not contain more than 2.3 Lovibond units.

(v) Bacteriological Tests : These are rarely carried out as a routine but when indicated, are used for detection of M tuberculosis, B abortus or some other bacteria. Under such circumstances 100 ml of milk is centrifuged at 3000 rpm for half an hour. Deposits of centrifuged milk also can be cultured for other organisms in appropriate media such as the Wilson Blair medium for the enteric group of organisms and the tellurite medium for C diphtheriae.

Inspection of Dairies and Milk Depots : The dairy should be inspected in a definite sequence and with a view to scrutinize all details in the process of production of milk / milk products, their wholesomeness, quality and safety for consumers. All the concerns described above should be covered. Sampling of milk may be carried out periodically at the dairy farm, milk depot and also at various points on the consumer line. The tests for nutritional ingredients, adulteration, pasteurization, bacterial contamination and keeping may be specifically requested as indicated.

Meat hygieneMeat has got high nutritive value but it deteriorates fast. That is why it is notorious for severe bacterial infections and food poisonings. Meat hygiene is therefore extremely important at all levels of food processing.

Inspection of MeatFresh Meat : The common signs of deterioration can be elicited by the following methods (3).

(a) Smell : The outside of the carcass should be smelt. A foul smell is a reliable indication of decomposition.

(b) Appearance and Firmness : Fresh meat is firm and elastic. Decomposed meat loses its firm elastic consistency and tends to become soft and slimy.

(c) Colour : It should be uniform. On decomposition the fat becomes pale and the muscle appears dark brown to black. Discoloured patches may emerge with time.

(d) Skewer Thrust Test : A skewer must be thrust into the substance of the meat and should be smelt. Meat with an unpleasant smell is unfit for consumption.

Fresh Fish : The common signs of deterioration are as follows:

(a) Smell : It is probably the most important test of soundness. Fish with an unpleasant smell should be rejected, even if all other tests are in its favour.

(b) Appearance : When freshly caught the gills are bright pink, but after death they rapidly become darker and in a matter of an hour or so assume a liver colour. The longer the fish is kept, the darker are the gills.

(c) Firmness : The flesh should be firm to touch, not rapidly separated from the bones, and should not tear easily. If flesh pits readily under pressure, decomposition must be suspected.

(d) Colour : It should be uniform. There should be no evidence of discoloured patches on the skin. These are usually seen first along the line of the backbone.

(e) Eyes : These should be prominent and not sunken, collapsed or dull.

Table - 2 : Interpreting Physical Tests of Milk Inspection

Visual Inspection Likely Cause Interpretation

Ropy milk or slimy milk

Disease of the udder or contamination with Lactis vascosus. Not acceptable

Blue milk Infection of animal due to tuberculosis or Ps cyanogena. Not acceptable

Red milk Crushed udder Not acceptable

Highly coloured Presence of colostrum. Acceptable

Dirty milk Manurial dust from the flanks and tail of the cow, or dirt in the container

Not acceptable

Taste Likely Cause Interpretation

Altered taste Feeding of the cow (e.g. with turnips). Acceptable

Medicinal taste Cow is being administered some drugs Not acceptable

Souring of milk Likely bacterial fermentation Not harmful, but not acceptable either

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(f) Floatation Test : If not eviscerated, a sound dead fish sinks in water while a decomposed one floats, belly up.Tinned Meat and Fish

During canning the interior of the tin and its contents are subjected to heat, though an absolute sterility is not achieved, but the growth of remaining live organisms and spores is so inhibited that hermetically sealed cans should normally remain sound for several years. Under tropical conditions, the rate of deterioration is somewhat accelerated and spoilage may result even in an intact tin. The date of packing and the recommended last date for usage, must therefore always be kept in mind. The acidity of preservative sauce may cause erosion of the tin and eventually results in pin point leaks. This may lead to bacterial infection.

Tins / Cans to be Viewed with Suspicion

Damaged, dented or rusted tins ●Leaking tins ●Excessively convex tins ●‘Blown’ tin (owing to the formation of gas from ●decomposition)A bulging tin under pressure (‘Springer’) ●Tainted, foul smelling or bad taste of contents ●If in doubt, subject to laboratory analysis ●

Poultry : Although it is the custom in temperate climates to allow poultry and game to hang for some days in order to improve flavour and tenderness, this is usually not practicable in India. Fresh poultry have bright prominent eyes, the feet are limp and pliable, the flesh moderately firm and the skin pale. Staleness is shown by stiff and dry feet, dull and collapsed eyes, soft and flabby flesh and probably a greenish discolouration around the crop.

Slaughter House SanitationFilthy slaughter houses are always a menace to the public health due to large collection of offal undergoing putrefaction and the continuous flow of blood, urine and faecal matter in the surrounding areas. A poorly managed slaughter house emanates rotten smell and it becomes a source of disease and nuisance to the public. Fly breeding and contamination of meat are the two major health hazards. Thus, for proper sanitary control, all slaughtering should be carried out in well maintained, licensed public slaughter houses (abattoirs) wherein hygiene rules must be followed strictly. A good slaughter house should conform to these basic standards (3) :

Design : The slaughter house should be well ventilated and totally fly proof. It should have sufficient running water supply. Adequate provision should be there to deal with blood, offal and waste animal products. It should be fitted with scaffolding having chrome plated hooks for dressing of animals.

Building : The slaughter house should be built with brick and concrete and well protected against rodents, cats and dogs. A concrete boundary wall is desirable. Adequate toilet/wash and hand-washing facilities (with soap and water) must be available.

Floor and walls : Special notice should be taken of the floor and general cleanliness of the place where the carcasses are dressed. Floor should be made of impervious concrete. The interior walls should also be of smooth concrete, which should be lime washed frequently.

Drains : Concrete channels should drain all liquid waste from the lairs and the slaughter room to a place of disposal outside, through covered drains. All the drains must be cleaned frequently. The manholes must also be frequently checked. Drains must be in a good state of repairs as damaged/broken drains are unhygienic.

Waste disposal : The liquid waste should be run into a water carriage sewer. All solid refuse should be burnt in the incinerator.

Employees : The employees must preferably be permanent. They must wear clean clothing and be free from communicable diseases. They must undergo initial and periodical examination. They must also take routine immunization.

Inspection of Slaughter House : A regular inspection of slaughterhouses is essential to ensure that it does not become a focus for the spread of infections. The abattoir must be inspected regularly and thoroughly. The most important points to note are : (a) The structural soundness of the building. The construction

of the floor which should be made of cement concrete.(b) The fly proofing, rat proofing and dog proofing of the

premises.(c) The method of disposal of offal, blood, animal excreta and

discarded animal tissues.(d) The sanitation of the lair.(e) The spaciousness of the separate slaughtering, skinning

and hanging rooms and their ventilation.(f) Availability of water for maintaining the sanitation.(g) The maintenance of equipment of slaughtering, skinning

and handling and finally the personal hygiene of the workers.

Sanitary Inspections & Suggested Standards for Food Catering & Eating EstablishmentsA high standard of tidiness and cleanliness of all premises of the catering and eating establishments should be ensured. The following important aspects must be monitored :

(a) Kitchen premises - General Principles : The entire kitchen premises should be spacious, lighted, fly proof, rat proof, airy and spotlessly clean at all times. The kitchen complex should have a separate cooking room (actual kitchen), a storeroom for fresh provisions, a preparation room, a scullery and a room for the cooks’ clothing. The design of a kitchen must be planned with the principles of hygiene in mind with regard to the sources of food-poisoning bacteria, importance of hot and cold storage and prevention of cross-contamination. So far as possible there should be separate work areas for raw and cooked food.

Floors : Floors must have non-slip surfaces, should be impervious to moisture and easy to clean. There should be a provision to raised or move the equipment to allow floor to be cleaned underneath.

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Walls : Walls should also be impervious walls that reduces condensation and is easy to clean. The wall and floor junctions should be covered for easy cleaning, and equipment should be fixed away from the wall to allow for cleaning.

Ceiling : Ceiling should be smooth, should resist condensation, and easy to clean. Provision for exhaust/chimney-vents must be made.

Lighting : Lighting must be good, both natural and artificial, particularly over the work and preparation areas, sinks and cooking equipment. Shadows must be avoided.

Ventilation : Natural and mechanical ventilation is necessary to prevent a rise in temperature, smoke and humidity.

Conveniences : Toilets should not open directly into food-preparation rooms. Foot-operated flushes are desirable. Wash basins should be available in or adjacent to the toilet.

(b) Kitchen proper : The kitchen should be sufficiently large. A properly constructed cooking range is recommended. This will not only economize the consumption of fuel but also keep the kitchen clear of smoke. The kitchen should be fly proof and well ventilated. It should be meticulously clean and tidy. The floor should be well cemented and free from cracks and crevices. The cooking range should be flanked with platforms for cooks to sit and for prepared food to be kept, awaiting removal to a food serving hatch, racks or hot-plates. Chapati baskets must be lined with clean cloth which is washed daily. All food should be kept covered.

Kitchen equipment : Ease of cleaning is an important factor in selecting all surfaces, equipment, and utensils. The following facts must be kept in mind : (1) Keep surfaces, equipment and utensils clean and in good

repair; they should not be old or worn.(2) Slicing machines, mincing machines, and can openers

require frequent and thorough cleaning; they must be easy to dismantle and reassemble. In-plant cleaning may be necessary for fixed parts of equipment.

(3) Use separate boards for raw meat, cooked meat, and vegetables.

Choose appropriate materials for ease of cleaning; for example, synthetic and/or natural rubber hardened with plastic fillers, high molecular weight, medium-density polyethylene, or phenolic fibre laminates. For cleaning, use hot water and a detergent combined with or followed by a disinfecting agent such as hypochlorite; avoiding cloths and using disposable paper instead.

(c) Preparation Room : Preparation room is meant for the preliminaries of cooking such as peeling, cutting and washing of food. Provision of fly proofing and good ventilation is necessary. The preparation of vegetables should always be done on a zinc-topped table or granite slabs fitted with a chopping board on it rather than on the floor. The peeling and refuse should be deposited directly in a covered refuse bin. A meat chopping block preferably of a special hardened plastic (high density polypropylene) must be provisioned that is thoroughly washed and cleaned after use. It must be disinfected with a suitable agent (e.g. hypochlorite) and covered with a layer of powered salt and dried in the sun.

Preparation room should be supplied with hot and cold water for which foot operation is preferable. A soap dispenser, kept in a hygienic condition is also a must. A nail brush with plastic or nylon back and bristle should be available. Hand drying should be done using individual methods such as paper towels. Common towels may cause cross infection.

(d) Store Room : A separate fly proof and airy store-room for raw fresh food stuffs should be provided. Raw foodstuffs should be kept in baskets/ crates ensuring free circulation of air and stacked on shelves. A cool room or refrigerator must be available where fresh fruits, vegetables, milk and curd can be stored. Meat, fish and poultry should be kept refrigerated or frozen. Grains, pulses, flour and other dry stuff should be kept in racks, away from the walls, either in neatly tied bags or in boxes in a separate well ventilated store-room. Equipment and utensils should be stored separately. A room for the cooks clothing and other necessaries should be provided separately.

(e) Scullery : The scullery should be dry, clean and tidy. Sinks should be adequate, and draining boards should be sufficient and clean All utensils after use should be thoroughly cleaned, washed, dried and kept in clean places. Tables should be scrubbed with washing soda and water twice a day using a hard brush.

(f) Dining Room : The dining room should be clean, fly proof, well lit and ventilated. While serving food, it should not be exposed to flies or dust. It should be presented in a manner that will enhance the acceptability or appeal, and reduce wastage. An effort should be made to supply hot food. A hot plate should be incorporated in the serving hatch or platform.

(g) Washing Arrangements : Efficient washing-up arrangements are necessary to clean and remove bacteria from all dining room and kitchen equipment. The essential provisions are : (1) Good layout of washing-up area.(2) Correct temperature of wash and rinse water.(3) A good detergent suited to the type of water.(4) Orderly methods of work in rinsing, stacking, racking, and

storage.Methods of Washing the Crockery, Cutlery and Utensils

One Sink Method ● : This is commonly used but is an inefficient method since crockery and cutlery may still be contaminated with bacteria.Two Sink Method ● : It is suitable for domestic as well as for large scale use. The dishes are rinsed, scraped, and wiped off, with paper. Food particles are removed. Utensils are then washed in hot water, (46-50°C) with measured detergent. They are rinsed in racks in hot water at 77-82°C. Both wash and rinse waters should be changed as soon as they become soiled or cold. They must be dried before storage.Dish washing machine ● could also be used.Mops and cloths ● : They harbour bacteria and can contaminate hands, equipment and cutlery. They require daily washing and disinfection preferably by heat. Paper should be used in place of dish cloths and towels.

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(h) Waste disposal

Within the kitchen : Scraps of food attract bacterial growth and vermin. It is therefore important to dispose off the waste correctly. Waste must be collected in pedal-operated bins which can be emptied regularly and washed out or in paper or plastic bags on pedal-operated stands. Bags can be sealed and put into dustbins, incinerated, or collected by the local refuse collection service.

Outside the kitchen : Sufficient waste bins or paper or plastic sacks must be provided to prevent over spilling. Bins with well-fitting lids should be placed in the shade on a stand (10 to 12 inches) high above a concrete area with drainage which can be easily cleaned. Plastic bags with lids should be wall-mounted to give good ground clearance for hosing down. Bins should be kept as dry as possible.

(j) Vermin and fly control : Rats, mice, flies, cockroaches and ants are the most common pests. If premises does not provide food and shelter infestation can be prevented. For details on extermination the chapter on entomology may be referred to.

Control of Flies(1) Do not provide a breeding ground such as uncovered refuse

bins. Bins should be kept as dry as possible.(2) Destroy flies by insecticidal spraying of the refuse area in

summers to prevent breeding.(3) Prevent access to kitchen and food by fly-proof windows,

doors and ventilators. Food must be kept covered.(4) Electrical fly killers will kill flies without the hazards

associated with aerosol sprays.Cockroaches

These are active at night. They get attracted to warm places, such as heating pipes. The hiding places (cracks and crevices) which provide shelter must be sealed off. Close-fitting lids prevent access to food. The area should be treated with suitable insecticide.

Sprays and other insecticide formulations

These must be used with great care in the kitchen premises Pyrethrum spray is relatively safer to be used in this setting.

Hazard Analysis and Critical Control Points (HACCP)HACCP is an approach to food safety focusing on identifying and controlling critical points in the food production and distribution chain that may lead to food hazard. HACCP incorporates a set of food safety strategies specific to the tasks and settings of the food chain. These strategies apply to farmers working in the field to those responsible for food handling and production before it reaches the consumers table. Food handlers at all levels are trained to implement key strategies to eliminate or control food borne infection triggers at critical points in the ‘operation’.

Principles of HACCP : The standard approach to HACCP has been specified by the Codex Alimentarius, 1997, and follows the following seven basic principles : 1. Analyze hazards : In a setting of food hygiene the hazard

could be biological, (microbes); chemical (toxin); or physical

(ground glass or metal fragments). These potential hazards and measures to control them are identified.

2. Identify critical control points. These are points in a food’s production from its raw state through processing and transport to consumption at which the potential hazard can be controlled or eliminated. Examples are cooking, cooling, packaging, and metal detection.

3. Establish preventive measures with critical limits for each control point. For a cooked food, for example, this might include setting the minimum cooking temperature and time required to ensure the elimination of a harmful microbes.

4. Establish procedures to monitor the critical control points. Such procedures might include determining how and by whom cooking time and temperature should be monitored.

5. Establish corrective actions to be taken when monitoring shows that a critical limit has not been met--for example, reprocessing or disposing of food if the minimum cooking temperature is not met.

6. Establish procedures to verify that the system is working properly for example, testing time-and-temperature recording devices to verify that a cooking unit is working properly.

7. Establish effective record keeping : This would include records of hazards and their control methods, the monitoring of safety requirements and action taken to correct potential problems.

SummaryPrevention of food borne infections and food poisoning can be achieved through appropriate steps taken at the all levels of food processing i.e. production, supply, procurement, processing of raw food, transport, cooking, storage, distribution and finally serving and eating of food. Immaculate personal hygiene of cooks, design and hygiene of the kitchen premises, appropriate storage of food and healthy cooking practices are vital for prevention of food borne diseases.

Milk and meat are also potential sources of various food borne diseases. Adequate hygiene measures should be implemented through their entire course of procurement and processing. Sanitation of dairy and slaughter house is of paramount importance in achieving this aim. Pasteurization of milk is the process of rapidly heating, maintaining it uniformly over a definite period and rapidly cooling it thus destroying most of the pathogenic microorganisms. Various methods of pasteurizing milk are: Holder (Vat) method, Continuous Flow Method, High Temperature Short Time (HTST) Method, Ultra High Temperature (UHT) Method. Various methods and tests are used to monitor pasteurization.

Study QuestionsLong Question : Enumerate the hazards of an unsanitary kitchen. What measures would ensure adequate kitchen hygiene of a large eating establishment?

Short Notes : (1) Botulism (2) HACCP (3) Golden principles of food hygiene (4) Pasteurization (5) Hygiene inspection of meat

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MCQs1. Which is true for mushrooms : (a) It is a nutritious food

(b) Some mushrooms could cause food borne disease (c) Some mushrooms could cause food poisoning (d) All of the above

2. Which of the following is generally not a source of food borne diseases (a) Dust (b) Skin infection (c) Home preserved food (d) Fruits

3. Pasteurization destroys (a) All pathogenic organisms (b) Some pathogenic organism (c) Most pathogenic organisms (d) No pathogenic organisms

4. Which of these insecticides is relatively safe for kitchen use : (a) Abate (b) Sodium Hypochlorite (c) Baygon (d) Pyrethrum

5. Which of these is the ideal method of disposing off solid refuse from slaughter house : (a) Incineration (b) Land fill (c) Sell it off to a contractor and get some money (d) Chemical treatment

Answers : (1) d; (2) d; (3) c; (4) d; (5) a.

ReferencesDavidson S, Passmore R, Brock JF, Truswell AS. Human Nutrition and 1. Dietetics. 6th ed. Churchill Livingstone, ELBS London. 1975.Frank JF, Barnhart HM. Food and Dairy sanitation. In : Last RJ (Ed) : Maxcy 2. Rosenau Public Health and Preventive Medicine. Appleton-Century-Crofts, USA. 12 th Ed 1986; Chap 18 : 765 - 806.Public Health & Preventive Medicine for the Armed forces. 8th Ed 2000. 3. Department of Community Medicine, Armed Forces Medical College, Pune, IndiaFood Poisoning and Food Hygiene. Hobbs BC, Roberts D. 5th Ed. Edward 4. Arnold, London. 1989.

135 Nutritional Programmes in India

Rajul K Gupta

In the less fortunate parts of the world, immense food related problems are a painful reality. Every day 800 million people in the developing world, ie 18% of the total world population, have to sleep hungry. In South East Asia, one out of four persons go hungry. In Sub Saharan Africa the condition is still worse; one third of the population does not get enough food. World over, 175 m children (under five years of age) are underweight. As many as two billion women and children are anaemic, 250 million children suffer from xerophthalmia, two billion people are at risk of Iodine deficiency…; the magnitude of the problems related to nutritional inadequacies is colossal.

Interventions by IndiaOver the past five decades India has been able to achieve self sufficiency in food production, through various interventions. Green revolution brought about an exponential increase in agricultural production, laying the foundation of self sufficiency. The government of India launched and improved the Public Distribution System, thereby facilitating the easy accessibility of food grains to the common masses at an affordable price.

Research in the field of nutrition was strengthened with the augmentation of the ICMR governed National Institute of Nutrition (NIN) at Hyderabad and the CFTRI at Mysore. In this series of events, various direct interventions were introduced through National Nutritional Programmes in the late 1960s and early 1970s. In addition certain interventions were inherently built up within other (non nutritional) programmes to improve the nutritional status of community.

Current Nutritional Deficiency StatusThe nutritional state of the country still remains much below the desirable levels. Even though the agricultural production may be good, it does not automatically ensure enough nutrition of masses, owing to various reasons. These could be as diverse as poverty, lack of food security and ignorance.

The figures speak for themselves. More than one fourth (26.1%) population is below poverty line. As many as half (49%) of rural and more than one third (36%) of rural Indian children are underweight. A staggering 2.2 million are afflicted with cretinism and 6.6 million are mildly retarded. Nutritional blindness affects 7 million children in India, mainly because of vitamin A deficiency.

Many a challenges remain before us as far as nutritional adequacies are concerned. National programmes reflect the concern of the government of India towards the problem and is a way to bridge this inadequacy. Various nutritional programmes have been conceived over the past five decades with an aim of improving the nutritional state of our country. These have met with reasonable degree of success. A brief outline of some of the more important programmes is given here.

Direct Interventions : The Nutritional ProgrammesThe various nutritional programmes are being run by different ministries. These programmes are listed below :

Ministry of Social WelfareICDS programme ●Balwadi nutrition programme ●Special Nutrition programme ●

Ministry of Health and Family WelfareProphylaxis against nutritional anaemia ●

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Vitamin A prophylaxis programme ●Iodine Deficiency Disorders Control programme ●

Ministry of EducationMid Day Meal programme ●

Balwadi Nutrition Programme The Balwadi Nutrition Programme was initiated in 1970 by the Ministry of Social Welfare. It was meant for the children from rural areas, in the 3 to 6 years age group. It was run through Balwadis. Meals were provided to the children with an aim of catering for 300 Kcal and 10 to12 g protein per day for each child. The Balwadis had also endeavored to provide pre-primary education to the children.

Special Nutrition Programme Special Nutrition Programme was also started in 1970 by the Ministry of Social Welfare. This programme was operational in the urban slums and tribal areas in addition to the rural areas. It had a wider scope than the Balwadi Nutrition Programme as it not only benefited children from 1 to 6 years but also the pregnant women. It provided supplementary nutrition for 300 days in a year. Children obtained food, providing 300 Kcal and 10 to 12 g protein. Pregnant women were provided with food supplementing 500kcal and 25 g protein. This programme has slowly been merged with the ICDS in most of the states.

Applied Nutrition Programme The Applied Nutrition Programme was introduced as a pilot project in Orissa in 1963, which was extended later to other states. It had focused on production of more vegetables and fruits and ensuring their consumption by children, pregnant and lactating women. Nutritional education was also a thrust area. Kitchen gardening, poultry, bee-keeping etc. were also encouraged.

National Nutritional Anaemia Prophylaxis ProgrammeThe programme for Prophylaxis against nutritional anaemia was started in the year 1970, during the fourth 5-year plan (1969-74) by the Ministry of Health and Family Welfare to prevent nutritional anaemia in mothers and children. Distribution of the Iron-Folic Acid tablet (IFA tablets) to pregnant women and children under 12 years of age is an important component of this programme.

Doses and Formulations : Women (pregnant, lactating and family planning acceptors) are given one tablet of iron and folic acid containing 100mg elemental iron and 0.5mg folic acid. Children in the age group of 1 to 5 years are given one tablet iron containing 20 mg elemental iron (60 mg ferrous sulphate) and 0.1mg folic acid daily for a period of 100 days. Recently (2007) the government of India recommended that infants (6-12 months should also be included in the programme and a liquid formulation must be incorporated for children for easy dispensing for children between 6-60 months. Dispersible tablets must also be used, which are easy to use under the ‘programme conditions’.

There is another recent recommendation to include school children (6 to 10 years of age) and adolescents (11 to 18 years of age) also in the programme. Children will be provided 30

mg elemental iron and 250 microgram folic acid for 100 days. Adolescents will be provided the same dose as that for adults. Adolescent girls will be given priority.

The distribution of the tablets is carried out through the Primary Health Centres, MCH Centers in Urban areas and the ICDS.

Critique : It is generally agreed that the programme has failed to make any impact on the anaemia scene in the country. The incidence of anaemia has hardly changed over the past decade, as is clear from the comparison of figures from NHFS II and III. Some of the important causes of the poor outcome of this programme are summarized in Box - 1.

Box - 1 : Causes of Poor Outcome of National Nutritional Anaemia Prophylaxis Programme

Poor perception of the problem (of anaemia) by the population.

Inadequate outreach of target population.

Poor compliance.

Medicine supply & stocks inadequate and poor quality.

Knowledge of functionaries and beneficiaries poor.

No attention given to educational and training components of programme.

Evaluation system not implemented.

Achieving Control of Iron Deficiency : The following actions are required to achieve control of iron deficiency : 1. Better appreciation of the problem by the community and

care givers.2. Better organisation of primary health services to effectively

render iron supplementation.3. Strengthening of the supplementation programme.4. Nutrition education with respect to Do’s and Dont’s of iron

nurtures.5. Development of suitable fortificant and its effective

implementation.6. Active involvement of medical community especially the

nutritionists, haematologists, internists, paediatricians, obstetricians and community medicine specialists to combat iron deficiency.

7. Joint action by the Government, NGOs, medical and biomedical scientists, agriculturists and planners.

8. Using biotechnology for enhancing iron and ferritin contents of foods like soyabean and other seeds.

The experience from other countries teaches that long term measures for control of anaemia are more effective. The most promising intervention is fortification of food items with iron over long periods. These food items can be as varied as salt, sugar, milk, cereals, etc. India has already perfected the technology of double fortification of salt with iodine and iron. Nutrition education is also another long term measure that is likely to change the face of anaemia if followed well.

National Programme for Prophylaxis against Blindness in Children due to Vitamin A DeficiencyThe deficiency of Vitamin A continues to be a public health

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problem in India. Many surveys indicate the prevalence of Bitots spots to be higher than 0.5% and night blindness in the range of 0.7-2%. The solution is to supplement oral vitamin A to children. Vitamin A Prophylaxis Programme was started by the Ministry of Health and Family Welfare in 1970 with this aim. National Institute of Nutrition (NIN), Hyderabad rendered the necessary technical assistance.

The aim of the programme was to decrease prevalence of Vitamin A deficiency form the current 0.7% to less than 0.3%. The 10th five year plan had set a target to eliminate vitamin A deficiency as a public health problem and decrease prevalence of night blindness to below 1% and Bitots spots to less than 0.5% in children of 6 months to 6 years of age.

Dosage : Under this programme a total of 9 lakh IU of Retinol palmitate is administered orally in 5 doses. The first dose of 1 lac IU is given at 9 months, starting along with the measles vaccine followed by the second dose at 15 months of 2 lakh IU. This is followed by another 3 doses of 2 lakh IU at 6 monthly intervals, till the age of 3 years (ie 1 lakh IU at 9 months and 2,00,000 IU each at 15 to18,24,30 and 36 months of age).

Implementation : The vitamin A doses are being administered by Anganwadi workers under the supervision of ANM. The programme is being implemented through the RCH programme.

Critique : This programme has significantly contributed to our endeavour of elimination of Vitamin A deficiency in India. The morbidity has steadily declined. Integration of vitamin A administration with RCH and immunization programme has made it logistically much simpler and practical to implement. Some episodes of deaths of children following vitamin A intake has brought the programme to disrepute. There is however no scientific explanation of mortality even after administration of double the recommended dose of vitamin A. The media must refrain from sensationalizing these news stories without solid scientific evidence. The health community too, must counter it through health education campaigns.

Iodine Deficiency Disorders (IDD) Control ProgrammeNational Goitre Control Programme was launched in 1962. In1992 the programme was renamed as National Iodine Deficiency Disorders Control Programme. The components of the programme are : a) To conduct surveys to establish magnitude of the problemb) Provision of Iodized saltc) IDD monitoringd) Manpower traininge) Health Education (IEC) activitiesSurveys : Surveys have proved beyond doubt that it is not only the Sub Himalayan Goiter belt but almost all states of India are endemic for IDD. More than 200 million people are living at risk of IDD.

Provision of iodized salt : The orders on banning sale of non-iodized salt have not been consistent over the past few decades. The exact policy on ban has been fluctuating. Moreover it was at the convenience of the states to implement the order. As a result some states have been following a strict ban and others not. The Ministry of Health and Family Welfare again issued a notification banning the sale of non-iodized salt in November

2005 under the PFA Act, to be effective from mid 2006.

The quality control of iodized salt is also important. Testing kits for spot qualitative analysis of iodine in salt have been developed. The iodine content of salt at production and consumption levels should be 30 and 15 ppm respectively. Iodized salt has been introduced in the public distribution system of most of the states.

IDD Monitoring : Continuous monitoring of the IDD status is vital to observe the progression of the condition. This is carried out through various surveys. Iodine in salt and urinary iodine excretion are also monitored. IDD monitoring laboratories have been established at district levels in 17 states. A national reference laboratory has been set up at National Institute of Communicable Disease at New Delhi.

Manpower Training : Various institutions run courses for manpower training in various facets of IDD control. Workers are trained in goiter survey methodology and laboratory technology with respect to iodine level monitoring in urine and salt, etc.

Health Education and IEC Activities : Government provides fund to run IEC campaign to increase awareness on consumption of iodized salt intake. Endemic districts are under operation of IEC activities through 268 units of Directorate of Field Publicity. Doordarshan is also used for IEC campaigns. Global IDD day is celebrated on 21st Oct. The misconceptions regarding consumption of iodized salt are also managed through the IEC campaign.

Critique : It was conceived that universal iodization of salt will root out IDD. But that has not really happened, even after a decade of ‘universal iodization’. It is primarily because of the fact that we have not been able to achieve universal immunization, which was the main pillar of the programme. The priorities and policies of the state governments have been varying, and in the bargain the iodization status of salt suffers, compromising the programme. There is a ban on the sale of un-iodized salt but the same has to be ensured through various administrative mechanisms of respective states.

The allocation of funds is very small in comparison to other national programmes, since the priority attributed to it is lower. There have been ‘roadblocks’ in the transportation of salt through the railways. These administrative problems have to be sorted to enable a smooth programme. Cost of iodized salt too is a constraint for poor society in India. Only a strong and committed political and bureaucratic will could help the programme succeed.

Midday Meal ProgrammeIt was Madras Presidency in the year 1923 that started the concept of providing cooked meals to children studying in corporation schools of Madras city. It was expanded to a larger scale in 1961, thus India became one of the first countries to have started the Midday Meal Programme, then called as the School Lunch Programme. Other states also joined in and programmes run by Gujarat and Kerala are also widely acclaimed. In 2001, a landmark decision was given by the honourable Supreme Court of India, which made it mandatory for all government primary schools to provide cooked meals. The primary aim of the programme was to provide at least

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one nourishing meal to the school going children per day. The objectives were :

It served as an incentive for the children to attend school. ●To reduce dropouts from school. ●To improve the nutritional status of the child ●

There are certain additional advantages of the programme too. It also serves as an opportunity to impart basic health / nutritional education to children. Moreover some local women get employment to cook food for the mid day meal.

It must be remembered that the programme provides a supplement, and not a substitute to the food eaten at home. This meal provides one third the total daily energy requirement and half the need of proteins (300Kcal and 8-12 g of proteins). The central government (Ministry of Education) supplies the full quota of grains to the states. Food that could be cooked easily, available locally and at low cost is preferable. To avoid monotony it is desirable to change the menu frequently.

Critique : The mid day meal concept was a noble one as it primarily serves the underprivileged rural primary children. The sustainability of the programme however depends on the political will, community participation and prudent running of the programme. The programme has to be saved from ill-publicity which it sometimes attracts through news of food-poisonings associated with the programme. The standards can be improved through a sustained improvement of quality of service.

Integrated Child Development Services (ICDS)The Integrated child development program (ICDS) was initiated by the government of India on 2nd October 1975 by the Ministry of Social Welfare. It is the world’s largest early child development program. It was initially started in 33 blocks (1975) but now it encompasses 6500 blocks, employing more than 6 lakh Anganwadi Workers (AWW) and equal number of helpers. It is providing its outreach services to 33.2 million children and 6.2 million pregnant and lactating women. It is an inter-sectoral programme which seeks to directly reach out to children, below six years, especially from vulnerable and remote areas and provide early childhood education, health and nutrition along with the care of the women in the reproductive age group (women of 15-45 years, pregnant and lactating women). Currently, services under the scheme are being provided to about 562.18 lakh beneficiaries, comprising of about 467.18 lakh children (0-6 years) and about 95 lakh pregnant and lactating mothers through a network of about 7.48 lakh Anganwadi Centres.Objectives of ICDS : 1. Lay the foundation for proper psychological development

of the child2. Improve nutritional & health status of children 0-6 years3. Reduce incidence of mortality, morbidity, malnutrition and

school drop-outs4. Enhance the capability of the mother and family to look

after the health, nutritional and development needs of the child

5. Achieve effective coordination of policy and implementation among various departments to promote child development

This programme has a major nutritional component : Supplementary nutrition to children below 06 years of age, ●nursing and pregnant mothers from low income families.Nutrition and health education to all women in age group ●of 15 - 45 years.Referral of serious cases of malnutrition or illness to ●hospitals.

Services : The Scheme provides many services in an integrated manner through community-based workers and helpers. The services are provided at a centre called the ‘Anganwadi’. The Anganwadi, literally a courtyard play centre, is a childcare centre, located within the village. A package of following six services is provided under the ICDS Scheme : 1. Supplementary nutrition2. Non-formal pre-school education3. Immunization4 Health Check-up5. Referral services6. Nutrition and Health EducationThe three services namely immunization, health check-up and referral are delivered through public health infrastructure i.e. the Sub Centres, PHCs and CHCs under the MoHFW.

Target Groups & Service Provider

Services Target Group Services Provider

Supplementary Nutrition

Children below 6 years; pregnant and lactating mothers

Anganwadi Workers (AWW) & Anganwadi Helper (AWH)

Immunization*Children below 6 years; pregnant and lactating mothers

ANM/MO

Health Check-ups*

Children below 6 years; pregnant and lactating mothers

ANM/MO/AWW

ReferralChildren below 6 years; pregnant and lactating mothers

AWW/ANM/MO

Pre-School Education

Children 3-6 years AWW

Nutrition & Health Education

Women (15-45 years)

AWW/ANM/MO

* AWW assists ANM in identifying & mobilizing the target group to health-

centres

Supplementary Nutrition : This includes supplementary feeding and growth monitoring; and prophylaxis against vitamin A deficiency and control of nutritional anaemia. All families in the community are surveyed, to identify children below the age of six and pregnant and nursing mothers. They avail of supplementary feeding support for 300 days in a year. By providing supplementary feeding, the Anganwadi attempts to bridge the protein energy gap for the beneficiaries.

Growth Monitoring and nutrition surveillance are two important activities that are undertaken. Children below the age of three

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years are weighed once a month and children 3-6 years of age are weighed every quarter. Weight-for-age growth cards are maintained for all children below six years. This helps to detect growth faltering and helps in assessing nutritional status. Besides, severely malnourished children are given special supplementary feeding and referred to health sub-centres, PHCs as and when required.

Supplementary Nutrition Norms : Nutritional supplements are provided to the extent indicated in Table - 1.

Table - 1

BeneficiariesCalories

(cal)Protein

(g)

Children below 3 years 300 8-10

Children 3-6 years 300 8-10

Severely malnourished Children on medical advice after health check-up

600 16-20

Pregnant & Lactating (P&L) Mothers 500 20-25

Non Formal Pre-School Education : This component for the three-to six years old children in the Anganwadi is directed towards providing and ensuring a natural, joyful and stimulating environment, with emphasis on necessary inputs for optimal growth and development. The early learning component of the ICDS is a significant input for providing a sound foundation for cumulative lifelong learning and development. It also contributes to providing the child the necessary preparation for primary schooling and offering substitute care to younger siblings.

Immunization : Immunization services are delivered by the Ministry of Health and Family Welfare under its Reproductive Child Health (RCH) programme. The ICDS only tends to facilitate these services through a reiteration of the family to attend the immunization clinic at the relevant centre. In addition, the Iron and Vitamin “A” Supplementation to children and pregnant women is also facilitated.

Health Check-ups : This includes health care of children less than six years of age, antenatal care of expectant mothers and postnatal care of nursing mothers. These services are provided by the ANM/ Medical Officers from Sub-Centres and Primary Health Centres. The various health services include regular health check-ups, immunization, management of malnutrition, treatment of diarrhoea, de-worming and distribution of basic medicines etc.

Referral Services : During health check-ups and growth monitoring, sick or malnourished children, in need of prompt medical attention, are referred to the Primary Health Centre etc. The Anganwadi worker has also been oriented to detect disabilities in young children.

Nutrition and Health Education : Nutrition and Health Education is a also an important element of the work of the Anganwadi worker. This enables women in the age group of 15-45 years to look after their own health, nutrition and development needs as well as that of their children and families in a better way.

ICDS Staff : Anganwadi Worker, a lady selected from the local community, is a community based frontline voluntary worker of the ICDS Programme. She is also an agent of social change, mobilizing community support for better care of young children, girls and women. She is assisted by Anganwadi helpers. She reports to the supervisor. Child Development Project Officers (CDPOs) and District Programme Officers (DPOs) are the officers directing the programme within a block. Besides the Medical Officers, the Lady Health Visitors (LHVs) and Auxiliary Nurse Midwife and Female Health Workers from nearby Primary Health Centres (PHCs) and Sub-Centres work in an integrated manner with the ICDS functionaries to provide health, medical, immunization and referral services.Administration of the Scheme

Location : The administrative unit for the location of ICDS Project is the Community Development Blocks in rural areas, tribal blocks in tribal areas and ward(s) or slums in urban areas. For the purpose of working out the estimated number of beneficiaries, a rural/urban Project is assumed to have a population of 1 lakh and tribal project 35,000. One Anganwadi Centre normally caters to 1000 population in a rural/urban project and 700 population in a tribal project.

Sparsely populated hilly/desert areas : There is provision for setting up an Anganwadi in every village or hamlet having a population of 300 or more sparsely populated hilly/desert areas. Very small villages/ hamlets with a population of less than 300 are covered by the adjoining Anganwadi.

Finances : ICDS is a centrally-sponsored Scheme implemented through the State Governments/UT Administrations with 100% financial assistance for inputs other than supplementary nutrition which the States were to provide out of their own resources. From 2005-06, it has been decided to extend support to States up to 50% of the financial norms or 50% of expenditure incurred by them on supplementary nutrition, whichever is less.

Mini-AWCs : Mini-Anganwadis can be set up to cover the remote and low populated hamlets/ villages in tribal blocks having a population between150 to 300.

Anganwadi Workers : Anganwadi Workers (AWWs) and Helpers (AWHs) are “honorary workers” from the local community who come forward to render their services, on part-time basis, in the area of child care and development. Anganwadi Workers & Helpers are the grass roots functionaries to implement the ICDS Scheme. AWWs & Helpers, being honorary workers, are paid a monthly honoraria as decided by the Government from time to time. At present the AWW get about Rs 938 to1063 (depending on qualification and experience) and AWH gets Rs. 500 per month as honorarium.Critique : The ICDS programme has largely been a successful endeavour of the government of India. Given the very large scope of the beneficiaries (about 6 crores) and about 15 lakh AWW and AWH working in extremely diverse environs of states with varied ideologies, diverse terrains and constraints, there has to be criticism of the scheme in some quarters. The aim of the scheme was to reduce the incidence of mortality, morbidity, malnutrition and school dropouts, which has been achieved to a great extent. There is a criticism that the beneficiaries only

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visit the centre only during the meal timings. But provision of nutrition too has been an objective of the programme. Infant Mortality Rate (IMR) has declined from 110 in 1981 to 58 per thousand live birth in 2004. Similarly, under-5 mortality has declined from 161 in 1983 to 87 in 2003. Various surveys have revealed that there has been significant impact of the scheme. Many non-monetary benefits like insurance, incentives, preference in other jobs (teachers) have been given to the AWW and AWH. There is certainly a scope of enhancing the honorarium offered to these grass root workers.

SummaryAfter independence the government of India took many initiatives to ensure food security for the country. National nutritional programmes were a firm step in that direction. Ministry of Social Welfare runs the ICDS programme, Balwadi nutrition programme and special nutrition programme. Ministry of Health and Family Welfare runs the programmes for prophylaxis against nutritional anaemia, vitamin A prophylaxis programme and the iodine deficiency disorders control programme. The mid day meal programme is run by the Ministry of Education. The programmes have achieved improvement in the nutritional status of the children, pregnant and lactating women. More specifically the ICDS programme that has a strong nutritional component can be termed as a successful programme.

Study ExercisesLong Question : What are the objectives of the ICDS scheme? Discuss the benefits offered to various vulnerable groups under

the scheme.

Short Notes : (1) Mid day meal programme (2) Anganwadi worker (3) Iodized salt (4) Services under National Nutritional Anaemia Prophylaxis Programme (5) Supplementary Nutrition under ICDS

MCQs1. Mid day meal programme offers (a) Half of daily protein

and one third of calorie requirement (b) Half of daily protein and half of calorie requirement (c) One third daily protein and half of calorie requirement (d) One third of daily protein and one third of calorie requirement.

2. To a child under 3 years of age, ICDS provides : (a) 300 Kcal energy and 8-10 g protein (b) 300 Kcal energy and 16-20 g protein (c) 500 Kcal energy and 8-10 g protein (d) 500 Kcal energy and 16-20 g protein.

3. In rural areas, the administrative unit for the location of ICDS Project is (a) Gram Panchayat (b) Community Development Blocks (c) District head quarter (d) Primary Health Centre.

4. Which of the following is not run by the Ministry of Health and Family Welfare (a) Prophylaxis against nutritional anaemia (b) Vitamin A prophylaxis programme (c) Iodine Deficiency Disorders Control programme (d) ICDS Programme.

5. Which of these is not carried out at the Anganwadi centre (a) Supplementary nutrition (b) Non-formal pre-school education (c) Immunization (d) Nutrition and Health Education.

Answers : (1) a; (2) a; (3) a; (4) b; (5) c.

136 Nutritional Assessment and Surveillance of a Community

Rajul K Gupta

Assessment of Nutritional Status of Individuals and CommunitiesAims of Assessment of Nutritional StatusThe assessment of nutritional status is carried out with the following aims :

To map out distribution and geography of nutritional ●disordersTo identify high risk groups with respect to nutritional ●vulnerabilityTo assess various epidemiological factors for nutritional ●deficienciesMake recommendations to rectify shortcomings leading to ●nutritional deficienciesTo project for financial allocations and budget for food ●

materials at a large administrative level e.g. at the national level.

Various methods are available for the assessment of nutritional status. These are enumerated in Box - 1. These can be further sub-classified into direct and indirect methods of nutritional status assessment.

Box - 1 : ABCD… of Nutritional Status Assessment

Anthropometry

Biochemical & lab methods

Clinical assessment

Diet survey

Ecological studies

Functional assessment

G - - Vital statistics

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Direct Assessment of Nutritional Status The term ‘direct assessment’ refers to methods in which individuals or communities are investigated directly. The various methods that are available for the direct assessment are summarized in Box - 2.

Box - 2 : Direct Assessment of Nutritional Status

Clinical signs

Laboratory TestsBiochemical ●Haematological ●Parasitological ●

Biophysical Methods

Anthropometry

Assessment of Nutritional Status using Clinical Signs : Clinical examination is a widely practiced direct method to assess the nutritional status of individuals and communities. Assessment of clinical signs is based on the examination for changes believed to be related to inadequate or excessive nutritional intake, that can be observed in superficial tissues (skin, eyes, hair, mouth) or in organs close to the surface (thyroid, skull).

Caution with Clinical Examination : The cheapness and the relatively easy organization of clinical examination for nutritional assessment, might sometimes lead to the assumption that the method is simple, can be quickly mastered by a beginner, and yield results that are quick to interpret. But this is not the case. This method has got its own limitations, advantages and disadvantages. Expertise is required to select it as a valid method in a given situation, to conduct it and to interpret the results obtained.

Classification of Clinical Signs : Based on their importance with regard to suggesting a nutritional etiology the clinical signs can be classified into three groups (1) :

Group 1 - Potentially Nutritionally Significant (Signs ‘strongly suggestive’ of dietary deficiency or excess) : Some signs are strongly suggestive of a particular nutritional deficiency or excess e.g. Bitot’s spots (Vitamin A), Flag sign (PEM). A list of these is summarized in Table - 1.

Group 2 - Signs that are of probable nutritional significance : There are some signs that are of uncertain nutritional significance. These have to be appreciated and interpreted in correlation with the case. e.g. Xanthomata eye might indicate high blood cholesterol, Corneal scar (previous infection, trauma, malnutrition, avitaminosis A), Fissure tongue, recession of gums, transverse ridging of nails, etc.

Group 3 - Signs that have no nutritional significance : These signs are not nutritionally significant but required to be differentiated from other nutritionally relevant signs. e.g. pterygium (an insignificant sign) is to be differentiated from Bitot’s spots, geographic tongue, pyorrhea.Assessment of Nutritional Status using Biochemical and Laboratory Methods : We have seen previously that clinical signs are often non specific and develop rather late in the

disease process. Biochemical changes, on the other hand can be expected to take place prior to clinical manifestations. Hence tests that can be conducted on easily accessible body fluids (blood and urine), can help to detect disease at a sub-clinical level even in a community setting.

Table - 1 : Signs ‘strongly suggestive’ of dietary deficiency or excess

Deficiency SignSuggested nutrient

abnormality

Pale conjunctiva Iron

Bitot’s spots Vitamin A

Angular stomatitis Riboflavin

Spongy, bleeding gums Vitamin C

Bilateral edema (young children) PEM

Thyroid enlargement Iodine

Bilateral epiphyseal enlargement of wrists

Vitamin D

Sign of ExcessSuggested nutrient

abnormality

Mottled enamel Fluoride

Dental caries Sugar

Available laboratory tests : Three groups of laboratory tests are available, namely, haematological tests, parasitological tests and biochemical tests. The haematological tests include the commonly done hemoglobin estimation, parasitological tests would include stool examination for intestinal parasites and biochemical tests include many tests like the urine examination for albumin, sugar, etc. Advanced biochemical test are taken up for vitamin, minerals and enzyme estimations as well, that indicate nutritional status. Normal range of some of these tests is given in Table - 2.

Assessment of Nutritional Status through Anthropometry : Nutritional anthropometry is the measurement of human body at various ages and levels of nutritional status. It is based on the principle that appropriate measurements should reflect any morphological variation occurring due to a significant functional physiological change. For example, a low Fat Fold Thickness reflects a shift in energy balance. The advantages of anthropometry are that it is simple, quick to do, easy to reproduce and objective. In some cases it identifies even subclinical changes resulting from nutritional variations.

Common Methods of Anthropometry : The common anthropometric methods should be quick, simple and easy to reproduce. Minimum training should be required to conduct the measurement. The commonly used methods are : Height; Crown-heel length and standing height; body weight, mid upper arm circumference; and fat fold thickness. Head and chest circumference are measured for children under five years of age.

Body Weight : Body weight is the commonest and simplest anthropometric measure used for the evaluation of nutritional status. It is a reflection of total body mass comprising of all

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body constituents. It is measured for both children and adults. Definite body weight standards are available to us. Body weight is an indicator of ‘current’ nutritional status of the individual, as weight fluctuates with nutrition. Unlike height which is irreversible, it reflects the nutrition state of the present day. It is therefore a useful indicator for acute disorders. Small illnesses like childhood diarrhoea is also good enough to alter the weight, it is thus a sensitive indicator.

Measurement of Weight : The ideal weighing instrument is the lever actuated balance or a beam balance. The balance must have a least count of not more than 100g. Balances using a ‘spring’ are not advisable as the spring loses its tension due to prolonged use and an error is inevitable. Commonly used bathroom scales are based on the ‘spring’ principle, thus they must be best avoided for scientific work. The balance which is in use must be calibrated frequently for best results. The precautions to be taken while measuring weight are given in the Box - 3.

Height : Height is an indicator of the linear growth of the individual. It is widely accepted that height is determined genetically. Environmental factors, most importantly nutrition and morbidity determine the extent to which the genetic potential will be harnessed, to achieve the maximum possible height. Growth retardation resulting from any environmental factors like infections, malnutrition, etc. result in a retarded height, resulting in stunting (or short stature). Height is

affected by long standing nutritional deprivation. A short or retarded height is thus indicative of chronic food insufficiency over a longer duration, unlike a reduced weight which indicates a short term nutritional deprivation or infection.

Box - 3 : Precautions while measuring weight

Use the right balance. Avoid bathroom scales.

Weight must be taken in minimum clothing.

Remove shoes before weight is recorded.

The zero-error must be checked and corrected before using a machine.

It is advisable to record weight in the morning (in basal conditions)

These precautions must be applicable in a standardized manner for all subjects (within a study group)

Measurement of Height : In young children, height is referred to as length or Crown-heel length in young children who cannot stand with ease (say up to 2 years of age). An infantometer is use to measure their recumbent ‘length’ (in lying position). In adults and older children, the height is measured using a vertical measuring rod, the Anthropometric rod.

The subject should remove his shoes and stand erect. He must keep his heels together and toes apart. He must look straight.

Table - 2 : Normal range of some biochemical tests (2)

Nutrient Test Normal (Acceptable) Low (Medium risk) Deficient (high risk)

Albumin (g/100ml) for age 6-17 yrs

Serum levels >3.5 2.8-3.4 <2.8

Vitamin A (μg/dl) Serum levels >30 20-30 <20

Vitamin D (ng/ml) Serum levels of 25-Hydroxy cholecalciferol

>10 05-10 <5

Vitamin E Ratio of serum vitamin/total lipids

>0.8

Vitamin K *PIVKAS accumulation If PIVKAS accumulates

Prothrombin time Delayed **

ThiaminUrinary thiamin

100μg/24 hrs or 65μg/g creatinine

Riboflavin Urinary Riboflavin 80μg/g creatinine

Niacin 2-Pyridone to NI-methyl nicotinamide ratio

1 to 4 <1

Vitamin B6 Vitamin B6 urinary excretion

<20μg/g creatinine

Pyridoxic acid excretion <0.5mg/day

Folic Acid Serum folate (ng/ml) >6.0 3.0-5.9 <3

RBC Folate (ng/ml) >160 140-159 <140

Vitamin B12 Serum B12 (pg/ml) <80

Ascorbic acid Plasma (mg/dl) >15 08/15/09 <8

* PIVKAS: Protein Induced by Vitamin K Absence. ** Prothrombin time is a functional test

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He stands against the anthropometric rod kept at his back, placed perpendicular to the ground. The investigator standing to the left holds the subject’s chin with his left hand and the occiput with the right little finger in the Frankfurt horizontal plane (an imaginary line joining the tragus of the ear to the eye). The moving head piece of the anthropometric rod is brought down and placed on the head with little pressure, in the saggital plane. The reading is taken. Average of three readings is recorded. The disadvantage of height as a measure of nutritional status is that it doesn’t indicate present nutritional status of the individual, but indicates only the past history of a chronic disease.

Mid-Upper Arm Circumference (MUAC) : Mid-upper arm circumference indicates the muscle development. Since poor muscle development is seen in PEM, the lower MUAC indicates poor nutrition. MUAC correlates well with weight, weight for height and clinical signs of malnutrition. It can be used to calculate the mid arm muscle circumference using a simple formula, if the value of fat fold at triceps is also estimated simultaneously. The mid calf circumference can also be used instead of MUAC.

The mid-upper arm circumference is measured on the non-dominant arm (left arm in case of right handed subjects and vice-versa) of the subject. The mid point between the tip of the acromion (of scapula) and olecranon process of ulna is located with the arm flexed at the elbow. It should be marked with a pen. The arm is now held hanging freely by the side of the subject and a fiberglass tape is placed gently but firmly embracing the arm without ‘squeezing’ the soft tissue, at the point marked in pen. The reading is taken to the nearest millimeter.

Interpretation : The usefulness of MUAC is based on the principle that MUAC remains almost constant between 1 to 5 years of age (increasing only approx 1.5 cm between 1 and 5 years of age). Thus fair degree of standardization can be achieved even if the age is not known in a preschool child. A cut off point of 12.5 cm is taken. MUAC of less than 12.5 cm is taken as low. To make the procedure of measurement even simpler and usable at the grassroot level, Shakir introduced a simple tricoloured tape in 1975, called as the Shakir’s tape. The red colour in the tape (which fell in the less than 12.5 cm zone) marked Danger, yellow or white colour, fell in 12.5-14 cm zone marked Caution and green colour more than 14.0 cm is considered as OK or normal.

MUAC can be used as an efficient technique for screening large population of children for malnutrition. Children thus screened, can be subjected to further anthropometric measurements and other (Clinical/biochemical) tests for specific nutritional deficiencies.

The biggest advantage of using the MUAC is that it is easy to conduct and it is age independent till about 5 years of age. A modified tape (Shakir’s Tape) can be used easily even by a village health worker.

Body Fat : Body Fat indicates reserve of energy in the body. The quantity of fat present subcutaneously at various sites indicates the gross nutritional status of the person. The thickness of fat can be correlated to the body content of fat. Fat distribution in and around the body varies with age, sex,

physiological, nutritional and health status of the individual.

Anthropometric Measurement of Body Fat : Fat fold thickness

Anthropometric measurement of body fat can be carried out at various subcutaneous sites. These sites are commonly undertaken : Two sites on the trunk namely sub scapular and supra-iliac and three sites on the extremities namely triceps, thighs and mid calf. Biceps fat fold is also done. The fat fold thickness at triceps is the most sensitive (to socioeconomic changes) and most reliable (indicator of obesity).

Fat fold at triceps is the commonest measure. It is carried out at the dorsal side at the same mid point where MUAC is measured. The skin fold is picked up between the thumb and the forefinger 1 cm above the midpoint, taking care not to include the underlying muscle. The tips of the skin fold calipers must be applied at the mid point at a depth equal to the skin fold. The skin fold is held gently in the left hand throughout the measurement. Average of two measurements must be taken.

Head and Chest Circumference : Head and chest circumferences are measures used in children. A neonate is born with a bigger head. The chest grows faster than the head in a normally nourished child in the 2nd and 3rd years of life. As a result, the chest circumference overtakes the head by about 1 year of age. In a child suffering from PEM, the chest grows at a lower rate and it remains smaller than the head even till 2 ½ to 3 years of age. This indicates a poor state of nutrition.

Head and chest circumferences are measured using a fiberglass tape. Head circumference is taken at the supraorbital ridges of the frontal bone (just above the eyes) in front and the most protruding point of the occiput in the back. The chest circumference is taken at the level of the nipples in mid inspiration.

Classification of Nutritional Status Based on Anthropometric Parameters

Weight for age : There are standard weights laid down for a particular age. Thus a given child’s weight (for his particular age), is compared to the ‘standard’ weight of a ‘normal’ child. This standard is taken as per the 50th centile of the Boston standard. The Gomez classification is one of the commonest classifications used to classify malnourishment into various grades.

Weight for age(%) = Weight of childWeight of 'normal child' of same age X 100

The grades as per Gomez classification are given in Table - 3.

Table - 3 : Gomez Classification

Malnutrition grade Weight/Age (%) of normal

Normal >90%

Grade I (Mild) 75 – 89 %

Grade II (Moderate) 60 – 74 %

Grade III (Severe) < 60 %

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The Indian Academy of Paediatrics (IAP) classification on the other hand puts the degree of malnutrition into four grades (Table - 4). This classification is used by the ICDS in India.

Table - 4 : Indian Academy of Paediatrics (IAP) Classification

Malnutrition grade Weight/Age (%) of normal

Normal > 80%

I Grade 70-80%

II Grade 60-70%

III Grade 50-60%

IV Grade <50%

Weight for height : The weight for height classification doesn’t take age into consideration. Weight is also related to height. Many a times age is not known. Weight for height is an age independent parameter. It is a good prognostic indicator of severe PEM and an index of current nutritional status. Weight for height of less than 80% of normal is considered to indicate wasting in preschool children.

Wasting and Stunting : In the Waterlow classification weight for height and height for age are used to classify children as normal, wasted, stunted and wasted and stunted. Children with low weight for height are considered as wasted and those with low height are ‘stunted’ (Table - 5).

Table - 5 : Wasting and Stunting - Waterlow classification

Weight for height

Height for age

Nutritional status Interpretation

Normal Normal Normal Normal

Low Normal Wasted Acute malnutrition

Normal Low Stunted Nutritional dwarf

Low Low Wasted and stunted

Acute on Chronic malnutrition

Body Mass Index (BMI) : Body Mass Index (BMI) is the ratio of weight in Kg to square of height in metre.

BMI =Mass (Kg)

Height (m)2

It gives an indication of the nutritional status, esp. obesity. Now-a-days in context of lifestyle diseases, BMI is taken as an indicator of risk of cardiovascular diseases as well.

BMI does not measure the body fat but relates well with the degree of obesity. The categories of obesity as pronounced by the WHO are depicted in Table - 6. A BMI of 25-30 is considered as a warning sign and may warrant intervention, especially in the presence of additional risk factors. A BMI of 30 or higher is generally considered the point at which some form of treatment is required. Obesity Class III i.e. BMI >40 or morbid obesity, is a medical condition that impairs a person’s overall health and therefore requires medical attention.

Table-6:Grades of obesity based on BMI (WHO, 1998) (3)

BMI ClassificationRisk of co-morbidities

< 18.5 Underweight Low

18.5-24.9 Healthy/normal weight Average

25 – 29.9 Pre-obese (Overweight) Mildly increased

30 – 34.9 Obesity Class I Moderate

35 - 39.9 Obesity Class II Severe

> 40 Obesity Class III Very severe

The guidelines have been revised and made more stringent lately for Asians, considering the fact that Asians (esp. South East Asians including Indians) are more susceptible to metabolic syndrome. These are summarized in Table - 7.

Table - 7 : Grades of obesity for Asians (5)

BMI Classification Risk of co-morbidities

< 18.5 Underweight Low

18.5-23 Normal weight Increasing but acceptable

23 – 27.5 Pre-obese Increased

>27.5 Obese High

Dietary Assessment for Nutritional StatusA nutritional survey is never complete without a diet survey. We may be able to find out that there is a nutritional deficit through clinical, laboratory or anthropometric methods, but in order to find out if this nutritional deficiency is because of diet and which particular diet/nutrient, we have to invariably resort to a diet survey. It is thus an integral part of nutritional survey. A diet survey objectively defines importance of diet in various health state and disease (2). Diet survey is nothing but the scientific assessment of food consumption, and using this data for various purposes including assessment of nutritional status.

Methods : Various methods are there to undertake diet surveys. These are appropriate in different settings (6) and are summarized in the Box - 4.

Box - 4 : Methods of Diet survey

Food balance sheet method

Inventory method

Weighment method

24 hr Recall method (Questionnaire method)

Dietary score method

Food Frequency Questionnaire method

Duplicate sample (chemical analysis) method

Diet Balance Sheet Method : This method is used when information regarding availability and consumption of food is required at a macro level like at the global, national, region or state levels. The total food supplies available and used up at a

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given level are taken into account in this method. Effectively the difference between receipt (of food various sources) and expenditure over a given period of time gives the food consumed by population. The consumption per capita/day is worked out as :

Food consumed by populationMid yr pop x 365

These figures are used for various types of planning and budgeting, namely plans for agriculture, fertilizers, productions, imports and Public Distribution System (PDS). The method has got certain demerits. It is a gross method. Secondly the consumption of rich and poor is equated and averaged out when this method is used. It gives the consumption pattern but doesn’t include purchasing power of the individual.

Inventory Method : As mentioned earlier the inventory method is carried out at an institutional level, on a homogenous group as present in a hostel, jail, mess, army barrack, orphanage etc. It is essentially done from books. Amounts of various food stuffs available as per records are taken into consideration. The balance of various food items is again checked after a reference point of say 7 days (one week).

Individual consumption / day =

Stocks at beginning of week - Stocks at end of weekNo. of individuals x No. of days

The Merits are that it is fast, much easier, less cumbersome and faster than the weighment methods. It is also fairly accurate. It may not indicate an accurate individual food consumption but is fairly satisfactory for the purposes of planning.

The Demerits are that it doesn’t account for wastage. Secondly, it gives only the mean individual consumption but actual individual consumption is not reflected. Thirdly, the estimates are as good as the food records made available. Lastly, the results will be affected if the subjects are eating some food stuff obtained from any source other than the common kitchen under question.

Weighment Method : In this method the foods are actually weighed using a grocer’s balance. Both raw and cooked food are weighed. In community surveys (at a family level), the raw food is weighed rather than the cooked food, since weighing cooked food is not acceptable to the families. In an institution however, the cooked food can also be weighed, since cooking is carried out at a central kitchen. While using weighment method at a family level the following points are important : 1. Convince the housewife of the need of the survey for the

benefit of the family2. Avoid holidays/fares/festivals/feasts as the dietary practice

of these days does not reflect the actual dietary practices.3. It should be carried out for 3 to 7 days consecutively.4. At least two visits a day for lunch and dinner have to be

made.5. Two investigators should be available - one talks and

weighs and the other records observations.6. Any pets, breast fed children, guests etc. should be

considered.

The method : Weigh the raw food before cooking. It is preferable to weigh the food again after cooking. A conversion factor is arrived at. For example let’s assume that the weight of raw rice is 100 g. The weight of cooked rice becomes 400g. Thus a conversion factor of 100/400 or ¼ is arrived at. In other words 1 g cooked rice represents 1/4 g of raw rice. Or if a person eats 400g cooked rice it is equivalent to 100g of raw rice. The nutrient contents of raw rice are extracted from standard Food Composition Tables. The same process is employed to estimate the nutrient contents of all food preparations.

Ideally both, raw and cooked foods must be weighed. But if it is not possible to weigh the cooked foods an approximate conversion factor can be taken. Obviously this will lead to some degree of error. Another alternative is to measure the volumes of raw and cooked foods and subject them to weight conversions. In practice measuring volumes of cooked portions actually eaten by the individuals is easier than weighing the portions eaten. The volumes can be converted into weights and subsequently into nutrients, through standard tables. The merits of this method are that it accounts for the non edible parts of food as well. The wastage is also taken into account. This method is more accurate than the inventory method. The demerit is that it is a very cumbersome, time consuming and tedious process as it involves weighing of all foods.

24 hour Recall (or Questionnaire) Method : The 24 recall (questionnaire) method is a relatively easy method based on the recall capabilities of the individual over a period of the past 24 hours. Since it is a short term retrospective method it is more prone to errors.

A set of cups and ladles standardized for volume are used. The housewife is asked about the types of food items prepared at the time of breakfast, lunch and dinner. The raw ingredients used for cooking each meal are noted. The cups are exhibited to the housewife. The cooked food items are noted in terms of these cups. The intake of each food item by the specific individual in the family is also assessed by using these cups.

The method is fairly accurate. It take lesser time than the weighment method. However, the disadvantage is that the method is based on recall capability of the respondent so there is a likelihood of ‘inaccurate recall’ and error in derivation of nutrients. A fair degree of cooperation is to be sought from the respondent. The process is a cumbersome.

Food Frequency Questionnaire (FFQ) Method : Food frequency questionnaire (FFQ) method is based on the principle as to how frequently an item is consumed over a period of time. It is an epidemiological technique used to study the meal patterns and dietary habits of people. It can be used to assess the specific dietary intakes during pregnancy, lactation, etc. It can even be conducted through post. For example a FFQ may read “In one week how often do you consume the following items….”

Item Frequency (Consumption Per Week)

Meat 1 2 3 4…..

GLV 1 2 3 4…..

Sprouts 1 2 3 4……

This filled up questionnaire is then analysed, using pre-decided values of for nutrients for different food items.

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Nutritional SurveillanceIt is clear from the earlier chapters that the state of nutrition of an individual or a community depends on a variety of (unrelated) factors. These could be as diverse as the ‘health’ of the crops, state of rainfall, GDP, per capita income, efficiency of the public distribution system, availability of food and the health state of the community.

Given this dynamic and ever changing state of availability and use of food, it is vital to keeping a constant watch over all these factors concerning nutrition, in order to continuously assess the situation, give an early warning and take appropriate decisions that will lead to improvement in the nutritional status of population. This on-going process of constant scrutiny of the nutritional situation and factors influencing them and its application in the public health interest is termed as nutritional surveillance. The word was used first in 1974 with respect to drought relief, during a World conference in nutrition. A nutrition surveillance programme was developed for the developing countries 1976. The term has been used extensively by the UNO since 1980. The process of nutritional surveillance finds the following applications : a) It provides inputs for health and development planningb) It is useful for programme management and evaluationc) It provides timely warning and intervention to prevent

(short term) food consumption crisis and plan for long term action

Steps : The various steps of nutritional surveillance are : a) Identify community/populationb) Data collectionc) Data transitd) Data processinge) Interpretationf) Responses and Planningg) Improvementh) Further implementationMethodology of Nutritional Surveillance : The methodology of the nutritional surveillance can be outlined through answering the following basic questions :

What is the problem? ● → Define & describe the type of nutritional problem e.g. malnutrition (acute or chronic), micronutrient deficiency, etc.Who is at risk? ● → Describe the population groups affected by area, socioeconomic status, biological/physiological status, etc.Why is this population at risk? ● → Identify the causal factors. These causes could be immediate (non availability of food, poor health, etc) or of long standing nature like unequal resource distribution, poor sanitation and infections.Where to get the data from? ● → Identify the data sources. These will depend on the purpose for which surveillance has been undertaken.

Purpose of surveillance Data source

Health and development planning

Household survey

Data from records Programme management and evaluation

Interviews and records Timely warning and intervention programme

Rainfall, prices, employment Health system surveys

Define food supply system. The food can be obtained ●mobilizing the existing stores, through national and international aid, improving the agricultural production, etc.Obtain the data, analyse and provide feedback to decision ●makers. Finally, evaluate the nutritional surveillance system.

Nutritional RehabilitationThe cases of severe malnutrition are treated in a hospital setting. Such a treatment no doubt, does make the child survive; it doesn’t guarantee that he will live a life free of malnutrition and disease in future. Besides only medical, additional inputs like those of social, physical, psychological and emotional rehabilitation have to go in, if the child is to live a life of positive health.Principle : More often than not it is seen that after a short spell in the hospital, once the child returns back to the original social milieu, the condition recurs. The child either dies or becomes extremely vulnerable to subsequent infections, malnutrition, disease and death. The basic principle of nutritionally rehabilitating a child is not only to treat his malnutrition and related acute complications, but to prevent a recurrence of the condition.

Methods : The process of rehabilitation is to be dove-tailed with treatment. It can be undertaken at three levels, depending on the severity of the condition and the facilities available.

(a) Hospital : The child is hospitalized in severe cases or when he has concomitant complications. Special standardized dietary regimes (intensive feeding with high proteins and energy dense diets) are required to be instituted and continued for a long time to come. Systematic education of parents in food selection and cooking has also to be imparted. The standardized dietary regimes and specific nutritional education It is initiated in the hospital but is required to be followed up either at the day care centre or at home.

(b) Day Care Centre : A day care facility is an intermediate arrangement between the hospital and home. Children who are not required to be admitted to a hospital or those who have been discharged from the hospital are expected to visit the day care centre. This centre may be run by a health worker who is trained in preparation of special feeds for malnourished children and who could educate the mothers on preparation of special feeds suitable to the particular child (as discussed in last paragraph). Any health facility like an anganwadi centre, sub-centre or a PHC can be used as a day care centre. The advantage of a day care centre (over hospital) is that it

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is cheaper; the mother can spend the day at the centre under supervision of a trained health worker, learn sufficient skills in specialized feeding and child-craft, in an informal setting, closest to her home environment and really imbibe it.

(c) Domiciliary : In case the child is not severely affected, after medical consultation, he can be treated at home. He could also be one who has been weaned off a hospital or a day care set-up. To maintain health of child it is important that the mother is trained in handling the ‘special’ nutritional needs of this child.

SummaryThe condition of the body resulting from intake, absorption and utilization of food and the effect of pathological factors is termed as nutritional status.

Nutritional status is assessed too map out distribution and geography of nutritional disorders, identify high risk groups and to assess various epidemiological factors for responsible for nutritional deficiencies. It is also an administrative tool used to allocate budget for food materials at a large scale. The important methods are anthropometry, biochemical and laboratory methods, clinical assessment, diet survey, ecological studies, functional assessment and indirect assessment from vital statistics data.

There are clinical signs that may be ‘strongly suggestive’ of dietary deficiency or excess (e.g. Bitot’s spots), of probable significance (e.g. corneal scar) and those that are of no nutritional significance (e.g. pterygium). Clinical signs might develop rather late and are subjective and non specific.

Biochemical tests on the other hand give objective and quantitative indication of nutritional status, but these are costly and instrument intensive.

Anthropometry remains the sheet anchor of nutritional assessment. Weight, height, head and chest circumference, MUAC and fat fold thickness are the common anthropometric parameters used. Many derived parameters like the BMI, weight for age, weight for height, etc are also used in different situations.

Various methods of diet survey are used to ascertain as to what an individual or a group of people are eating. This indicates the deficiency of nutrients in the diet and thus appropriate measures can be suggested to improve it. The main methods Food balance sheet method are inventory method, weighment method, 24 hour recall method (Questionnaire method), dietary score method, food frequency questionnaire method and duplicate sample (chemical analysis) method. The inventory method, weighment method and 24 hour recall method are the most commonly used dietary survey methods.

Nutritional Surveillance is an on-going process to keep a constant watch over all the nutrition related factors, in order to continuously assess the situation, give an early warning and take appropriate actions.

Nutritional Rehabilitation aims at re-establishing the severely malnourished child medically, nutritionally and psychologically into the family and society. The aim is to prevent a recurrence

of acute malnourishment. This can be achieved through appropriate measures begun at the hospital. Subsequently the child may be managed at a day care centre or at home.

Study ExercisesLong Questions : (1) Enumerate the various methods for nutritional assessment. Describe any one in detail. (2) What is nutritional surveillance? Outline the methodology of nutritional surveillance. (3) What are the various anthropometric techniques available to assess nutritional status of a 5 year old child? How can weight for age be useful to ascertain malnutrition in this child?

Short Notes : (1) Mid Upper Arm Circumference (2) 24 hour recall method (3) FFQ (4) Using BMI to assess CED in adults (5) Disadvantages of using clinical signs for nutritional status assessment

MCQs1. All can indicate nutritional status except : (a) Fall in weight

(b) Falling hair (c) Failure to gain height (d) Flag sign2. All are signs of PEM except (a) Flag sign (b) Unilateral

pedal edema (c) Low weight for age (d) Dermatoses3. Stunting is __________ weight for height but _________

height for age : (a) Normal; Low (b) Low; Normal (c) Low; Low (d) High; low

4. Acute malnutrition may be indicated by : (a) Stunting (b) Wasting (c) Stunting and wasting (d) All of the above

5. Which of these is not true for nutritional surveillance : (a) It is an ongoing process (b) It can be used as a nutritional survey technique (c) It is a close scrutiny of events related to nutritional changes (d) It provides timely warning for action

Match the following

Age Suitable anthropometric measure

6. New born (a) MUAC

7. 3 years (b) Weight

8. 42 years (c) BMI

9. 8 years (d) Head & chest circumference

10. 1 ½ years (e) Weight for age

Answers : (1) b; (2) b; (3) a; (4) b; (5) b; (6) b; (7) a; (8) c; (9) e; (10) d.

ReferencesJelliffe DB, Jelliffe EFP. Community Nutritional Assessment. Oxford University 1. Press. 1989.Bamji MS, Rao NP, Reddy V. Textbook of Human Nutrition. 2nd ed. Oxford & 2. IBH Publishing Co Pvt Ltd, New Delhi. 2003.World Health Organization, 1998. Obesity. Prevention and managing the 3. global epidemic. Report of the WHO Consultation on obesity. WHO, Geneva.Based on James WPT, ferro-Luizzi, Waterlow JC. Definition of chronic energy 4. deficiency in adults—Report on working party of the intervention dietar energyconsultation group. Am J Clin Nutr., 42; 969-981,1988.Astrup A. Obesity. In : Human Nutrition, Editors : Geissler C, Powers H,2005, 5. 380-395.Thimmayamma BVS, Rao P. Diet Survey Methods. ICMR. National Institute 6. of Nutrition, Hyderabad.

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137Food Processing, Food Adulteration, Food Additives, Preservatives, Food Toxicants and Food Fortification

Rajul K Gupta

Food ProcessingFood processing is the technique used to transform raw ingredients into food or to transform food into other forms for consumption. It can be done either at home or by the food processing industry.

Aim of Food Processing : Food processing is aimed at improving the colour, appearance, palatability, taste, texture, keeping quality and marketability of food. Food processing makes the food attractive and many a times makes it a long-life food product. Foods used in certain special situations can not be used without processing. Some of these situations can be space travel, high altitude expeditions, disaster aid situations, combat missions by soldiers, etc. Some common food processing techniques are enumerated in Box-1.

Processing helps to remove toxins, eases marketing and distribution of foods. In addition, it increases seasonal availability of many foods, enables transportation of delicate perishable foods across long distances and makes many kinds of foods safe to eat by de-activating spoilage and pathogenic micro-organisms. Food processing techniques are also used to add extra nutrients such as minerals and vitamins to food preparations.

Disadvantages of Food Processing : Food processing can sometimes lower the nutritional value of foods. Some vitamins are very sensitive to heat and are lost on cooking (e.g. vitamin C). Some water soluble vitamins can be lost on washing with water. Food additives such as colours, flavouring agents and preservatives, used while processing the foods, may be unhealthy. Some are known to be allergic or even carcinogenic. Processed foods (like junk foods) often have a higher ratio of calories to other essential nutrients than unprocessed foods, and may provide empty calories. Processing also increases the prices of food products.

Food AdditivesThe concept of adding “non-food” substances to food products is not new. Pickling preserves the food articles such as mango, lime etc. for fairly long periods by the addition of salt and spices. Salt and spices were the traditionally used food additives. These can be considered as natural additives.

With industrialization, increasing demand of ‘ready to eat food’ and use of modern techniques, the food processing industry is relying heavily on chemical additives. The food additives improve taste, flavour, texture and colour. They also help increase the shelf-life of food. Now a days majority of the processed foods contain some food additive or the other. Some commonly used food additives are enumerated in Box - 2.

Box - 1: Some Common Food Processing Techniques

Peeling and skinning (fruits and vegetables)

Mincing (meat)

Liquefaction (fruit juice)

Fermentation (Soy, beer, cocoa)

Baking (cakes, pastries, bread)

Sprouting (cereals, pulses)

Steaming (rice)

Boiling (vegetables)

Carbonation (beer, soft drinks)

Packaging (most commercial foods)

Canning (juices, fruits, fish)

Sauce and ketchups (tomato)

Brewing (tea)

Chopping or slicing (vegetables)

Pureeing (vegetables and fruits)

Pickling (vegetables)

Emulsification

Cooking (most foods)

Frying (French fries, pakories)

Grilling (chicken)

Pasteurization (milk)

Spray drying (milk powder)

Dehydration (fish, vegetables, soup powders)

Jam and jelly (fruit, vegetables)

Wines and ciders

Freeze drying (meat)

Box - 2 : Some Commonly Used Food Additives (Emulsifiers, Stabilizers, Thickeners and Gelling Agents) * (1)

Name Food

Lecithins Chocolates, margarine, potato snacks

Citric Acid Pickles, dairy products, baked products

Tartaric Acids Baking powder

Alginic Acid Ice creams, desserts

Agar Ice cream, soups, tinned ham

Gums Ice creams, soups, confectionery

Pectin Jellies

* A list of antioxidants and preservatives is given in the next section

Definition : Food additives are the non-nutritious substances added intentionally to food, generally in small quantity, to improve the basic properties of food like its appearance, flavour, texture etc.

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Food additives can be classified into the following two broad categories :

1. Additives deliberately added to fooda) Colouring agents e.g. saffron, turmeric.b) Flavouring agents e.g. vanilla essencec) Sweeteners e.g. saccharin, cyclamated) Preservatives e.g sorbic acid, sodium benzoate (details

given in next section)e) Acidity imparting agents e.g. acetic acid etc.f) Thickening Agents e.g. alginate (from seaweed) and casein

used in ice creams, cheese, yogurt etc.g) Emulsifiers: Keep water and oil mixed together. e.g. lecithin,

monoglycerides and diglycerides are used in margarine, baked goods and ice cream.

h) Anti-Oxidants : Prevent spoilage, flavor changes, and loss of color caused by exposure to air e.g. Vitamin C and Vitamin E.

These are generally considered safe for human consumption. However, certain preservatives such as nitrites and nitrates can lead to the production of toxic substances, e.g. nitrosamines that have been implicated in cancer etiology.

2. Contaminants : They get incorporated incidentally through packing, processing, farming practices (insecticides) or other environmental contaminants.

Provisions of Law Applicable to Food Additives : The use of food additives is subjected to government regulations throughout the world. In India two regulations viz. the Prevention of Food Adulteration Act (PFA Act) and the Food Products Order are in vogue. The PFA Act has been discussed separately. Use of food additives that are not permitted by law is considered to be an adulterant. In case the quantity of the food additive exceeds the permissible limit then also the food is considered adulterated. It is also required by law that the nature and quantity of the additive shall be clearly printed on the label that is affixed to the container. Whenever any extraneous colouring agent is added to a food article, the words ‘Artificially Coloured’ shall be printed on the label.

At the international level, FAO/WHO have established the Codex Alimentarius Commission as its principal organ. Protection of the health of consumers is the primary aim of this commission.

Food PreservativesIt is not possible to consume food immediately on production as we don’t have access to farm fresh food all the time. If we can’t consume the food quick enough, the food tends to get spoilt. As soon as a food is harvested or cooked, the process of food spoilage sets in. The enzymes and other chemicals (e.g. acids and alcohols) present in foods initiate the process of deterioration. Micro-organisms (bacteria and fungi) are the prime agents that cause spoilage under suitable conditions. Environmental factors like heat and humidity enhance the process of spoilage. Once spoilt the food no more remains fit for consumption and may lose its original nutritive properties as well. Preserving food therefore becomes imperative. Preservation is undertaken with the following aims:a) Increasing the keeping quality of foodb) Preserving its nutritional characteristics

c) Preserving the appearance, colour and texture of foodMethods of Food Preservation : Preservatives are centuries old. Since ancient times, salt has been used to make pickles, cure meats and fish. Sugar has also been added to fruits to conserve them. Herbs, spices and vinegar have also served as preservatives for centuries. These early preservatives (sugar and salt) produce food environments of high osmotic pressure that deny bacteria the conditions needed by them to propagate. Jams and jellies are preserved as solutions of high sugar content.

The Modern Day Preservatives could either be natural or synthetic.

Natural Food Preservation : As discussed earlier salt and sugar are the commonest natural preservatives. Another group of natural preservatives target enzymes in fruits and vegetables that continue to metabolize even after they are cut. For instance lemon juice contains citric and ascorbic acids which inhibit the action of enzyme phenolase that turns cut surfaces of apples and potatoes brown.

Anti-Oxidants : Anti-Oxidants not only preserve foods through preventing spoilage but also limit flavour changes and loss of colour caused by exposure to air. Vitamin C and Vitamin E are used as antioxidants. Other antioxidant preservatives are compounds like BHA (Butylated Hydroxyanisole).

Anti-microbial Preservatives : Anti-microbial preservatives inhibit the growth of microbes. Benzoic acid, sulfur dioxide and ethanol have long been used as preservatives. Other common anti-microbial preservatives are calcium propionate, sodium nitrate, sodium nitrite, sulphites, sulphur di-oxide, sodium bisulphite, potassium hydrogen sulphite, disodium EDTA.

Microbes as preservatives : All microorganisms are not harmful. Some microbes are responsible for the production and preservation of certain foods. Microbial action is a part of the production of cheese and flavouring agents. Sauerkraut is both processed and preserved by lactobacilli. Yeast cells ferment sugars, producing alcohol and help to preserve them.

Irradiation: Food irradiation using radioactive rays or high-intensity X-rays or streams of electrons is a modern method of food preservation. It has the advantage of preserving food while in their packets. There is minimal person-to-food contact reducing the possibility of contamination. Food is not required to be exposed to chemical preservatives which may be harmful. Irradiation extends the shelf lives of foods such as strawberries, potatoes, onions, grains, etc. Irradiation does not make foods radioactive, but may cause changes in food colour or texture.

Some commonly used food chemical preservatives are enumerated in Box - 3.

Health Concerns on Food Preservatives : There have been health concerns with many chemical additives like colouring and flavouring agents. Preservatives are also not untouched with these fears. Some modern synthetic preservatives have become controversial because they have been shown to cause respiratory or other health problems. Sulfur dioxide (often used to preserve wines) is irritating to the bronchial tubes of persons who have asthma, and nitrites have been implicated as carcinogens. Some preservatives are known to cause allergic reactions including anaphylactoid reactions.

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Box - 3 : Commonly Used Food Preservatives (1)

Preservative Food

Antioxidants

Ascorbic acid Beer, soft drinks, fruits, meat, powdered milk

Tocopherols Vegetable oils

Gallates Vegetable oils, fats, margarine

BHA and BHT Fats, margarine in baked products

Other Preservatives

Sorbic Acid Cheese, yogurt, soft drinks

Acetic Acid Pickles, sauce

Lactic Acid Sauce, confectionery

Propionic acid Bread, cakes, flour

Benzoic Acid Soft drink, pickles, fruit products, jams

Sulphur dioxide Soft drinks, fruit products, beer, cider, wine

Nitrites Cured meats, cooked meats and meat products

Nitrates Meat products, cheese

Food FortificationFood Fortification is the process by which a nutrient is added to commonly eaten foods to improve the quality of the food. WHO has defined food fortification as “the process whereby nutrients are added to foods in relatively small quantities to maintain or improve the quality of diet of a group, a community, or a population.” Fortification is the addition of nutrients at levels higher than those found in the original or in comparable foods. The food that carries the nutrient is referred to as the food vehicle; and the nutrient added is the fortificant.

Fortification of food is a public health measure aimed at reinforcing the usual dietary intake of nutrients with additional supplies to prevent/control some nutritional disorders. A food fortification program is usually undertaken when there is a widespread and consistent nutritional deficit in the population’s diet. Food fortification has been commonly used as a method to control micronutrient deficiencies.

The term food enrichment is used for replacing nutrients lost in processing. It occurs with grains, as some vitamins and minerals are lost in the milling process.

The Need for Fortification : One of every four people in the world suffers from micronutrient deficiencies. Globally, the key micronutrient deficiencies are that of iodine, vitamin A and iron. These vitamins and minerals are referred to as micronutrients because the body needs them in minute quantities for normal growth and development. All these major micronutrient deficiencies can be overcome at a community level by the simple process of fortification. Some of the fortification programmes of demonstrated effectiveness are: iodization of salt for combating endemic goitre, fortification of vanaspati ghee, butter and milk with vitamins A and D and fluoridation of water to prevent dental caries. Recently, technology has

been developed at the National Institute of India, Hyderabad in India for the twin fortification of salt with iodine and iron. Some initiatives taken by the Government of India on food fortification are given in Box - 4.

Box - 4 : Some Facts on Fortification - Initiatives by the Government of India

Wheat flour (atta) : In February 1970, the Government of India launched a programme in Bombay for fortification of atta with vitamins and minerals, and for increasing the protein content by admixture with edible groundnut flour.

Edible oils: Fortification of Vanaspati (hydrogenated oil) with vitamin A has been made compulsory (2,500 IU of vitamin A and 175 IU, vitamin D per 100 g of Vanaspati) by the Government or India.

Common salt: Under the PFA act common salt has to be fortified with iodine (commonly potassium iodate) in a dose of 30 ppm at production site and 15 ppm at consumer end.

Choosing a Food Vehicle and a Fortificant : While choosing an ideal food vehicle the following aspects are considered:a) The food should be consumed by all population groups

that is at risk of the particular nutritional deficiency.b) The food should be used regularly and in consistent

amounts by the entire population at risk.c) Taste, appearance and smell of the food should not change

after fortification.d) The fortificant should remain stable under extreme

conditions such as cooking, food processing, delivery and storage.

e) The food should not be consumed in amounts that would present a risk of consumption at toxic levels of the fortificant.

f) The food should not increase the cost of food.Benefits of Food Fortificationa) It effectively prevents major micronutrient deficiencies at a

small cost.b) Fortification does not require change in the dietary habits

of the population.c) It can be implemented relatively quickly and can be

sustained over a long period of time.d) It being a population based approach, benefits all.e) It is a very cost-effective approach.

Food Adulteration and the Prevention of Food Adulteration Act (PFA)Food is a substance consumed for eating or drinking (except for water and drugs). Unscrupulous traders use the practice of adulteration for their ulterior motives. Any material which could be used for adulteration is called as an adulterant. Commonly it is believed that adding a substandard stuff to food (e.g. water to milk) is adulteration, but as per the law the word adulteration has a much wider connotation.

The Prevention of Food Adulteration (PFA) Act was enacted by the parliament in 1954. The PFA Rules were framed by an expert body called the ‘Central Committee for Food Standards’ in 1955. Various amendments have been made in the act since then.

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Objective : The PFA Act was enacted with the main objectives of :a) Ensuring pure & wholesome foodb) Protecting against fraudulent & deceptive trade practicesAdulterationAn article is deemed adulterated if ‘it is not of the nature, substance or quality as demanded by the purchaser; if the food contains other substances that affect injuriously the nature, substance or quality of food; if the food is substituted by an inferior or cheaper substance; or if any constituent of the food has been abstracted; or if it contains any poisonous ingredient, the food is said to be adulterated’ (PFA Act). Some common food adulterants are enumerated in Box - 5.

Box - 5 : Some Common Food Adulterants

Food Item Adulterant

Cereals Mud, grit

Dal Kesari dal, dyes

Dhania Horse dung

Black pepper Papaya seeds

Chilli Brick powder

Tea Gram husk

Milk Water

Mustard seeds Prickly poppy seeds

Sweets Non permitted colours

Ghee Vanaspati

As per the PFA Act the following acts amount to adulteration of food:a) If any article has been prepared, packed or kept under

unsanitary conditions whereby it has become contaminated or injurious.

b) If the article is filthy, putrid, rotten, decomposed or from a diseased animal or vegetables; or is insect infested or is otherwise unfit for human consumption.

c) It is obtained from a diseased animal.d) Contains a non prescribed colouring matter or

preservative.e) The mal-practices like mixing, substitution, concealing

the quality, misbranding, selling decomposed food, adding toxicants, extracting food material or giving false labels also amount to adulteration.

Process : Whenever an instance of food adulteration comes to the notice, a food sample is collected from the site. The sample can be collected by a government functionary like the food inspector or even by the consumer (1986 amendment). The consumer/purchaser can get food analyzed, provided the vendor is informed of this intent and the purchaser pays fees to the designated laboratory to carry out the analysis.

Sample collection, disposal and analysis : The food inspector expresses his intent of collecting the sample and getting it analyzed under the PFA Act to the vendor in advance. The cost of food item (sample) is paid to the vendor. The signatures of

the shopkeeper / vendor are taken. In case the shopkeeper/vendor refuses to put his signature, an independent witness is made to sign. In case the witness also refuses to sign, the food inspector endorses a certificate to this effect. The sample is divided into three parts, they are packed and sealed. The sample number one is submitted to public analyst under intimation to the local health authority (The local health authority is an officer appointed by the government through a gazette notification to be the in charge of health administration, in a given area. Generally this responsibility lies with the municipal/cantonment health administrators). The 2nd and 3rd samples are kept as reserve samples and are deposited with the local health authority for safe custody. Sample analysis is carried out by the local government public analyst. The report is submitted to the local health authority. In case the sample is found to be adulterated suitable action is taken by the court of law. The vendor can apply to the court, within 10 days to get the reserve sample, kept in the custody of the local health authority, analyzed at the relevant Central Food Laboratory, for confirmation. For the purpose of this reconfirmation four reference laboratories have been established and notified by the government of India. These labs have been allocated a zone of responsibility and certain predefined regions/states/union territories are dependent on them. These laboratories are located at Mysore, Kolkata, Pune and Ghaziabad (Box - 6).

Box - 6 : Central Food Laboratories (CFL) and States Dependent on them

Central Food Laboratory Dependent states

Mysore Gujarat, Himachal Pradesh, Haryana, Punjab, UP, Maharashtra

Kolkata North Eastern states, Orissa, Andaman & Nicobar

Pune AP, Delhi, J&K, Karnataka, Kerala, Rajasthan, Tamil Nadu

Ghaziabad Bihar, Goa, MP, West Bengal

Punishment : Following the hearing, the court awards a sentence to the guilty. A minimum imprisonment of 6 month to a maximum of life imprisonment (in cases of grievous hurt or death) can be awarded. The court may also impose a fine of Rs 1000 to Rs 5000.

Food ToxicantsEven today there is always a lurking fear that some antisocial elements might poison a source of water. While such acts are deliberate, a toxic or poisonous substance might be present as an integral component of a foodstuff. In a small dose it may not have any significant toxic effect, but in a larger dose or when consumed over a prolonged period it may even be fatal. Many possible toxic effects of foods are known. Table - 1 indicates the great variety of ill effects that natural food poisons might have.

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Table - 1 : Some Possible Toxic Effects of Common Foods (2)

Food stuffActive toxic ingredient

Effects on

Some bananas5-Hydroxytrypta-mine, adrenaline, noradrenalin

Central or and Peripheral nervous systems

Some types of cheese

Tyramine Blood Pressure

Almond, cassava Cyanide Tissue respiration

Some fish/meat Nitrosamines Cancers

Mustard oil adulterated with argemone oil

Sanguinarine Epidemic dropsy

Kesari dal (Lathyrus)

Beta Oxayl Amino Alanine and others

Neurolathyrism

Brassica species (seeds)

Glucosinolates, thiocyanate

Goitre

Green potato SolanineGastrointestinal upset

Mushrooms (A muscaria, A phalloides)

Various toxins CNS effects

Groundnuts Aflatoxin Aflatoxicosis

Lathyrus ToxinThe ancient Indian text ‘Bhava Prakasham’ describes the Kesari dal and neurolathyrism. Hippocrates has also described it in the pre-Christian era. Lathyrus and related pulses (‘tares’) were poorly regarded even in the Biblical times, as is clear from a quote from the Bible.

Cantani coined the term lathyrism in Italy. In India too Lathyrus sativus is deliberately sown with wheat in the dry districts. If the rains are good, wheat overgrows the lathyrus (and it is not harvested), but if rain fails and there is poor crop of wheat, a reasonable crop of lathyrus is reaped. Lathyrus is a tasty and high protein pulse. If eaten in small quantities it probably does not cause toxicity. If consumed in larger amounts (providing more than 50% of energy) a severe disease of the nervous system may result, leading to spastic paralysis. Some landlords (zamindars) used to pay their labourers in kind, the form of Kesari dal and not in cash. In this situation Kesari dal used to become the staple diet for these poor people and a cause of neurolathyrism. Neurolathyrism is a crippling disease of the nervous system characterized by gradually developing spastic paralysis in lower limbs, occurring mostly in those consuming a pulse, Lathyrus sativus in large quantities. In animals a variant of the disease i.e. osteolathyrism affecting skeletal system is seen.

The disease is seen in some European, African and Asian countries. Cases are reported from Spain, Algeria, Ethiopia, Mexico, Afghanistan and India. In India it is seen in some districts of Madhya Pradesh, Maharashtra, UP, Bihar, Rajasthan, Assam and Gujarat. Old literature reports thousands of cases

of Neurolathyrism occurring in epidemic proportions in some given regions, but now no outbreaks are reported, only sporadic cases occur in certain areas.

Lathyrus Sativus (Kesari dal) : Lathyrus sativus is also referred to as Teora dal, Lak dal, Batra, Matra, etc. It looks like Arhar dal (toor dal) red gram or bengal gram. However its seeds are triangular in shape and greyish in colour. It is cheaper and a rich source of protein.

In 1962 a neurotoxin, β-N-Oxayl Amino-L-Alanine (BOAA) was isolated from the common vetch (Vicia Sativa), which frequently grows as a weed in Lathyrus sativus. In 1963, another toxin β-N-oxayl-L-α,β di-aminopropionic acid was isolated from the seeds of Lathyrus sativus. Both of these can cause neurological lesions in primates. These toxins are neuro-exitants and can be removed by soaking in hot water and rejecting it.

Clinical Features : If more than 30% energy is obtained from Kesari dal for more than six months, the signs and symptoms may appear in the form of spastic paralysis. The condition is known as Lathyrism. It is most commonly seen in men in the age group 15-45 years. The onset of Lathyrism is sudden, often preceded by exertion or exposure to cold. A patient may find himself paralyzed on getting up in the morning. Sometimes backache and stiffness of legs precede the paralysis of legs. The condition is spastic paralysis of lower limb.

The underlying pathology is the toxin induced degeneration of spinal motor tracts (pyramidal tracts) and sclerosis. The motor nerves to muscles of trunk, upper limbs and sphincter are spared. The sensory system is also not involved.

The patient may pass through progressive stages of severity. In the latent stage the patient may be apparently healthy. In the mild stage there is stiffness and weakness of legs, exaggerated knee and ankle jerks and clonus may follow. As the disease progresses the gait may be affected and the patient walks with bent knees on tiptoe. The legs may become crossed and patient may develop scissor gait. The patient may be able to walk only with one stick and later with two sticks. Later on when paraplegia develops, walking may become impossible. Later the patient has to support his body on his hands, buttocks and heels for moving about (crawling stage). In the most severe stage patient can only move on ‘all fours’, supported by his hands. Many patients might be left with no other alternative but to resort to beggary.Detection of Toxin : The toxin can be detected through laboratory methods using the ninhydrin reaction, which gives a purple colour. Electrophoresis and biological methods (bioassay in animals) can also be used.

Prevention : The condition is preventable if pulse is removed from diet, at the earliest. Use of the legislation of Prevention of Food Adulteration act to limit the consumption of crop must be encouraged. In case the crop has to be consumed, the toxin can be removed by steeping. At the household level, steeping can be done by soaking the pulse in hot water for 2 hours. Water is then drained and pulse is dried in sun. The disadvantage of using this method is that the taste and nutrients are lost to an extent. At a large scale, parboiling can be done. The process is the same as used for parboiling rice. Soaking the pulse overnight in lime water and subsequently boiling or cooking it

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also helps in removing the toxin.

High dose vitamin C (1000 mg/day) prophylaxis for few weeks is also found to be useful. Nutritional education in the form of abstaining from the use of crop or using it in the manner prescribed above would be useful in preventing the consumption of toxic crops. Bringing about social changes in the form of improving the socioeconomic status would also help people not to fall prey to the toxic dal.

AflatoxicosisThe first known outbreak of Aflatoxicosis probably occurred in England in 1960, among young turkeys. Turkeys fed on infested groundnut meal had hepatitis and enteritis. The groundnuts concerned were harvested, stored and processed in high humidity conditions. The toxic effects were produced by a fungus Aspergillus flavus, a mould contaminating the nuts. Human cases have not been rare since then.

Causative Agent : Aspergillus flavus or another species Aspergillus parasiticus are storage fungi that affects foods in poor storage conditions of high temperature (30-37°C) and high humidity, as is common in the rainy season and during floods and cyclones.

Foods Infested : The fungus Infests improperly stored foods like maize, groundnut, soya, sorghum, rice, wheat, sunflower, tree nuts, spices and even milk and cheese.

Toxins : Brightly fluorescing furanocoumarin compounds known as the ‘aflatoxins’ are known to be responsible for the condition. Aflatoxin B1 is the most potent known natural hepatocarcinogen. Another toxin Aflatoxin G1 is also known. They are known to cause hepatitis (jaundice), ascitis, portal hypertension, liver cirrhosis and hepatocellular carcinoma.

ErgotismWhile aflatoxicosis is a storage fungus, Claviceps fusiformis and Claviceps purpura are field fungi. Crops get infested in flowering or seeding stages. Bajra, rice, sorghum, wheat and rye get commonly affected. Ergotamine is the toxin responsible for the clinical symptoms of nausea, vomiting, abdominal cramps, muscular cramps, giddiness, burning, itching and gangrene of digits and limbs.

Epidemics of aflatoxicosis were known as St. Anthony’s fire in France in the 11th century. The disease was referred to as ‘fire’ because of the intolerable burning pain in the limbs, which became black and shriveled (gangrenous) and eventually dropped off. The legend also goes to say that the condition used to improve when the patients visited the St Anthony’s shrine located a distance away. The patients probably improved because of the discontinuation of consumption of ergot affected cereals, as they shifted to the new location (of the shrine).

Epidemics were common in many European countries like Germany, Poland, England and Russia till the late eighteenth century, when it was related to the consumption of fungus (Claviceps purpura) infested rye. Besides the symptoms enumerated above, convulsions, palsies and discordant movements were also known, indicating the affliction of the nervous system. The Claviceps fusiformis infestation of bajra in India is a milder clinical entity as compared to the more severe classical European variant described above. This fungus

produces alkaloids of the clavine group that has milder toxicity than ergotamine. Claviceps fusiformis infestation leads to nausea, vomiting, abdominal cramps and drowsiness. The recovery is usually complete.

FusariumFusarium incamantum is another field fungus affecting crops like sorghum, rice and maize. It is seen in the subtropical and temperate regions. The fungus produces toxins like deoxynivalenol and fumonisin which are responsible for certain clinical symptoms like vomiting and diarrhoea. The episodes of mouldy ragi poisoning in India (1929) and Alimentary Toxic Aleukia (haemorrhagic rash, bleeding nose, leucopenia) seen in Russia during the Second World War were due to fusarium.

Detection of Mycotoxins : Many sophisticated methods are available for the detection of Mycotoxins. Thin Layer Chromatography (TLC), Radio-immuno Assay (RIA) and ELISA tests are available. Several rapid kits are also available for detection of aflatoxicosis, etc.

Prevention : Four broad groups of steps should be taken (3):

1. Plant Breeding : Cultivating varieties of rye, bajra, millets, and wheat resistant to disease (ergotism) can radically minimize the problem.

2. Good agricultural practices during pre and post harvest period : Good pre-harvest agricultural practices like avoiding water stress, minimizing insect infestation, are effective in reducing aflatoxin contamination in groundnuts and maize. Good post harvest and storage conditions for grains and nuts are also of paramount importance. These foods must be stored under ideal humidity and temperature conditions. Appropriate drying, storage and reducing the chances of moisture entry in the stores also limit the probability of contamination with storage fungi. If contamination does occur the infested grains can be removed using the floatation method in which the grain is allowed to float in 20% salt water. The infested grains floats and can be easily removed. Air floatation and hand picking techniques can also be used.

3. Detoxification : Ammonia process is being used to detoxify aflatoxin affected groundnuts and remove the mycotoxin. The detoxified product is available only for animal feeds and is not suitable for human consumption.

4. Health Education: The community must be educated about the ill effects of the conditions and the importance of the preventive measures described above.

Epidemic DropsySeveral cases of epidemic dropsy were reported from many states of India as recently as in the year 1996. Similar outbreaks have been occurring off and on in the past as well. It was discovered by Indian scientists in the early twentieth century that the condition is attributable to contamination of mustard oil with argemone oil. Subsequently the toxic alkaloid sanguinarine was isolated from argemone oil and was chemically analysed. It was also determined that sanguinarine interferes with the oxidation of pyruvic acid, which is responsible for the dropsy.

The Prickly poppy plant grows indiscriminately and wild in India. It has large prickly leaves and bright yellow flowers (some species have white flowers as well). Argemone mexicana

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is the species most commonly incriminated. The argemone seeds closely resemble mustard seeds. They mature with the mustard crop and may be harvested together. Argemone seeds (or oil) can be mixed with mustard to deliberately adulterate it. The contamination may sometimes be accidental.

Clinical Features : As the name suggests, the patient gets generalized swelling manifested as bilateral pedal edema of sudden onset. Patient may get diarrhoea. In advanced stage patient gets dyspnoea and signs of congestive cardiac failure (CCF). If not treated death may ensue. A mortality rate of 5 to 50% has been reported.

Detection of Toxin :

(a) Nitric Acid test: When nitric acid is added to a sample of oil, a brown orange colour emerges, indicating the presence of argemone oil. The sensitivity of this test is low. It is positive only if at least 0.25% of argemone oil is present in the sample.

(b) Paper chromatography: Paper chromatography is a test with much higher sensitivity, detecting argemone oil even at 0.0001%.

Prevention : The growth of argemone plant must be discouraged and the plants must be weeded out. Unscrupulous traders deliberately adulterating argemone oil to mustard oil must be tried under the PFA Act. Early detection and institution of control measures must be encouraged to limit the severity and further spread of morbidity. Educating and making the public aware of the problem and likely solutions will also go a long way in preventing the condition.

SummaryFood processing is the technique used to transform raw ingredients into food or to transform food into other forms for consumption. The basic aims of food processing are to improve the colour, appearance, palatability, taste, texture and keeping quality of food. Food processing includes various techniques like pickling, fermentation, baking, Pasteurization and canning. Loss of nutrients (in some cases) could be a major disadvantage of food poisoning.

Food additives are the non-nutritious substances added intentionally to food, generally in small quantity, to improve the basic properties of food like its appearance, flavour, texture, etc. Almost all processed foods contain food additives.

Food preservatives are used to increasing the keeping quality, preserving the nutritional characteristics, appearance, colour and texture of food. There are few natural food preservatives known. The synthetic ones include certain preservatives like antioxidants and other chemicals.

Food Fortification is the process whereby nutrients are added to foods in relatively small quantities to maintain or improve the quality of diet of a group, a community, or a population. Addition of iodine to salt is the most well known example of fortification.

Study ExercisesLong Question : What is the role of the PFA Act? Describe as to how a food sample can be obtained from a shop and how is it dispatched.

Short Notes : (1) Fortificant (2) Neurolathyrism (3) Common mycotoxins (4) Epidemic dropsy (5) Aims of food processing

MCQs1. Vanilla essence is a food : (a) Additive (b) Fortificant

(c) Supplement (d) Toxicant2. Which of the following is not a mycotoxin : (a) Aflatoxin

(b) Sanguinarine (c) Deoxynivalenol (d) Fumonisin3. PFA Act was enacted in the year : (a) 1950 (b) 1954

(c) 1962 (d) 19864. _______ can take a food sample under the PFA act :

(a) Consumer (b) Health inspector(c) Anyone authorized under the gazette (d) Any of the above

5. _________ are not to be used for preservation of foods : (a) Irradiation (b) Bacteria (c) Antibiotics (d) Antioxidants

Match the following

Food item Role

6. Papaya seeds (a) Flavouring agent

7. Sanguinarine (b) Adulterant

8. MSG (c) Fortificant

9. Salt (d) Toxicant

10. Iodine (e) Vehicle

Answers : (1) a; (2) b; (3) b; (4) d; (5) c; (6) b; (7) d; (8) a; (9) e; (10) c.

ReferencesGandy JW, Madden A, Holdsworth M. Oxford handbook of nutrition and 1. dietetics. Oxford University Press, 2007, New DelhiPassmore R, Eastwood MA. Human Nutrition and Dietetics. 8th ed. Churchill 2. Livingstone, ELBS London. 1986.Bamji MS, Rao NP, Reddy V. Textbook of Human Nutrition. 2nd ed. Oxford & 3. IBH Publishing Co Pvt Ltd, New Delhi. 2003.

• 798 •

138Nutrition during Special Situations : Disasters, Fairs and Festivals, Community Feeding of Children

Rajul K Gupta

There might be certain situations wherein nutrition assumes special importance and has to be catered for in a different manner. The resources required may be different and those available may be limited, in that given situation. There may be many such states; few selected important situations are discussed in this chapter.

Nutrition during Disaster SituationsHistory is replete with the instances of disasters and their inevitable implications on human nutrition. May it be the Bengal or the Irish famines (in which millions died of starvation) or even a prolonged military conflict, it is the common population that suffers the most and starves in extreme cases.

Unfortunately the epidemiology of the nutritional consequences of a disaster unfolds in a pathetic manner. Irish famine can be taken as a typical example (See Box - 1).

Box - 1: A Peep into the Genesis of Nutritional Problems in a Disaster through the Irish Famine

It was an unassuming fungal disease, the potato blight, which initiated the Irish famine, as “potato rotted in the ground, there was horrible stench all over”, the poor farmers lost all and they had no money to buy food. They became idle and unemployed and out of work, since they subsisted only on the potato crop! Sanitation suffered and diseases like dysentery, diarrhoea and Scurvy took on. Cholera epidemics were a common place. Due to extreme cold and wet winter of 1846, and hardly any money to buy warm clothing, typhus and relapsing fever (“Famine fever”), compounded the problems. Starvation followed and millions died. They tried to migrate to the New World - America, but many died enroute in the ships, some overloaded ships sank killing scores of people on board. Those who reached were too rickety and miserable to work even in America…

Any disaster as such, leads to scarcity of food but other inevitable consequences of disaster lead to disease prone conditions like overcrowding, poor sanitation, natural vagaries, lack of water, and lack of health care. These multiple factors in turn, worsen the scarcity of food and malnutrition. Starvation and epidemics force people out of the town displacing them. There is panic and social disruption. People become helpless and may die in large numbers. They might have to be moved to relief camps, which too are not problem free.

Importance of Nutrition in DisasterNutrition assumes extreme importance in a disaster situation as food is a primary requirement for sustenance of life. Nothing depletes human morale more than the non availability of food. Micronutrient deficiency is a reality in the absence of food,

and so is death. Starvation and malnourishment are common. Malnutrition leads to infection esp. in children and this vicious cycle is deadly.

The effect of disaster is not the same on everyone. Vulnerability of people to disaster depend on the severity and duration of disaster, degree of preexisting poverty, failure of the population to get timely food, aid, work and wages. In case the prevailing disaster conditions like conflicts continue, the recovery can not be expected to occur. The physiological groups most vulnerable to the consequences of disaster in general and poor nutrition in particular are the young children, pregnant and lactating women, the sick, disabled, and the elderly.

The requirement of food during disaster depends on the number and age distribution of people, their mean heights and weights, physical activity levels, environmental temperatures and the malnutrition and (ill) health status (1,2). The energy requirements for disaster situation is summarised in Table - 1.

Table - 1 : Energy requirements for disaster situation (2)

Group Age Male (Kcal)

Female (Kcal)

Combined (Kcal)

Under 5s 0-4 1320 1250 1290

Children 5-9 1980 1730 1860

Adolescents 10-14 2370 2040 2210

Adolescents 15-19 2700 2120 2420

Adults 20-59 2460 1990 2230

Elderly > 60 2010 1780 1890

Pregnant/lactating

285/500 (extra)

285/500 (extra)

Whole population

2250 19102080 (say

2100)

There is a general consensus that about 2100 Kcal per head should be catered for planning the energy requirements for a disaster situation. Proteins must contribute to 10-12% of the energy (about 52g of proteins per day). Fats must provide 17-20% of energy (46g of fat); half from invisible sources and half from visible fats (23g each). Critical micronutrients like iron, iodine, vitamin A and other vitamins (thiamine, niacin, vitamin C) must also be provisioned for, systematically. Ensuring the provision of locally available foods and maintaining their continuous supply would go a long way in disaster relief. At times, fortified foods and pharmaceutical supplements are also called for. A typical food survival ration is outlined in Table-2.

Meeting Nutritional Requirements in a Disaster SituationNutritional requirements in a disaster situation can be effectively met through being prepared all the time for a disaster and instituting sound interventions in the event of disaster.1. Be Prepared … Disaster may Strike

The community has to be taught to be always prepared for a disaster. Such preparations not only keeps the community confident that they can meet the ‘unknown challenge effectively’ but such a preparation can make the difference

• 799 •

between life and death. Simple steps of storing food and water at vantage points and regularly replenishing them are some basic ‘preparation’ measures. The basic tips for storing water and food are summarised in Box - 2.

Box - 2 : Be Prepared … Disaster may Strike

Store Water For drinking - @ 2 lit / person / day ●For cooking - @ 2 lit /person /day ●At least for 3 days (2 weeks) ●If supplies run low, don’t ration water ●Don’t risk dehydration ●Store in a cool, dark place at home, office, vehicle ●Preferably in store-bought, factory-sealed water ●containerOr in washed, rinsed food-grade containers ●Change every six months ●

Store FoodThat is eaten regularly ●Requires no refrigeration, preparation, cooking ●Include vitamin, mineral, protein supplements ●Store two weeks supply ●Canned food can be stocked ●Stock for infants – formula feed, pacifiers, medicines ●Wrap perishables and keep sealed ●Empty opened packages into screw-top / airtight jars ●Avoid fatty, high protein, salty foods ●

Don’t forgetCan opener, disposable cups, plates, knife, sugar, salt, ●plastic bagsTo replace water/foods at regular intervals ●

Replace at six monthly intervalsDry fruits, biscuits, infant formula ●

Replace at yearly intervalsCanned meat ●Vegetable soups, fruit juices ●Jelly, butter, instant cereals, vitamins ●

Store indefinitelySome foods like dried corn, dry noodles instant coffee, ●tea, soft drinks, vegetable oils, salt, soybean, wheat and rice can be stored almost indefinitely.

2. Interventions in the event of disaster

Rapid initial assessment will have to be undertaken to ascertain the origin of nutritional problem (failure of crops, war, drought, etc.), demographic profile of the affected population, baseline health data, factors affecting interventions like security, water, food and potential logistics constraints e.g. transport, roads, food supply, etc. Based on the above data the strategy for a particular feeding programme is chalked out. Many types of feeding programmes are available, depending on the situation. These are outlined in Fig. - 1. Various feeding programme strategies are described here in brief.

Fig. - 1 : Feeding programme strategy (4)

Feeding programmes

General food distribution Selective feeding prog

Supplementary feeding prog Therapeutic feeding prog

Targeted SFP

Blanket SFP

General Food Distribution (GFD) :The aim of the general food distribution strategy is to provide food to all for a basic level of survival. The limitations in this strategy are that the food might be insufficient to meet needs of all the people and the most vulnerable groups might be ignored. In any case it is a useful strategy esp. in the beginning of the disaster aid. It is done either through supplying cooked meal as an emergency measure or distributing dry ration when the situation has stabilized and people can cook in makeshift camps/shelters. The third option could be mass feeding the population with cooked meal. The principle is to provide energy dense foods on an immediate and urgent basis. 1 metric ton cereals can cater for the energy requirement of 1850 males for 1 day (5).

Presuming the individual consumption at a rate of 540g/person/day, the planning figures to determine food needs (in metric tons) has been worked out in Table - 3.

Table - 3 : Planning figures to determine food needs (3)

(Food quantity in metric tons @ 540g/person/day)

Popu-lation

1 day

1 month

3 months

6 months 1 year

1,000 0.54 16.20 48.60 97.2 197.10

5,000 2.70 81.00 243.00 486.0 985.0

10,000 5.40 162.00 486.00 972.0 1971.0

50,000 27.0 810.00 2430.00 4860.0 9855.0

1 lakh 54.0 1620.0 4860.00 9720.0 19710.0

(Basis of calculation: Requirement in metric tons = No. of persons per day x 0.540/1000 Kg)

Table - 2 : Typical food survival ration (3)

(Quantity in g based on 2100 Kcal/person/day)

ItemRation Option

1 (g)Ration Option

2 (g)

Rice/Wheat flour 415 430

Pulses 45 0

Vegetable oil 25 25

Groundnuts 35 35

Canned fish 0 30

Sugar 15 15

Salt 5 5

Total 540 540

• 800 •

It must be remembered that any food that is offered should be culturally acceptable, as close to routine food, available for consumption in a digestible form, suitable to vulnerable groups and must contain adequate quantity of micronutrients.

Organizing Mass Feeding : Mass feeding can be undertaken in institutions and refugee camps. Local foods should be used as far as possible. The calculations for mass feeding are similar to the one shown above. Mass feeding must be undertaken in enclosed areas. Public kitchens have to be established under supervision of administrators. Timings must be fixed for meals. Distribution of cooked food can also be done through families. Some special feeding regimes have to be thought of, for the elderly, infants and pregnant women (6).

Selective Feeding Programme : Selective feeding programme have to be undertaken for vulnerable groups. It could be a supplementary feeding programme or therapeutic feeding programme. The aim of the supplementary feeding programme is to provide necessary nutrient supplements to the vulnerable groups like under fives children with malnutrition, pregnant and lactating women. This helps prevent deterioration of nutritional situation through correction of moderate malnutrition, prevention of severe malnourishment, infections like measles, pertusis, ARI, diarrhoea and chances of epidemics and mortality (7) The planning figures for supplementary feeding for typical daily rations (with monthly totals) providing 350 Kcal, 15 g protein/person/day) are given in Table - 4.

Table - 4 : Planning figures: Supplementary Feeding (3)

(Typical daily rations (with monthly totals) providing 350 Kcal, 15 g protein/person/day)

Item (daily)

Amount (g)

Energy (Kcal) Fat (g) Protein

(g)

Monthly (metric

ton)

Cereal 50 180 - 4 1.50

Veg oil 10 89 10 0 0.30

Wheat-soya

55 204 3 11 1.65

Salt 5 0 0 0 0.15

Total 120 473 13 15 3.60

Therapeutic Feeding : The aim of a therapeutic feeding programme is to help in medical and nutritional treatment of severely malnourished children (8) This is aimed to reduce infant and child deaths esp. because of severe PEM. Therapeutic feeding provides an intensively managed, carefully balanced medical regimen. It helps in the rehabilitation of severely malnourished children. It can be undertaken at a residential level wherein the mothers (along with the sick malnourished children) are admitted and treated with special focus on nutrition. An alternative approach is to take care of the children in the day care centres established for this purpose. The mothers visit such centres for day long period, get medical attention and learn the basic skills in child nutrition, care and disease prevention. Besides the severely malnourished young vulnerable children and adolescents, the low-birth-weight babies, orphan infants who lack inadequate traditional care are

also the prime focus of therapeutic feeding. Mothers of infants with lactational failure are also given such care.

Conclusion : It can be well appreciated that nutrition during a disaster situation is not merely providing a ‘feed’. But it involves anticipating, preparing and training for disaster beforehand; assessing the disaster situation in terms of impact, demography and resources; making an immaculate plan; implementing the plan and learn from the mistakes. Infant feeding, nutrition for the elderly and nutrition for pregnant and lactating women remain special situations and need expert attention.

Fairs and FestivalsIndia is a country of fairs and festivals. There is no month that doesn’t have a festival or two. People tend to enjoy themselves during various festivals. Fairs and community feeding are integral to festivals. Fairs and festivals pose threat to public health as well, as people tend to congregate in large numbers in restricted spaces. The community is put to numerous risks; these could be as diverse as stampede, heat exhaustion, heat stroke, dehydration, infections, outbreaks, violence, terrorist threats, building collapse, fire, etc. The public health aspects pertaining to food in fairs and festivals are dealt with in brief, in the subsequent paragraphs. Mass feeding (during a festival) whether at the level of household or a community, poses threat to the people. The factors that make the community more vulnerable to food borne disease during mass feeding are:

Large congregation of people ●Compromised food hygiene ●Scarcity of water ●Business interest of people that compromises basic ●hygieneFlies and other pests ●Indiscriminate littering of waste and poor waste disposal ●FacilitiesInadequate (hand, raw foods, utensils) washing facilities ●Inadequate toilets and wash rooms ●Participation of unspecified food handlers ●

Responsibilities of Local Health Authority It must be appreciated that the local health authority has a major role to play in managing health during fares and festivals and ensuring proper measures to prevent disease. The local health authority is responsible for: a) Selecting the correct site for establishing the ‘food centre’b) Selecting right agents/contactors providing food material

(raw and cooked)c) Ensuring appropriate source of foodd) Provision of safe drinking watere) Licensing the food shops and eateriesf) Food hygiene and inspectionsg) Attending to complaintsh) Food sampling as per the PFA act and follow up actioni) Food and workplace safetyj) Control of infectious disease and prevention of food

poisoningk) Fly and pest controll) Educating the community on various aspects of food

hygieneThe most common issues that must be ensured by the

• 801 •

administrators are :Adequate contingency planning and consistent procedures ●Communication between management and food handlers ●Adequate training, information, instruction and supervision ●for allHazard analysis pertaining to feeding ●Recognition of potentially hazardous procedures. ●

Responsibilities of the CommunityThe local health authority might make rules and try to enforce them, but it is the community that has to ensure their implementation in the right earnest, for its own benefit. The community must take the responsibility of adhering to the rules laid down by the health authority. The community must be aware of various aspects of food hygiene, food safety, foods to be consumed and foods to be avoided during mass gatherings. The importance of flies and pests, safe drinking water and basic procedures like hand washing and proper garbage disposal must be appreciated by the community. Unhygienic and unlicensed food vendors must be shunned and reported against. The community must co-operate in the efforts of the authorities in maintaining food hygiene.

Role of Food Handlers The responsibility of food handlers becomes even more important in the situation of fairs and festivals as they can transmit infection to numerous people. Their responsibilities have been discussed in detail in the chapter on food borne infections. Only the most salient points are repeated here. To prevent food borne infections hand-washing is of utmost importance. Hands must be washed with soap and water after visiting the toilet, handling rubbish, handling raw foods, putting hand over your nose or mouth and before starting work or after taking a break. Hands must be dried with clean towels. The nails must be clipped short; food handlers must be vaccinated against common diseases esp. typhoid. If the food handler is sick or has diarrhoea, it is best to refrain from kitchen duties.

Taking Care of FoodWhenever a communal feeding is planned either at home or at a community centre the following simple points must be ensured:

Once procured, the food must be cooked at the earliest but ●closest to the time of consumptionPrepare and store raw and cooked food separately ●Expiry date must be checked for all packed foods ●Keep pets and pests away from food and food preparation ●surfacesWash hands thoroughly before preparing food, and after ●going to the toiletWash worktops and utensils ●Avoid food containing uncooked eggs ●Ensure food is piping hot ●Keep hot food hot and cold food cold ●Food handlers with diarrhoea / vomiting must be excluded ●Food freshly cooked is usually safe. Eating stale food (more ●than couple of hours old) constitutes greater risks of food borne diseaseFood has to be thoroughly cooked and must be hot when ●

servedUncooked food apart from fruits and vegetables that can ●be peeled must be avoidedFoods exposed to flies and pests must be shunned ●

Taking Care of Cleaning and Waste ManagementClean premises will reduce the risk of contamination, avoid pest infestations, provide a safe and pleasant environment to work. These simple guidelines must be observed:

Always keep the premises clean ●A cleaning schedule must be followed. Staff must be ●nominated to clean a particular equipment or area, on a given day Keep all chemicals locked away from food ●Provide suitable dustbins with lids. Ensure their regular ●evacuation. Regularly clean refuse areas ●

Taking Care of Drinking Water, Ice and BeveragesIt must be ensured that only clean and safe drinking water is used. The source of water must be ascertained and safety ensured. If in doubt do not drink that water. Bottled or carbonated water might be safer! Water used for recreational purposes (such as swimming) is often contaminated and must not be consumed.

Commercial ice must be avoided unless one is sure that it is made from safe water and has not been contaminated by dirty hands, pests, or equipment. Ice-cream from unreliable sources may be contaminated and cause illness. If in doubt avoid it.

Beverages such as hot tea, coffee, beer, carbonated soft drinks or fruit juices are usually safe to drink. Expiry dates and seals must be checked. Avoid unpasteurised milk, cheese, paneer and other products.

Specific FoodsSome food stuff must be viewed with suspicion and consumed only if one is sure of their safety, as there is a higher potential of food poisoning with them. Some of these are enumerated in the Box - 3.

To keep these foods safe ensure strict temperature control during the entire course of food processing: delivery, correct freezing, thawing, refrigeration, cooking and serving. They must be protected from contamination (bacterial and chemical). The entire supply line of the food product must be traced for hygiene.

Box - 3 : Suspicious foods - Consume with care!

Cooked meats and poultry

Milk, cream, artificial cream, cottage cheese (paneer) custards and dairy produce

Cooked eggs and products made with fresh shelled eggs (mayonnaise)

Fish and sea foods

Cooked rice

Ice

Salads, vegetables and fruit eaten raw

Sandwiches and filled rolls

• 802 •

Duties of Health OfficersHealth officers have the responsibility to ensure implementation of laid down health policies. They inspect premises for ensuring hygiene, correct cooking practices, storage and distribution of food, etc. They undertake surveillance to keep an eye on the cases reported as diarrhoea, vomiting and dysentery and rule out if they were food poisoning. They would also ensure taking samples from suspicious locations. Health officers can arrange to collect samples and have them examined at the Public Health Laboratory.

If a restaurant or food shop is implicated, the officer will carry out an inspection of the premises and take food samples for examination (if required). Mainly the officer looks for the bacterial risks arising from the type of food handled in the business and how food is stored, prepared, cooked and served. They investigate incidences of outbreaks of food poisoning in detail; recommend and take appropriate prevention and control measures.

Community Feeding of ChildrenThere are many instances when the community feeding of children has to be resorted to. It is commonly seen as part of certain national nutritional programmes. The Mid Day Meal Programme, Balwadi Programme and under the ICDS programme (Anganwadi), children are fed in groups ranging from a few dozens to thousands. While running such a programme is essential for the up-liftment of the nutritional status of children, such a mass feeding entails tremendous risk as well, given the large numbers involved. There have been occasional reports indicating food poisoning episodes in such congregations of children. This not only puts the lives of children at risk but also puts the very programme at stake of disrepute and rejection by the community. It is therefore imperative to take adequate measures to prevent such situations.

Infants and children are more vulnerable to infections owing to a poorly developed immune system and higher vulnerability to infections. For this reason it is important to take extra care when preparing food for infants and young children.

Preparing food for infants and childrenSome precautions that must be taken for preparing foods for infants and children are enumerated in Box - 4.

SummaryNutrition assumes extreme importance in a disaster situation as food is a primary requirement for sustenance of life. At an average energy requirement is 2100Kcal/person/day. It is best to be prepared for a disaster. Food and water must be stored at vantage points. After a disaster various feeding programmes namely a) General food distribution b) Selective food distribution can be resorted to. The latter can be applied either as a supplementary or a therapeutic feeding programme depending on the situation and the distribution of beneficiaries. Organizing a mass feeding programme for the disaster struck and refugees might pose a challenge to the authorities, so, sound administrative acumen is needed to make it a success, besides merely providing the relief material.

Mass feeding during fares and festivals is a common and frequent feature in India. Large scale food preparation and distribution poses a serious public health threat if the same is not organized as per basic principles of hygiene. The local health authorities have to ensure implementation of relevant rules. Close monitoring and effective surveillance of health and hygiene during the feeding is indispensable. The community has a major role to play in marinating health through following the rules laid down. Community must make effort to be aware of the basics of food hygiene and the dos and don’ts of eating in a large communal gathering. Cooks and food handlers must also realize their responsibilities to stop spread of infection.

Community feeding of children is often resorted to through various feeding programmes organized by the government, under the national programmes (Mid Day Meal, ICDS, etc). Special care in procurement, processing and distribution of food must be taken to prevent instances related to food poisoning. This can be achieved through immaculate kitchen hygiene, healthy food handlers and an aware community. We must strive to achieve these.

Box - 4 : Guidelines for Preparing Food for Infants and Children

Raw food must be procured from authentic sources

Immaculate personal hygiene of cooks must be ensured

Dining area, tables, chairs, bibs must be thoroughly cleaned before and after every meal

Kitchen surfaces, floors, platforms, etc. must be immaculately clean

Avoid foods that are more likely to cause food poisoning e.g. cream, raw eggs, paneer, meat dishes, salad, etc.

Kitchen towels and cloths must be changed daily or more often

‘Cook fresh and consume fresh’ should be the rule

Avoid storing cooked food for another day

Discard left-overs

Children must wash their hands after visiting the toilet or touching pets.

• 803 •

Study ExercisesLong Question : Discuss the nutritional interventions that could be undertaken in the event of an earthquake.

Short Notes : (1) Storing food for disaster (2) Therapeutic feeding programme (3) Community feeding of children (4) Post exercise feeding of athletes (5) Precautions with drinking water during fairs

MCQs1. At an average ____________ Kcal/person should be catered

for planning food aid during disaster: (a) 2100 (b) 1850 (c) 2400 (d) 2800

2. Water must be stored @ ________lit for drinking and ____ lit for cooking (per day): (a) 1,1(b) 2,2 (c) 2,3 (d) 3,2

3. One metric tonne grains are sufficient to feed_______________ males/day in a disaster situation : (a) 2100 (b) 1850 (c) 1000 (d) 1500

4. In a disaster situation the aims of therapeutic feeding includes all except (a) Medical treatment of severely malnourished (b) Nutritional treatment of severely malnourished (c) Reduce infant/child deaths (d) Treat cases of infections

5. Community feeding of children is undertaken in all except (a) ICDS programme (b) Mid day meal programme (c) Balwadi programme (d) School health programme

Match the following

Act Responsibility of

6. Take food samples (a) Community

7. Lay down policy (b) Local health authority

8. Report diarrhoea cases (c) Food handler

9. Report own illness (d) Local doctors

10. Maintain food hygiene (e) Health officers

Answers : (1) a; (2) b; (3) b; (4) d (5) d; (6) e (7) b; (8) d; (9) c; (10) a.

ReferencesICMR, Nutrient Requirements & RDA for Indians: A report of the expert 1. group. National Institute of Nutrition, Hyderabad, 2005.WHO, The Management of nutrition in major emergencies. Geneva, 2000.2. USAID, Field operations guide for disaster assessment and response, 2005 3. UNHCR/WFP Guidelines for selective feeding programmes in emergency 4. situations. Geneva, United Nations High Commissioner for Refugees, 1999Passmore R, Eastwood MA. Human Nutrition and Dietetics. ELBS. Churchill 5. Livingstone, Edinburgh, 1986.Pasricha S, Thimmayamma BVS, Dietary Tips for the elderly. National 6. Institute of Nutrition, Hyderabad, 2005.WHO, Communicable disease control in emergencies : A field manual, 7. Geneva, 2005.WHO, Management of severe malnutrition: A manual for physicians and 8. other senior health workers. Geneva, 1999.McArdle WD, Katch FI, Katch VI. Exercise Physiology: Energy, nutrition and 9. human performance. 4th ed. 1996. Williams and Wilkins, Baltimore, USA

• 804 •

Table - 1 : Nutritive Value of Commonly Used Foods (per 100g) (1)

Food stuff Proteins (g) Fat (g) Fibre (g) Carbohydrates (g)

Energy (Kcal) Iron (mg)

Wheat flour 12.1 1.7 1.9 69.4 341 4.9

Rice polished 6.8 0.5 0.2 78.2 345 0.7

Rice parboiled 6.4 0.4 0.2 79 346 1

Bajra 11.6 5 1.2 67.5 361 8

Maize dry 11.1 3.6 2.7 66.2 342 2.3

Bengal gram 17.1 3 3.9 60.9 360 4.6

Soya bean 43.2 19.5 3.7 20.9 432 10.4

Rajmah 22.9 1.3 4.8 60.6 346 5.1

Redgram 22.3 1.7 1.5 57.6 335 2.7

Beans 1.7 0.1 1.8 4.5 26 0.61

Spinach 2 0.7 0.6 2.9 26 1.14

Tomato 0.9 0.2 0.8 3.6 20 0.64

Carrot 0.9 0.2 1.2 10.6 48 1.03

Onion 1.2 0.1 0.6 11.1 50 0.6

Potato 1.6 0.1 0.4 22.6 97 0.48

Groundnut 25.3 40.1 3.1 26.1 567 2.5

Guava 0.9 0.3 5.2 11.2 51 0.27

Amla 0.5 0.1 3.4 13.7 58 1.2

Mango 0.6 0.4 0.7 16.9 74 1.3

Orange 0.7 0.2 0.3 10.9 48 0.32

Banana 1.2 0.3 0.4 27.2 116 0.36

Lime 1.5 1 1.3 10.9 59 0.3

Grape green 0.5 0.3 2.9 16.5 71 0.52

Grape blue 0.6 0.4 2.8 13.1 58 0.5

Papaya 0.6 0.1 0.8 7.2 32 0.5

Egg 13.3 13.3 - - 173 2.1

Fish (Hilsa) 21.8 19.4 - 2.9 273 2.1

Chicken 25.9 0.6 - - 109 -

Milk, cow 3.2 4.1 - 4.4 67 0.2

Milk, buffalo 4.3 6.5 - 5 117 0.2

Ghee - 100 - - 900 -

Butter - 81 - - 729 -

Veg oils - 100 - - 900 -

Cheese 24.1 25.1 - 6.3 348 2.1

Curd 3.1 4 - 3 60 0.2

Jaggery 0.4 0.1 - 95 383 2.64

139 Nutrition Tables

Rajul K Gupta

• 805 •

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• 806 •

Table - 3 : Major Contributors of Energy to Our Diet (Some raw foods and their energy content per 100g) (1)

Food stuff Energy (Kcal) Food stuff Energy (Kcal)

Cereals & Millets Non vegetarian foods

Wheat flour 341 Egg (hen) 173

Rice polished 345 Fish (Hilsa) 273

Bajra 361 Chicken 109

Maize dry 342 Mutton (lean) 118

Ragi 328 Pork (muscle) 114

Pulses & Legumes Milk & milk products

Bengal gram 360 Milk, cow 67

Soya bean 432 Milk, buffalo 117

Rajmah 346 Milk, human 65

Redgram (Arhar) 335 Butter 729

Greengram (Moong) 334 Ghee 900

Lentil (Masoor) 343 Cheese 348

Pea dry 315 Curd 60

Fruits & Vegetables Nuts

Banana 116 Groundnut 567

Apple 59 Cashew nut 596

Grapes, pale green 71 Coconut, fresh 444

Custard apple 104 Miscellaneous

Jack fruit 88 Jaggery 383

Raisins 308 Sugar 398

Potato 97 Veg oils 900

Table - 4: Calorie Content of Selected Cooked Food Items (per serving) (2)

Food item Kcal Food item Kcal

Samosa (1no.) 256 Dalia (1 plate) 80

Masala dosa (1no.) 360 Khichri (1 plate) 160

Kachori (2 no.) 500 Biscuits (4 no.) 150

Omelette (1egg) 236 Poha (1 plate) 120

Puri (4 no x 25g each) 320 Bread (2 slices) 125

Chapati with ghee (4 no.) 360 Chapati (2no x 35g each) 160

Cake (1small piece) 250 Kheer (1 katori) 120

Butter chicken (1 katori) 400 Cornflakes (1bowl) 190

Chicken biryani (200g) 400 Veg salad 50

Malai paneer (1 katori) 270 Butter milk (1 glass) 90

Paratha (2no x 50g each) 360 Jam (2tsp) 40

Ice cream (100ml) 250 Dhokla (2 pcs) 100

Pastry (1 no.) 290 Green leafy veg (1katori) 130

Milk cake (1 piece) 300 Idli (2no x 55g each) 155

Butter (2 tsp) 180 Dosa (2no x 45g each) 250

Fried Cashew (50g) 375 Tinned cheese (2tbsp) 105

• 807 •

Table - 5 : Signs ‘Strongly Suggestive’ of Dietary Deficiency or Excess (3)

Sign of Deficiency Suggested nutrient abnormality

Pale conjunctiva Iron

Bitot’s spots Vitamin A

Angular stomatitis Riboflavin

Spongy, bleeding gums Vitamin C

Bilateral edema (young children) Protein and Energy

Thyroid enlargement Iodine

Bilateral epiphyseal enlargement of wrists Vitamin D

Sign of Excess Suggested nutrient abnormality

Mottled enamel Fluoride

Dental caries Sugar

Table - 6 : Normal Range of Some Biochemical Tests (4)

Nutrient Test Normal (Acceptable)

Low (Medium risk)

Deficient (high risk)

Albumin (g/100ml) for age 6-17 yrs

Serum levels >3.5 2.8-3.4 <2.8

Vitamin A (μg/dl) Serum levels >30 20-30 <20

Vitamin D (ng/ml)Serum levels of 25-Hydroxy cholecalciferol

>10 5-10 <5

Vitamin E Ratio of serum vitamin/total lipids >0.8

Vitamin K *PIVKAS accumulationIf PIVKAS

accumulates

Prothrombin time Delayed **

Thiamin Urinary thiamin100μg/24 hrs or

65μg/g creatinine

Riboflavin Urinary Riboflavin 80μg/g creatinine

Niacin2-Pyridone to NI-methyl nicotinamide ratio

1 to 4 <1

Vitamin B6 Vitamin B6 urinary excretion<20μg/g creatinine

Pyridoxic acid excretion <0.5mg/day

Folic Acid Serum Folate (ng/ml) >6.0 3.0-5.9 <3

RBC Folate (ng/ml) >160 140-159 <140

Vitamin B12 Serum B12 (pg/ml) <80

Ascorbic acid Plasma (mg/dl) >15 8-15 <8* PIVKAS: Protein Induced by Vitamin K Absence** Prothrombin time is a functional test

• 808 •

Table - 7 : Approximate Fatty Acid Composition of Common Fats and Oils (g/100g) (5)

Oil/Fat Saturated MUFA Linoleic acid α-linolenic acid Predominant FA

Coconut 90 7 2 <0.5 SFA

Palm kernel 82 15 2 <0.5 SFA

Ghee 65 32 2 < 1.0 SFA

Vanaspati 24 19 3 <0.5 SFA (t-FA)

Red palm oil 50 40 9 <0.5 SFA + MUFA

Palm oil 45 44 10 <0.5 SFA + MUFA

Olive 13 76 10 <0.5 MUFA

Groundnut 24 50 25 <0.5 MUFA

Rape/Mustard 8 70 12 10 MUFA

Sesame 15 42 42 1.0 MUFA + PUFA

Rice bran 22 41 35 1.5 MUFA + PUFA

Cotton seed 22 25 52 1.0 PUFA

Corn 12 32 55 1.0 PUFA

Sunflower 13 27 60 <0.5 PUFA

Safflower 13 17 70 <0.5 PUFA

Soyabean 15 27 53 5.0 PUFA

ReferencesGopalan C, Ramasastri BV, Balasubramanium SC. Nutritive Value of Indian 1. foods, National Institute of Nutrition (ICMR), Hyderabad. 1999.Pasricha S, Count what you eat. National Institute of Nutrition (ICMR), 2. Hyderabad. 1989.Jelliffe DB, Jelliffe EFP. Community Nutritional Assessment. Oxford University 3. Press. 1989.Bamji MS, Rao NP, Reddy V. Textbook of Human Nutrition. 2nd ed. Oxford & 4. IBH Publishing Co Pvt Ltd, New Delhi. 2003.Ghafoorunissa, Krishnaswamy K. Diet and Heart Disease. 2000 National 5. Institute of Nutrition, Hyderabad – 500007.